From a public health perspective, there is probably no more important or daunting challenge than reducing the prevalence of the most common mental disorders, namely anxiety and depression. These disorders have a combined community prevalence rate of between 15% and 30% (Cox et al. 1987; Robins et al. 1991; Goldberg & Huxley, 1992; Kessler et al. 1994; Meltzer et al. 1995) and account for one-third of days lost from work due to ill health (Jenkins, 1985a) and one-fifth of all consultations in general practice in the UK (Williams et al. 1986). The common mental disorders are associated with impairments in physical and social functioning at least as severe those associated with chronic physical illnesses (Wells et al. 1988; Klerman, 1989; Wohlfarth et al. 1993; Ormel & Costa e Silva, 1995; Spitzer et al. 1995; Martin et al. 1996), and a mortality rate nearly twice that of the general population (Murphy et al., 1987; Klerman, 1989; Lloyd et al. 1996). The public health importance of these disorders, even in mild form, is further demonstrated by the finding that low levels of depression resulted in 51% more days lost from work than major depression (Broadhead et al. 1990). The total annual cost of the common mental disorders in the UK may amount to £6 billion, of which two-thirds arises from lost productivity (Croft-Jefferys & Wilkinson, 1989). Despite the availability of simple, cheap and effective treatments (Paykel & Priest, 1992; Effective Health Care, 1993; Brugha, 1995), one study found that the prevalence of these disorders in Britain may have increased recently (Lewis & Wilkinson, 1993).

Background. This paper describes the rationale and methodology of the first national psychiatric morbidity surveys to be carried out in Great Britain. The objectives of the surveys were to estimate the prevalence of psychiatric morbidity among adults aged 16–64 living in Great Britain; to identify the nature and extent of social disabilities associated with psychiatric morbidity; to describe the use of health and social services by people with psychiatric morbidity and to investigate the association between mental illness and potential environmental risk factors in a household sample.

Methods. Four separate surveys were carried out in order to meet the objectives; a private household sample (N=10108), a sample of institutions caring for the mentally ill (N=1191), a sample of homeless people (N=1166), and a supplementary sample of patients with psychosis living in private households (N=350). A two-stage assessment procedure was used, in which all subjects were given the Revised Clinical Interview Schedule (CIS-R) administered by lay interviewers to assess neurotic symptoms and disorders and a psychosis screen, including the Psychosis Screening Questionnaire. Those who were positive on the psychosis screen were then interviewed by psychiatrists using the SCAN (incorporating the tenth edition of the Present State Examination).

Conclusions. Large scale national surveys such as this augment the inadequate data on psychiatric morbidity that are routinely available and are, therefore, an important source of information upon which to base policy and generate aetiological hypotheses. These surveys provide a possible model for similar surveys in other countries.

Background. This paper describes the Household Survey from the National Survey of Psychiatric Morbidity. This covered a sample drawn at random from the population of Britain, with the exception of the Highlands and Islands of Scotland.

Methods. The Postcode Address file was used as the sampling frame. Nearly 13000 adults aged 16–65 were selected for interview, of whom 10108 (79·4%) were successfully interviewed. Eight per cent could not be contacted and 13% refused interview. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects were also screened for psychosis, and screen-positive individuals were examined by psychiatrists using SCAN.

Results. Sixteen per cent of subjects scored above the standard cut-off of 12 on the CIS-R. The overall 1-week prevalence of neurotic disorder was 12·3% in males and 19·5% in females. Unmarried and post-marital groups had high rates of disorder, as did single parents and people living on their own. Respondents in Social Class I had notably lower rates of neurotic disorder than the remainder of the sample. Unemployment was strongly associated with disorder. Subjects living in urban areas had a higher overall prevalence, but there was no significant variation by region. Black respondents had higher rates of disorders that were entirely explained by their age, family type and social class. Individual neurotic disorders were all significantly commoner in women, with the exception of panic disorder. The 1-year prevalence of functional psychoses was 4 per 1000, with no sex difference. Alcohol and drug dependence was considerably more prevalent in men.

