Background. An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient.

Methods. A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps.

Results. Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24·2 (8·8–66·6). The population attributable fraction (PAF) for depression attributable to handicap was 0·78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone.

Conclusions. Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

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. It has been suggested that the expression of psychosis may reflect an active morbid process that is associated with increasingly poor outcome unless ameliorated by antipsychotic drugs.

Methods. The subjects of this study were 48 in-patients with schizophrenia, many of whom had been admitted before the introduction of antipsychotic drugs to rural Irish psychiatric hospitals in the late 1950s. Each patient was assessed for positive and negative symptoms, and for general and executive (frontal) cognitive function.

Results. After controlling for age and for duration and continuity of subsequent antipsychotic treatment, current severity both of negative symptoms and of general cognitive impairment was predicted strongly by increasing duration of initially untreated psychosis; duration of illness following initiation of antipsychotic medication failed to predict the severity thereof. Neither of these indices of illness duration predicted the severity of positive symptoms or of executive dyscontrol.

Conclusions. Increasing duration of initially untreated psychosis was associated specifically with heightened accrual of prominent negative symptoms and general cognitive impairment. Executive dyscontrol, though also prominent in these patients, may be ‘locked-in’ at an earlier phase of the illness.

Background. Since depressive disorders are now eminently treatable and early detection and treatment could bring substantial benefits, it is critical to address alternative presentations of depression in the general medical setting. Concern regarding under-diagnosis of depression in general medical settings has given rise to the question of whether the clinical disorder of depression differs qualitatively or only quantitatively across care settings.

Methods. Symptom profiles of depression were compared across care sectors to investigate how the presentation of depression among general medical service users might differ qualitatively from speciality mental health service users. Data on depression symptoms within 6 months of interview gathered in three community surveys that were part of the NIMH Epidemiologic Catchment Area Program were analysed using methods developed to assess item bias. The subjects were 4931 and 363 persons who reported a visit to the general medical sector or to speciality mental health respectively, within 6 months of interview.

Results. Compared with speciality mental health service users, general medical service users were less likely to present dysphoria (adjusted Odds Ratio, aOR=0·57; 95% Confidence Interval, CI=0·38–0·84) and feeling worthless, sinful, or guilty (aOR=0·63; 95% CI=0·40–0·98), but were more likely to present fatigue (aOR=1·71; 95% CI=1·09–2·69), even after holding constant other characteristics that might influence reporting of symptoms as well as level of depression.

Conclusions. These results suggest that there are qualitative differences in depression presenting in general medical care compared with speciality mental health care and call for a reconceptualization of depression in the general medical setting.

Background. Experimentally induced depressed mood is a suggested model for retarded depression. We describe the neural response associated with induced mood and the locus of the interaction between systems mediating mood and cognitive function.

Methods. Normal subjects performed a verbal fluency task during induced elated and depressed mood states. Regional cerebral blood flow (rCBF) was measured as an index of neural activity using Positron Emission Tomography (PET).

Results. In both elated and depressed mood state rCBF was increased in lateral orbitofrontal cortex, rCBF was also increased in the midbrain in elated mood. In the depressed condition rCBF was decreased in rostral medial prefrontal cortex. Verbal fluency produced an expected increase of rCBF in left dorsolateral prefrontal, inferior frontal and premotor cortex, anterior cingulate and insula cortex bilaterally, the left supramarginal gyrus posteriorly and the thalamus. Activation in the verbal fluency task was attenuated throughout the left prefrontal, premotor and cingulate cortex and thalamus in both elated and depressed mood conditions. An attenuation of anterior cingulate activation was specific to depressed mood.

Conclusions. Alteration of mood is associated with activation of orbitofrontal cortex which may be critical to the experience of emotion. The mood induced modulation of verbal fluency induced activations is consistent with resting state findings of decreased function in these regions in depressed patients. The present data suggest that resting state rCBF profile may represent the modulation of spontaneous activity in this network by a core system that is dysfunctional in depression.

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.

