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. In 1975, a special commission appointed by the German Parliament submitted its report on the desolate state of psychiatric care in the old Federal Republic of Germany including suggestions for much-needed reforms. Among them was a call for the reduction of existing prejudices against mentally ill people. This study addresses the question as to what attitude is commonly found among the general public towards the mentally ill nowadays, two decades after the first step towards reform in psychiatric care and focuses on social distance.

Methods. Between spring 1990 and the end of 1993, a total of 11 representative surveys were carried out in Germany, eight of them in the former Federal Republic, or the old Länder.

Results. Even today, mentally ill people are met with a great deal of rejection by the German public. Alcohol dependants are rejected most, even more so than those suffering from schizophrenia. Personal experience with mental illness is associated with a lower level of derived social distance, which may be attributed to an increase in positive emotional reactions and reduced feelings of anxiety. There is an association between a person's attitude towards the mentally ill and his/her overall value orientation.

Conclusions. Although, for methodological reasons, we are not able to show a significant change in attitude in the wake of the reform in psychiatric care, our results lend support to one of the basic assumptions of community psychiatry, namely the premise that personal contact with the mentally ill can help to reduce feelings of resentment towards the latter.

Background. The purpose of this experiment was to investigate mechanisms underlying commonly-observed verbal memory impairments in schizophrenia, and especially the hypothesized encoding deficit.

Methods. A verbal memory task was administered to 38 patients with schizophrenia and 38 normal controls. Three functions involved in long-term memory – encoding, early phase of storage, retrieval – were investigated. First, non-organizable lists were compared to semantically-organizable lists in a free recall task, in order to vary encoding conditions. Superficial encoding (measured by a ‘sequence’ index) and deep encoding (measured by a categorization index) were assessed. Secondly, early storage was investigated by varying the delay between learning and recall. Lastly, cues were provided for organizable lists (semantic cues) and non-organizable lists (recognition sheet), in order to vary retrieval conditions.

Results. An analysis of variance revealed an interaction between type of list (organizable, non-organizable) and group, showing that patients used organization less than controls. A further analysis showed that deep encoding was impaired. Also, although the propensity to use superficial encoding was unimpaired, its efficiency was less. The analysis of variance revealed no interaction with delay or with either type of cue. A correlation was found between deep processing and memory performance in both groups.

Conclusions. A major deficit in encoding appeared in the patient group, with a lesser use of deep encoding and a lesser efficiency of superficial encoding. On the other hand, the early phase of storage and the retrieval function seemed unaffected. Overall memory performance appeared to be related to the depth of encoding.

Background. Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested.

Methods. The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression.

Results. Overall, 26·7% of adults in our sample with MDD met criteria for SP and 28·4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54·8%) compared with those with neither SP nor APD (31·1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of co-morbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness.

Conclusions. Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.

Background. In this study, we tested the hypothesis that low smooth pursuit gain in schizophrenia is related to an abnormality in motion perception.

Methods. The subjects were 19 schizophrenics treated with clozapine and 19 controls. In addition to smooth pursuit and motion perception paradigms, sustained attention was also assessed using a continuous performance task (CPT).

Results. In the patient group, there was a statistically significant negative correlation between smooth pursuit gain and motion perception threshold (r =−0·60, P<0·01). This relationship was not secondary to attention deficits as assessed by the CPT.

Conclusions. Our results are consistent with the notion that the smooth pursuit gain deficit is related to a deficit in motion perception rather than in attention. Brain area V5 (also referred to as ‘MT’ in macaque), located in the parieto-occipital region, is known to be critically important both for motion perception and gain. Thus, our results point to an abnormality in this area in schizophrenia.

Background. A relationship between the anticonvulsant and antidepressant properties of electroconvulsive therapy (ECT) has been hypothesized. The goal of this study was to see whether the anticonvulsant effects of ECT could be measured in a clinical setting and whether there was any relationship between the anticonvulsant effects of ECT and the antidepressant response to it.

Methods. We examined the temporal relationship between change in seizure duration (as an index of anticonvulsant activity) and improvement in Hamilton Rating Scale for Depression scores in a retrospective sample of 114 depressed patients who received 145 courses of ECT. A linear mixed effects model was utilized for analysis so that the repeated measures nature of the data could be taken into account.

Results. Both seizure duration and depression scores decreased significantly through the course of ECT. However, no evidence was found for a relationship between decrease in seizure duration and clinical improvement as measured by Hamilton ratings.

Conclusions. The process underlying the reduction in seizure duration through a course of ECT may not be related to antidepressant efficacy.

Background. Little is known about the extent and correlates of unmet need for mental health services in community samples of children and adolescents.