Conclusions. For the first time, the survey provides data on the prevalence and correlates of psychiatric disorder on a nationwide sample that can be used to inform equitable and effective national psychiatric services.

Background. Several previous studies have indicated high rates of schizophrenia in African-Caribbeans in the UK compared to White population.

Method. All people aged 18 to 64 years residing in two health districts in London who made contact with hospital or community services over a 1-year (Whites) or 2-year (ethnic minorities) period were screened for psychotic symptoms.

Results. One hundred and twenty-three patients passed the screen, of whom 100 were assigned a schizophrenic class by the CATEGO program. Of these, 38 were White, 38 African-Caribbean and 24 Asian. The incidence rate for broad schizophrenia was significantly higher for African-Caribbeans than for Whites. Asians showed a high rate among people age 30 and over, particularly women. Poor outcome at 1-year follow-up was significantly more common for African-Caribbeans than for the other two groups. The proportion of African-Caribbeans with a poor outcome was two and a half times greater than that of Whites. On a range of seven socio-demographic variables, African-Caribbeans differed from the other two groups only on unemployment.

Conclusions. A multitide of factors play a role in the aetiology of schizophrenia. Comparison of environmental factors in these groups may identify factors that contribute to the aetiology of schizophrenia.

Background. Several studies have replicated the finding of increased incidence of schizophrenia and related psychoses in first and second generation migrants from the Caribbean. The finding has remained consistent in studies employing different methods, but concern has been expressed about indirect methods of calculating the population at risk. This study aims to overcome these shortcomings.

Method. A further prospective study was undertaken in Nottingham assembling an inception cohort of psychotic patients (N=168) presenting from a defined catchment area. The 1991 census, which includes codings for self-ascribed ethnic origin, was used to calculate the denominator, employing correction factors for potential under-enumeration. Case-ascertainment was based upon all service contacts and subjects had in-depth assessments including the SCAN. Collateral history was obtained from informants.

Results. Subjects born in the Caribbean, or who had one or both parents born in the Caribbean, had a greatly elevated risk (incidence ratios above 7) for all psychotic disorders and for ICD-10 (DCR)-defined F20 Schizophrenia.

Conclusions. The size of the increase and the methodological safeguards employed support the validity of this now highly replicated finding. A personal or family history of migration from the Caribbean is a major risk factor for psychosis; the consistency of this finding justifies a systematic evaluation of potential aetiological factors. Any hypothesis derived from the evidence so far must explain: increased incidence in first and second generation migrants; increased risk for all psychoses (including affective psychoses); and an effect specifically associated with a migration history from the Caribbean to Northern Europe.

Background. Reports of an increased incidence of schizophrenia in Afro-Caribbean immigrants to the UK are a matter of much debate. It is of interest, therefore, that in the 1970s and 1980s many immigrants from Surinam and The Netherlands Antilles have settled in The Netherlands. The purpose of our study was to compare the risk of a first admission for schizophrenia for Surinamese- and Antillean-born persons aged 15–39 years to that for their Dutch-born peers in the period 1983–1992.

Methods. We used data from the Dutch psychiatric registry. Age-adjusted relative risks were calculated using Poisson regression analysis.

Results. The risk for the immigrants was found to be three to four times higher than that for the Dutch-born. Age-adjusted relative risks were significantly higher for male than for female immigrants.

Conclusions. The results provide evidence of an increased incidence in these immigrant groups and support similar findings on Afro-Caribbeans in the UK. Migration from Surinam was on such a large scale that selective migration of persons at risk for the disorder is unlikely to account entirely for these findings.

Background. Several studies during recent years have reported an increased occurrence of schizophrenia in selected immigrant groups. However, difficulties in establishing the population denominator for immigrant rates of mental disorder, selective referral for treatment, and other problems may have influenced such results. The current study aims at testing empirically the influence of some of these methodological problems.

Methods. Using nationwide case register data from Denmark, the diagnosis specific first-admission rates were compared between persons born in Denmark and other countries respectively. A case–control design was used to compare schizophrenia risk between different immigrant groups.