In a prospective cohort study of consecutive primary care attenders in south London, the estimated prevalence of non-psychotic psychiatric disorder was 45·6%, using the Revised Clinical Interview Schedule (CIS-R). The estimated 12-month incidence rate was 15·7%. Extremely high stability was found in CIS-R scores over 12 months (r = 0·65) and 68·8% of cases at baseline were also cases 12 months later. A clear difference emerged in the types of risk factor which were associated with the incidence and maintenance of disorder in the study population: while socio-economic variables, especially low household income and not having a partner were associated with a worse outcome among prevalent cases at baseline, such variables were only weakly associated with the incidence of psychiatric disorder after adjusting for potential confounders. The latter, notably family psychiatric history and the severity of psychiatric symptoms at baseline were independently associated with the incidence of psychiatric disorder after adjusting for other risk factors, including measures of previous psychiatric disorder.

Background. A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focusses on the cross-sectional relationship between depression and demographic variables, social support, and life events.

Method. A community survey of all residents over the age of 65 years of an electoral district in London, UK.

Results. There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12·4 (7·6–20·0).

Conclusions. Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

Background. The Parental Bonding Instrument (PBI) is a widely used measure of parenting, and is usually used to measure two parenting dimensions, care and over-protection. However, there is disagreement in the research literature about whether the PBI is best used as a two-factor or a three-factor measure.

Method. PBI scores from 583 US and 236 UK students were factor analysed to assess whether a three-factor solution was more satisfactory than a two-factor solution.

Results. A three-factor (care, denial of psychological autonomy and encouragement of behavioural freedom) solution was found to be more satisfactory than a two-factor solution. Using the three-factor solution, group differences that were not apparent with the two-factor solution were identified and it was found that the parenting behaviours associated with depression could be more accurately identified.

Conclusion. The authors suggest that with modifications, the PBI could be used to measure three parenting variables (care, denial of psychological autonomy and encouragement of behavioural freedom), which would allow greater accuracy of prediction and a greater understanding of underlying processes.

Patients with chronic fatigue syndrome (CFS) complain that they have difficulties with concentration and memory but studies to date have not found consistent objective evidence of performance deficits. Two groups of CFS patients, depressed and non-depressed, and healthy controls, were asked about concentration problems in general and specifically when reading. CFS subjects were more likely than controls to report that they had concentration problems when reading, that they needed to re-read text and that they failed to take in what they were reading. Subjects then performed a task in which their reading behaviour and text recall was measured. While all CFS subjects complained of general cognitive failures and of difficulties with reading, only depressed CFS subjects recalled significantly less of the text than controls. Severity of complaints about reading problems was not related to amount of text recalled, but was related to severity of depressed mood. However, subjects were able to evaluate accurately their ability to remember the text immediately after reading it and before being tested for recall. Additionally, subjects performed a paired-associate learning task on which no significant differences between the subject groups was found. It is concluded that deficits in cognitive functioning in CFS patients are more likely to be found on naturalistic than on laboratory tasks.

Background. The study attempts to recruit well known ‘cognitive’ event related potential measures as an objective estimate of cognitive and specific memory impairment in schizophrenia.

Methods. We examined 19 schizophrenic patients and 28 healthy controls using an auditory discrimination task to elicit event related potentials, and a number of neuropsychological tests, including tests of general intellectual ability, putative frontal lobe function and verbal memory.

Results. The late positive deflection presumed to be associated with stimulus evaluation (P300) was of lower amplitude and had a longer latency in the patients compared with controls of similar age and sex. We found correlations between P300 amplitude and latency, and neuropsychological performance scores in patients. There were correlations between decreased P300 amplitude and lower IQ and poorer memory performance, in particular, abnormal semantic clustering, discriminability and intrusion errors. Increased P300 latency was correlated with lower pre-morbid IQ, poorer total memory scores and serial clustering, but paradoxically less relative retrieval deficit and fewer intrusion errors.

Conclusions. These findings suggest that abnormal P300 is generally more likely to occur in patients with memory impairment.

Background. This study aimed to quantify the association between low IQ and the later development of psychosis in a population-based cohort study of 18-year-old conscripts.

Methods. Fifty thousand males conscripted into the Swedish army in 1969–1970 were followed by means of the Swedish National Register of Psychiatric Care up to 1983. Tests of verbal and visuospatial abilities, general and mechanical knowledge and several psychosocial variables were recorded at conscription.