Methods. Data were obtained from the 1285 parent/youth pairs interviewed at four sites in the USA and Puerto Rico in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Unmet need was defined to exist if psychopathology and associated functional impairment were present but no mental health services had been received in the previous 6 months.

Results. Of the total sample, 17·1% had unmet need. Adjusting for demographic variables, logistic regression analyses revealed that unmet need was significantly associated with: indicators of economic disadvantage, such as being on public assistance and not being covered by health insurance; opinions of the parents and children or adolescents that the latter had poor mental health; parental psychopathology; poor school grades; and parent-reported access barriers such as concern that the child would want to solve the problem unassisted, would refuse to attend mental health services, or would be hospitalized or taken away against the parent's will. No youth-reported access barriers were significantly associated with unmet need.

Conclusions. The economic correlates of unmet need may attain increased importance in the light of current reform in health care financing in the USA. Access may be facilitated by increasing parental knowledge of mental health services and enabling children and adolescents to initiate contact with services independently of their families.

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. There is little agreement on whether the prevalence of psychiatric disorder is elevated in HIV-seropositive (HIV +) populations compared with uninfected persons. However, evaluation of this issue has been limited by difficulties of sampling, study design and failure to control for other risk factors for disorder.

Methods. Prevalence and clinical characteristics of DSM-III-R major depressive disorder (MDD), generalized anxiety disorder, adjustment disorder, and alcohol and substance abuse/dependence were evaluated in a representative sample of HIV + men attending primary care physicians' offices in a defined geographical area. Lifetime prevalence at baseline and 1-year rates during longitudinal follow-up were determined for the 113 HIV + men, as well as 57 HIV – men, via standardized interview. Multivariate analyses considered unique and combined effects of HIV serostatus and other risk factors on likelihood of disorder.

Results. Although there were no differences in lifetime rates prior to baseline, HIV + men were at greater risk for disorders during the prospective study period. For MDD, this effect was maintained even after controlling for other risk factors. Several of these other factors bore their own effects: regardless of HIV serostatus, men were susceptible to psychopathology if at baseline they were younger, had a lifetime psychiatric history, or had poor social supports or a low sense of personal mastery.

Conclusions. The risk of certain psychiatric disorders appears uniquely elevated in HIV + men. Since other factors also influence risk, interventions designed to minimize psychopathology during HIV infection should attend to both HIV-related and non-HIV-related risk factors.

Background. Cognitive neuropsychological theories hypothesize a role for frontal lobe executive deficits in the aetiology of schizophrenic symptoms. The study examined the performance of a schizophrenic group on the Behavioural Assessment of the Dysexecutive Syndrome (BADS; Wilson et al. 1996), a test battery which assesses the ‘everyday’ difficulties associated with the dysexecutive syndrome. Performance of the schizophrenics was contrasted with that of brain injured and healthy volunteer groups.

Methods. Matched groups of 31 schizophrenic patients, 35 patients with brain injuries and 26 healthy volunteers were administered the BADS. Patients were also given tests of general intelligence and memory. Patients and their relatives/carers also completed a questionnaire rating day-to-day failures of executive functioning.

Results. Schizophrenic and brain-injured patients showed impairment on the BADS, compared to healthy controls. There were no significant differences between the two patient groups. Significant impairment was found in a subgroup of 16 schizophrenics who showed otherwise intact general intellectual functioning, suggesting the existence of a specific executive deficit. Among the schizophrenic patient group there was evidence of a dissociation between executive and memory impairments. A significant correlation existed between performance on the BADS and relatives ratings of executive problems for the brain injured group, but not for the schizophrenic group.

Conclusions. The BADS is a useful tool for identifying executive deficits in people with a diagnosis of schizophrenia, especially those who are otherwise generally intellectually intact. This is particularly important in the context of rehabilitation and community transition programmes.

Background. Past research and instrument development in caregiving have focused on specific aspects of caregiving or specific disability groups. This paper reports the scale characteristics of a new generic instrument developed to assess the experience of caregiving, and the social and emotional well-being of caregivers and a comparison group of ‘non-caregivers’.

Methods. Using computer-assisted telephone technology, a random survey of 26000 households was conducted in Victoria, Australia to identify and interview 976 caregivers of people who were aged or had a long-term illness or disability of any kind, and 219 non-caregivers. Both groups were re-interviewed after 15 months. Scales administered on each occasion to caregivers and non-caregivers included life satisfaction, positive and negative affect, social support and overload; and to caregivers, caring role satisfaction, resentment and anger, and, in relation to the care recipient, measures of help provided and needed, severity of disability and behaviour problems.

Results. On each occasion and with each sample all scales demonstrated a satisfactory reliability. With a subsample of caregiver–care–recipient dyads (N = 67), caregiver reports of severity of disability, level of helped needed and provided were validated externally by clinician assessments.