Results. Incidence rates of mental disorders among non-Danish residents calculated from admission data showed increased rates of schizophrenia (RR 1·7) and non-affective functional psychoses (RR 1·9). A case–control analysis utilizing non-psychotic admissions as control for schizophrenic admissions yielded essentially the same result, thus excluding selective referral as the sole explanation of the increased schizophrenia rate. However, this was almost exclusively due to increased rates in individuals born in countries neighbouring on Denmark.

Conclusions. While selective risk factors may be operating in various groups of immigrants, caution should be warranted in the interpretation of immigrant studies as large portions of transient visitors may obscure actual rates of mental disorders.

Background. This paper presents the first results of a two-stage psychiatric population survey, which uses a new method of directly evaluating needs for specific psychiatric treatment and the extent to which they have been met.

Method. The sample was drawn at random from the population of an area of inner south London with high levels of deprivation. Seven hundred and sixty subjects aged 18–65 completed the GHQ-28. All those scoring >5 and half of the rest were invited to take part in the second stage, comprising measures of mental state (SCAN), social role performance (SRPS), life events and difficulties (LEDS) and a Treatment Inventory. This information was used to rate the community version of the Needs for Care Assessment (NFCAS-C).

Results. In all, 408 subjects were interviewed in the second stage. The weighted 1 month prevalence of hierarchically ordered ICD-10 psychiatric disorders was 9·8%, the 1 year prevalence 12·3%. The equivalent prevalences for depressive episode were 3·1% and 5·3% respectively, while those for anxiety states were both 2·8%. At interview nearly 10% of the population were identified as having a need for the treatment of a psychiatric condition. This rose to 10·4% if the whole of the preceding year was assessed. Less than half of all potentially meetable needs were met. There was only partial overlap between diagnosis and an adjudged need for treatment.

Conclusion. A majority of people with mental health problems do not have proper treatment; given more resources and greater public and medical awareness, most could be treated by family doctors.

Background. In recent years diagnostic practice in psychiatry has become increasingly structured in an attempt to standardize definitions of disorders and improve reliability. At the same time there has been an increasing recognition of the need to take account of uncertainty in the process of diagnostic decision making. For the most part, diagnosis is still represented by a binary outcome while this is known to entail a substantial loss of information. Many diagnostic schemes involve, in part, taking thresholds on the numbers of symptoms required from symptom lists.

Methods. A model is proposed here, using ideas derived from latent class analysis to permit generalization from these schemes through moving from a binary to a probabilistic measure of psychiatric case status and replacing thresholds with smoothed transitions.

Results. An outcome measure is produced where disorder status is expressed in terms of probabilities without changing the meaning of the original measure. Prevalence estimates (using ICD-10 Depressive Episode criteria) are more stable and can be given with increased precision.

Conclusions. Disorder status when expressed in this way retains more diagnostic information and provides a useful extension to traditional binary analyses when looking at prevalence and risk factor estimation.

Background. Reliable prevalence and risk estimation of psychiatric disorder is a cornerstone to achieving objectives in public health psychiatry. Research strategies have increasingly depended, therefore, upon the progressive evolution and refinement of diagnostic approaches designed to reflect better current knowledge concerning prognosis, course and outcome but essentially the need to improve agreement between users of the various schemes.

Methods. This paper contrasts a conventional with a probabilistic approach to the diagnosis of depression based upon the OPCS United Kingdom National survey of psychiatric morbidity. The probabilistic approach, while designed to mimic current diagnostic practice in relation to the depressive disorders, naturally includes provision for the allocation of respondents on a scale of diagnostic uncertainty according to the severity of their presenting condition.

Results. Findings are reported arising from the application of the probabilistic method to three areas of research interest in public health psychiatry, namely; an evaluation of additivity of event exposure and depressive morbidity, secondly use of the approach for investigating psychosocial models of depressive disorder and thirdly for assessing the agreement between depressive disorder when classified according to competing diagnostic schemes.