Results. One hundred and ninety-five subjects were admitted to hospital with schizophrenia and 192 with a non-schizophrenic psychosis on ICD-8 criteria. The distribution of scores in those later diagnosed as suffering from schizophrenia was shifted in a downward direction, with a linear relationship between low IQ and risk. This remained after adjustment for potential confounders. The risk for non-schizophrenic disorders was also higher in those with lower IQ but the effect was less marked and non-linear. Only poorer performance on the verbal tasks and mechanical knowledge test conferred a significantly increased risk for schizophrenia after taking into account general intellectual ability. Low IQ at conscription was not related to age of onset.

Conclusions. The results confirm the importance of low intellectual ability as a risk factor for schizophrenia and other psychoses. This is unlikely to be due to prodromal decline or known confounders. The association could be directly causal with cognitive impairment leading to false beliefs and perceptions, or could be indirect with any factors causing lower IQ, such as abnormal brain development increasing the risk for schizophrenia.

Background. This study describes the differences in psychological distress, disability and psychosocial resources between types of major medical conditions and sensory impairments (collectively denoted as CMCs); and tests whether disability and psychosocial resources mediate CMC-specific mental health effects.

Methods. Data were obtained from a population-based, cross-sectional survey of 5078 non-institutionalized, late middle-aged and older Dutch persons. The predictors were 16 types of CMCs, including all major chronic medical diseases as well as impairment of hearing, vision, and cognition. The outcomes were assessed in terms of psychological distress as measured by the Hospital Anxiety and Depression Scale. Two aspects of disability were measured (namely, physical and role functioning) and also three psychosocial resources (namely, mastery, self-efficacy and social support).

Results. Level of psychological distress varied across type of CMC. Hearing impairment, neurological disease, vision impairment, and lung and heart disease had particularly strong associations with distress. The level of distress in patients with hearing impairment was 0·45 standard deviation higher than in those without hearing impairment (adjusted for demographics and all other CMCs). Roughly similar patterns of association were found between type of CMC and disability, and also, but to a lesser extent, mastery and self-efficacy. Stepwise multiple regression revealed that type of CMC accounted for 9%of the variance in distress initially, but this fell to 1% after the variance due to disability, mastery and self-efficacy was taken out. Social support was not a mediator. Disability and psychosocial resources accounted for 13% and 14% of the variance in distress, respectively.

Conclusion. These results support the conventional wisdom that it is not the nature of the condition that determines psychological distress, but instead the severity of the disability and loss of psychological resources associated with the condition on the one hand and the psychological characteristics of the patient on the other.

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. Data are presented on the general population epidemiology of DSM-III-R bipolar I disorder in the United States.

Methods. Data come from the US National Comorbidity Survey (NCS), a general population survey of DSM-III-R disorders. A modified version of the Composite International Diagnostic Interview was used to make diagnoses.

Results. A small (N=59) clinical reappraisal study showed that the only manic symptom profile that could validly be assessed with the CIDI is characterized by euphoria, grandiosity and the ability to maintain energy without sleep, which described approximately half of all clinically validated bipolar I cases in the NCS. Further analysis focused on this symptom profile, which involved N=29 cases in the total sample. Lifetime prevalence was estimated to be 0·4% and 12-month prevalence only slightly lower. Caseness was negatively related to income, education and age, positively related to urbanicity, and elevated among the previously married, never married and non-whites. All cases reported at least one other NCS/DSM-III-R disorder and 59·3% reported that their episode of bipolar disorder (either mania or depression) occurred at a later age than at least one other NCS/DSM-III-R disorder. Although 93·2% of lifetime cases reported some lifetime treatment, only 44·7% of recent cases were in treatment.

Conclusions. The type of bipolar disorder examined here is highly chronic, co-morbid and impairing. Increased efforts are required to attract current cases into appropriate treatment. Methodological research is needed to develop more accurate measures of other bipolar symptom profiles for use in general population epidemiological studies.

Background. The study examines the effect of an auditory discrimination task on regional brain perfusion in schizophrenic patients.