Conclusions. A comprehensive instrument to assess the experience of caregiving was developed. It is relevant to a broad range of ages, levels and types of disability and care provided; and, in assessing health and well-being, to both caregivers and non-caregivers. Scales, including both positive and negative dimensions, have demonstrated good internal consistency on two occasions. The instrument is potentially useful in a range of research and practical settings.

Background. Although replication is the heart of science, psychiatric geneticists rarely have the opportunity to replicate findings, especially more than once.

Methods. This article reviews results from three independent family studies of schizophrenia on which one of us conducted diagnostic reviews: the Danish Adoption Study (DAS), the Iowa 500 non-500 family study (IFS), and the Roscommon Family Study (RFS). We utilized DSM-III or DSM-III-R criteria and meta-analysis techniques.

Results. The odds ratios (OR) in personally interviewed, first degree biological relatives of schizophrenic and matched control probands for schizophrenia, other non-affective psychoses (ONAP), schizotypal personality disorder (SPD), unipolar affective illness (UPAI), bipolar affective illness (BPAI), and anxiety disorders were homogeneous across studies. For alcoholism, ORs were significantly heterogeneous. Schizophrenia, SPD and ONAP strongly aggregated in relatives of schizophrenic probands with decreasing common OR estimates of 16·2, 5·0 and 4·0, respectively. The common OR for anxiety disorders was 1·1, indicating no familial co-aggregation. For UPAI and BPAI, the common ORs exceeded unity (1·3 and 1·9, respectively), although only the former was statistically significant.

Conclusions. Schizophrenia strongly aggregates in families and shares familial factors with SPD and ONAP but not anxiety disorders. The familial factors of aetiological importance for schizophrenia and affective illness may be weakly related. With the exception of alcoholism, the patterns of psychiatric disorders in relatives of schizophrenic and control probands in these three studies were sufficiently similar that, despite their methodological differences, they can probably be viewed as replications of one another.

Background. Evidence suggests that schizophrenia may be a disorder with origins in early intrauterine mal-development. We have constructed a comprehensive anthropometric scale for the evaluation of dysmorphic features as an index of the nature and timing of developmental disturbance.

Method. A detailed set of craniofacial and bodily measures was compiled and applied to 174 patients with schizophrenia and 80 matched control subjects.

Results. Patients had significantly higher scores on this scale and displayed multiple anomalies of the craniofacial region with an overall narrowing and elongation of the mid-face and lower face. Twelve craniofacial anomalies independently distinguished patients from controls and these variables correctly classified 95% of patients and 80% of control subjects.

Conclusions. This new scale, while procedurally more exacting than the Waldrop scale, more clearly defines the topography of anomalies previously suspected in individuals with schizophrenia. These findings constitute direct evidence for disturbed craniofacial development in schizophrenia and indicate origins in the foetal period during which the characteristic human facial pattern evolves in close association with brain differentiation.

Background. Genetic influences on alcoholism risk are well-documented in men, but uncertain in women. We tested for gender differences in genetic influences on, and risk-factors for, DSM-III-R alcohol dependence (AD).

Method. Diagnostic follow-up interviews were conducted in 1992–3 by telephone with twins from an Australian twin panel first surveyed in 1980–82 (N=5889 respondents). Data were analysed using logistic regression models.

Results. Significantly higher twin pair concordances were observed in MZ compared to DZ same-sex twin pairs in women and men, even when data were weighted to adjust for over-representation of well-educated respondents, and for selective attrition. AD risk was increased in younger birth cohorts, in Catholic males or women reporting no religious affiliation, in those reporting a history of conduct disorder or major depression and in those with high Neuroticism, Social Non-conformity, Toughmindedness, Novelty-Seeking or (in women only) Extraversion scores; and decreased in ‘Other Protestants’, weekly church attenders, and university-educated males. Controlling for these variables, however, did not remove the significant association with having an alcoholic MZ co-twin, implying that much of the genetic influence on AD risk remained unexplained. No significant gender difference in the genetic variance in AD was found (64% heritability, 95% confidence interval 32–73%).

Conclusions. Genetic risk-factors play as important a role in determining AD risk in women as in men. With the exception of certain sociocultural variables such as religious affiliation, the same personality, sociodemographic and axis I correlates of alcoholism risk are observed in women and men.

Background. In post-traumatic stress disorder (PTSD) there is a need for self-rating scales that are sensitive to treatment effects and have been tested in a broad range of trauma survivors. Separate measures of frequency and severity may also provide an advantage.

Methods. Three hundred and fifty-three men and women completed the Davidson Trauma Scale (DTS), a 17-item scale measuring each DSM-IV symptom of PTSD on 5-point frequency and severity scales. These subjects comprised war veterans, survivors of rape or hurricane and a mixed trauma group participating in a clinical trial. Other scales were included as validity checks as follows: Global ratings, SCL-90-R, Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for DSM-III-R.