Conclusions. The results show application of the probabilistic approach to provide a firm basis for achieving gains in both the stability and precision of risk profile estimation for depressive conditions.

Background. To examine relationships between recent DSM-III-R psychiatric disorders and work impairment in major occupational groups in the US labour force.

Method. Data are from the US National Comorbidity Survey (NCS), a survey of respondents ages 15–54 in the US. Employed people are the focus of the report.

Results. There is substantial variation across occupations in the 30-day prevalences of NCS/DSM-III-R psychiatric disorders, with an average prevalence of 18·2% (range: 11·0–29·6%) for any disorder. The average prevalences of psychiatric work loss days (6 days per month per 100 workers) and work cutback days (31 days per month per 100 workers), in comparison, do not differ significantly across occupations. Work impairment is more strongly concentrated among the 3·7% of the workforce with co-morbid psychiatric disorders (49 work loss days and 346 work cutback days per month per 100 workers) than the 14·5% with pure disorders (11 work loss days and 66 work cutback days per month per 100 workers) or the 81·8% with no disorder (2 work loss days and 11 work cutback days per month per 100 workers). The effects of psychiatric disorders on work loss are similar across all occupations, while effects on work cutback are greater among professional workers than those in other occupations.

Conclusion. The results reported here suggest that work impairment is one of the adverse consequences of psychiatric disorders. The current policy debate concerning insurance coverage for mental disorders needs to take these consequences into consideration.

Background. A cohort study of a socially homogeneous group of teachers was commenced in 1978 to pursue possible risk factors contributing to the recognized female preponderance of depression.

Methods. Multiple measures of depressive experience included: (i) lifetime rates, duration and number of depressive episodes using two caseness definitions, DSM-III-R major depression and ‘all depression’ (which included a category of minor depression); (ii) self-report measures of state and trait depression, neuroticism, and self-esteem. DSM-III-R anxiety disorder rates are also reported and co-morbidity with major depression examined.

Results. At the 15-year review in 1993, the sample had a mean age of 39 years, there was a trend for a female preponderance in lifetime rates of major depression and ‘all depression’ (and which was more pronounced with the inclusion of data for anxiety disorders), with statistically significant differences in rates of social and simple phobias and combined anxiety disorders. Mean neuroticism scores were consistently higher for women.

Conclusions. The strong association between anxiety and depressive disorders suggests that greater reporting of anxiety and higher neuroticism scores in women may be a key determinant that contributes to any female preponderance in depression rates.

Background. In this paper we consider verbal hallucinations as inner speech with pragmatics. The specific pragmatic properties of verbal hallucinations investigated included the number of voices, the characteristics that individuate the voices, the sequential characteristics of the dialogues between voice hearers and their voices, the dialogical positioning of voices hearers, voices and other individuals, and how the voices influence voice hearers' activities.

Methods. These properties were examined in structured interviews with 28 individuals, 14 of whom had a diagnosis of schizophrenia, while 14 were students who did not use psychiatric services.

Results. The analysis showed that voices were most frequently individuated with reference to individuals significant to voice hearers. The talk with voices was typically mundane and related to voice hearers' on-going activities, as is the case for ordinary inner speech. The voices were typically orientated towards the voice hearer, without direct access to each other or to other people. Contrary to received wisdom, the voices typically did not impel actions of voice hearers, rather they influenced voice hearers' decisions on how to act. This was so irrespective of the diagnostic status of informants. Finally, we have found some differences between the voices of informants with, and without, schizophrenia. These concerned the alignment of voices, the type of action required by a voice and the degree of dialogical engagement between voices and voice hearers.

Conclusions. We conclude that verbal hallucinations can be fruitfully considered to be a genus of inner speech. Pragmatics can be used as a framework to distinguish verbal hallucinations in different populations.

Background. This paper is based on a rich archive of 1151 letters by patients, who were admitted to the Royal Edinburgh Asylum during the reign of Thomas Clouston (1873–1908).