Methods. Twenty patients were examined with single photon emission tomography (SPET), both resting and performing an auditory two-tone ‘oddball’ discrimination task. Statistical parametric mapping (SPM'95) was used to identify local activation effects and correlations between event related potential measures and regional perfusion.

Results. Compared with rest, patients activated left superior temporal gyrus during the task, together with right caudate. There was a (negative) correlation between P300-amplitude and perfusion during the activation procedure in both caudate nuclei and in the left lingual gyrus. No correlations were observed with P300-latency. Compared with healthy volunteers examined in earlier studies, our patients showed no frontal activation. This might be due to slightly different task demands in this study, but more likely to activation-hypofrontality in schizophrenic patients compared with controls.

Conclusion. Auditory discrimination tasks can be used in schizophrenic patients to control their ‘mental set’ during brain perfusion studies with SPET. This approach can yield information about specific brain mechanisms associated with such tasks, and may make comparison with healthy volunteers easier.

Background. Most research on syndromes of chronic fatigue has been conducted in clinical settings and is therefore subject to selection biases. We report a population-based incidence study of chronic fatigue (CF) and chronic fatigue syndrome (CFS).

Methods. Questionnaires assessing fatigue and emotional morbidity were sent to 695 adult men and women who had replied to a postal questionnaire survey 1 year earlier. Possible CFS cases, subjects with probable psychiatric disorder and normal controls were interviewed.

Results. Baseline fatigue score, the level of emotional morbidity and a physical attribution for fatigue were risk factors for developing CF. However, after adjusting for confounding, pre-morbid fatigue score was the only significant predictor. A minority of CF subjects, all female, had consulted their general practitioner; higher levels of both fatigue and emotional morbidity were associated with consultation. Possible CFS cases reported similar rates of current and past psychiatric disorder to psychiatric controls, but after controlling for fatigue or a diagnosis of neurasthenia the current rates were more similar to those of normal controls. Two new cases of CFS were confirmed.

Conclusions. Both fatigue and emotional morbidity are integral components of chronic fatigue syndromes. The demographic and psychiatric associations of CFS in clinical studies are at least partly determined by selection biases. Given that triggering and perpetuating factors may differ in CFS, studies that examine the similarities and differences between chronic fatigue syndromes and psychiatric disorder should consider both the stage of the illness and the research setting.

Background. There has been a widespread development of community multi-disciplinary teams aimed to deliver coordinated comprehensive mental health care, yet there is little published evidence on the quality of care and economics of providing such care for people with severe mental illness.

Method. This is a clustered randomized controlled economic comparison of the quality of care for patients with chronic schizophrenia by a multi-disciplinary community team with close links with primary care, and a traditional psychiatric service in a district general hospital psychiatric unit.

Results. Two years after it was established, patients with access to the community team had more of their needs met; they had fewer unmet needs; and they were more satisfied with the care they had received. They had more service contacts and received more interventions. The community team resulted in savings in the use of some hospital resources but these were not sufficient to offset the cost of the new service. The community team successfully directed care to patients with more needs, whereas no such relationship was evident for the traditional hospital-based service. Four years after the team was established, it met a greater proportion of needs for underactivity, daily living skills, use of public amenities and managing finances.

Conclusions. Better quality care was provided at 2 and 4 years after its establishment by the multi-disciplinary community service than the traditional hospital-based service. Resources were targeted more efficiently by the community service.

Data from a two-wave longitudinal study of an elderly community sample were used to assess whether cognitive complaints either predict subsequent cognitive decline or reflect past cognitive decline. Cognitive complaints and cognitive functioning were assessed on two occasions three and a half years apart. Cognitive complaints at Wave 1 were found not to predict future cognitive change on the Mini-Mental State Examination, an episodic memory test or a test of mental speed. Similarly, cognitive complaints at Wave 2 were unrelated to past cognitive changes on these tests after statistically controlling for the effects of anxiety and depression. Furthermore, cognitive complaints did not predict either mortality (after controlling for anxiety and depression) or future dementia. These results are evidence against the inclusion of cognitive complaints in diagnostic criteria for proposed disorders such as age-associated memory impairment, mild cognitive disorder and ageing-associated cognitive decline.