Results. The scale demonstrated good test–retest reliability (r = 0·86), internal consistency (r = 0·99). One main factor emerged for severity and a smaller one for intrusion. In PTSD diagnosed subjects, and the factor structure more closely resembled the traditional grouping of symptoms. Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity was obtained. The DTS showed predictive validity against response to treatment, as well as being sensitive to treatment effects.

Conclusions. The DTS showed good reliability and validity, and offers promised as a scale which is particularly suited to assessing symptom severity, treatment outcome and in screening for the likely diagnosis of PTSD.

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.

Background. It has been well established in the literature that a strong genetic component exists for schizophrenia. Available data are compatible with the hypothesis that for most cases of schizophrenia, the genetic component consists of multiple genes acting in an additive manner with the genotype for schizophrenia being present when the number of genes is greater than a threshold number. Twin studies suggest that the genotype for schizophrenia is unexpressed in some individuals who carry it. This phenomenon of reduced penetrance has led to a diversity of hypotheses concerning the aetiology of schizophrenia. Based on a review of the literature a neuro-developmental model is proposed for schizophrenia that involves the actions of the schizophrenia genotype, canalization and stochastic events.

Conclusions. The schizophrenia genotype is programmed to disrupt the migration of neuronal cells in the developing cortex during the second trimester, resulting in impaired embryogenesis. The presence of a specific lesion is the reason for the onset of schizophrenia later in life. The genotype for schizophrenia often remains unexpressed, or demonstrates variable expressivity, because of the actions of canalization and stochastic events that may allow migrating neuronal cells to reach or approach the target data. Stochastic events also influence whether canalization will be successful, therefore, chance plays a major role under normal conditions in determining whether the schizophrenia genotype will be expressed. Certain environmental factors acting during early development, such as high temperatures resulting from maternal illness, may increase the penetrance of the schizophrenia genotype.

Background. Negative associations between religion and suicide, in individuals and countries, may be mediated by the degree to which suicide is tolerated.

Methods. Linear regression was used to examine ecological associations between suicide tolerance, religion and suicide rates in 19 Western countries in 1989/90. Logistic regression was used to study associations between suicide tolerance and strength of religious belief in 28085 individuals in these countries. The concept of effect modifying function was used to examine whether the strength of the association between suicide tolerance and religious belief in individuals depended on the extent of religious belief in their country.

Results. Higher female suicide rates were associated with lower aggregate levels of religious belief and, less strongly, religious attendance. These associations were mostly attributable to the association between higher tolerance of suicide and higher suicide rates. In the 28085 subjects suicide tolerance and the strength of religious belief were negatively associated even after adjustment for other religious and sociodemographic variables and general tolerance levels (odds ratios: men 0·74 (95% CI 0·58–0·94), women 0·72 (95% CI 0·60–0·86)). This negative individual- level association was more pronounced in more highly religious countries but this modifying effect of the religious context was apparent for men only.

Conclusions. Ecological associations between religious variables and suicide rates are stronger for women than men, stronger for measures of belief than observance and mediated by tolerance of suicide. In individuals, stronger religious beliefs are associated with lower tolerance of suicide. Personal religious beliefs and, for men, exposure to a religious environment, may protect against suicide by reducing its acceptability.

Background. The consequences of major depression for disability, impaired well-being and service utilization have been studied primarily in younger adults. In all age groups the consequences of minor depression are virtually unknown. In later life, the increased co-morbidity with physical illness may modify the consequences of depression, warranting special study of the elderly. With rising numbers of elderly people, excess service utilization by depressed elderly represents an increasingly important issue.

Methods. Based on a large, random community-based sample of older inhabitants of the Netherlands (55–85 years), the associations of major and minor depression with various indicators of disability, well-being and service utilization were assessed, controlling for potential confounding factors. Depression was diagnosed using a two-stage screening design. Diagnosis took place in all subjects with high depressive symptom levels and a random sample of those with low depressive symptom levels. The study sample consists of all participants to diagnostic interviews (N=646).

Results. As in younger adults, associations of both major and minor depression with disability and well-being remained significant after controlling for chronic disease and functional limitations. Adequate treatment is often not administered, even in subjects with major depression. As the vast majority of those depressed were recently seen by their general practitioners, treatment could have been provided in most cases. Bivariate analyses show that major and minor depression are associated with an excess use of non-mental health services, underscoring the importance of recognition. In multivariate analyses the evidence of excess service utilization was less compelling.

Conclusions. Both major and minor depression are consequential for well-being and disability, supporting efforts to improve the recognition and treatment in primary care. However, controlled trials are necessary to assess the impact this may have on service utilization.

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.