Methods. All letters were examined for evidence of psychopathology, and the material obtained was organized under the various psychopathological categories, such as delusions or hallucinations, as defined by Sims (1988).

Results. A descriptive account of patient symptomatology is given. It is found that nineteenth century psychopathology is very similar to that of the modern day, and that most forms of morbid mental phenomena can be found in the patients' letters. More specifically, most of the cardinal symptoms of schizophrenia were described in the patients' correspondence. The letters also illustrate how mental symptoms reflect the cultural and scientific concerns of their time.

Conclusions. The evidence in the patients' letters argues for the unchanging nature of mental illness across time, at least for the last 120 years. It also demonstrates that patients admitted to the Royal Edinburgh Asylum suffered from serious mental illness, and it undermines the view that the Asylum was simply a dumping ground for society's disaffected.

Background. Previous research has suggested that behavioural problems displayed during the pre-school years are best understood as undifferentiated difficulties in manageability. The present study explored this issue, by examining the structure of British parents' ratings of their pre-school children's behavioural problems.

Method. The 19-item Behavioural Checklist (BCL; Richman, 1977) was completed by 1047 parents of 3-year-old children taking part in an epidemiological survey of child development.

Results. Factor analysis revealed six factors representing poor social adjustment, poor emotional adjustment, sleep problems, over-activity/inattention, eating problems and soiling. When these scores were used as a basis for cluster analysis, problem types clustered around six centres. The first, and largest, grouping was of children with no problems. Three further large groupings displayed specific but moderate problems (over-active, timid, and naughty children). The final two groupings displayed more extreme problems including anti-social behaviour. In one group these were accompanied by severe emotional problems and in the other by signs of hyperactivity. The reliability and validity of these clusters was supported. Parental ratings of behaviour problems taken when the children were 8-years-old suggested that the children in the hyperactive/conduct group were likely to have continued difficulties.

Conclusion. This paper argues against the homogeneity of pre-school behaviour problems but supports the idea that problems of a clinically significant level are likely to be co-morbid, with either problems of emotional regulation (neurotic) or those of behavioural regulation (hyperactive) accompanied by problems of conduct.

Background. We report on the change in cognitive function in a population sample of elderly people who have been examined on two occasions more than 3 years apart.

Methods. A sample of 1135 persons aged 70–102 years was interviewed at base-line then reinterviewed 3·6 years later with the Canberra Interview for the Elderly, which included tests of episodic memory and cognitive speed as well as the Mini-Mental State Examination and the National Adult Reading Test (NART).

Results. Mortality and loss to follow-up reduced the sample to 736, of whom 614 completed at least one test of cognitive performance on both occasions. Cognitive performance decreased with age, except on the NART. Decline over the follow-up period increased as a function of age in all cognitive measures, except the NART. Change in cognitive scores was close to normal distribution. Incident dementia was associated strongly with age and current level of cognitive performance, but not with rate of decline. Cognitive decline and the risk of incident dementia did not differ by gender.

Conclusions. A score indicating possible impairment in the very elderly carries a worse prognosis than for the younger elderly. Decline is almost universal in at least one cognitive area among those over the age of 85.

Introduction. Patients with unipolar depression show impaired performance on the Tower of London planning task. Positron emission tomography, which has previously identified resting state blood flow abnormalities in depression, was used to investigate neural activity associated with performance of this task in depressed patients and normal controls.

Methods. Six patients with unipolar depression and six matched controls were scanned while performing easy and hard Tower of London problems in a one-touch computerized paradigm and while performing a perceptuomotor control task.

Results. The patients in this study showed an expected task-related performance deficit compared with normal subjects. In normal subjects, the task engaged a network of prefrontal cortex, anterior cingulate, posterior cortical areas and subcortical structures including the striatum, thalamus and cerebellum. Depressed patients failed to show significant activation in the cingulate and striatum; activation in the other prefrontal and posterior cortical regions was significantly attenuated relative to controls. Crucially, patients also failed to show the normal augmentation of activation in the caudate nucleus, anterior cingulate and right prefrontal cortex associated with increasing task difficulty.

Conclusions. These findings provide evidence for cingulate, prefrontal and striatal dysfunction associated with impaired task performance in depression. The present results are consistent with a central role of cingulate dysfunction in depression as well as suggesting impaired frontostriatal function.

Background. Two recent surveys of depression among Chinese elderly people sampled different populations, used different case ascertainment methods and resulted in a seven-fold difference in prevalence rates. The present study was conducted to compare prevalence rates obtained with two commonly used methods in the same population, and to examine the risk factors for depression.

Methods. The target population included all residents aged 65 years and over in a rural Chinese community. Participants were interviewed for demographic and medical information, examined by a neurologist and administered Chinese versions of the Geriatric Depression Scale-Short Form (GDS-S), the Cognitive Abilities Screening Instrument (CASI) and an Activities of Daily Living (ADL) form. Individuals who screened positive on the GDS-S were also interviewed by a psychiatrist for diagnosis according to the DSM-III-R criteria.

Results. Among the 1313 participants, 26% screened positive on the GDS-S and 13% were diagnosed as having a depressive disorder, including 6·1% with major depression. Individuals with depressive disorders were more likely to have poor ADL scores, lower CASI scores, and chronic physical illnesses. They were also more likely to be female, older, illiterate and without a spouse, but adding these variables did not increase the overall association with the GDS-S score.

Conclusions. Depression was quite common in this Chinese rural geriatric population. The prevalence rate was twice as high when judged by depression symptomatology rather than clinical diagnosis. The critical risk factors were functional impairments, poor cognitive abilities and the presence of chronic physical illnesses.

Background. Several prior studies have found reduced hippocampal volume in victims of psychological trauma with post-traumatic stress disorder (PTSD). We were interested to determine if this finding was evident in women who were victimized by severe sexual abuse in childhood.

Methods. In this study, hippocampal volume was measured using quantitative magnetic resonance imaging (MRI) in 21 women who reported being severely sexually abused in childhood and 21 socio-demographically similar women without abuse histories.

Results. Women who reported sexual victimization in childhood had significantly reduced (5% smaller) left-sided hippocampal volume compared to the non-victimized women. Hippocampal volume was also smaller on the right side, but this failed to reach statistical significance. Left-sided hippocampal volume correlated highly (rs=−0·73) with dissociative symptom severity, but not with indices of explicit memory functioning.

Conclusions. These findings, which are generally consistent with prior reports of reduced hippocampal volume in combat veterans with PTSD, suggest that diminished hippocampal size may be either a consequence of trauma exposure or a risk factor for the development of psychiatric complications following trauma exposure. The observed relationship between symptom severity and hippocampal volume suggests that mesial temporal lobe dysfunction may directly mediate certain aspects of PTSD and dissociative disorder symptomatology.

Background. Diagnostic Related Groups (DRGs) and Healthcare Resource Groups (HRGs) do not predict accurately length of stay or resources needed for treatment in psychiatry. This preliminary study assessed the relative contribution of severity of illness, in combination with other variables, in predicting length of stay.

Method. Data were analysed on 115 consecutive admissions to a district psychiatric in-patient unit to assess the variables which most accurately predict length of stay. The variables included demographic data, diagnosis, clinical, social and behavioural measures.

Results. For initial admission, diagnosis of neurosis predicted shortest stay, but diagnosis alone accounted for only 14·6% of the variation in length of stay. Addition of Social Behaviour Scale score, living alone and specific psychiatric symptoms significantly increased the predictive value (adjusted R2=36·6%). Addition of variables available at discharge (use of ECT, major tranquillizers and antidepressants) significantly increased the adjusted R2 to 49·0%. Prediction of total length of hospitalization over a 12-month period, from the date of initial admission, indicated that mania predicted the longest stay and addition of other variables meant that only 18·9% of length of stay was predicted.

Conclusion. If these results are borne out in a larger study, they indicate that diagnostic or health related groups (DRGs) are only likely to be useful in psychiatry if they include more detailed social, clinical and behavioural variables.