This paper presents a structured review of the published information on the mortality of schizophrenia.

A meta-analysis of the literature.

Schizophrenia has a significantly increased mortality from natural and unnatural causes. Twenty-eight percent of the excess mortality is attributable to suicide and 12% to accidents. The rest of the excess mortality is from the same broad range of conditions which cause deaths in the general population. Further interpretation is hampered by confounding variables, wide confidence intervals and reservations about generalising from individual cohorts.

The available evidence suggests that schizophrenia is associated with a large increased mortality from suicide and a moderate increased mortality from natural causes. A number of possible interventions have been identified, but we do not yet have reliable means of detecting any changes in mortality which might result.

Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies – public and private – as well as for patients, families and the wider society.

The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.

Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of £2.6 billion, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.

Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.

It is widely suggested that many National Health Service (NHS) workers experience high levels of minor psychiatric disorder. However, inadequacies of sampling and measurement in studies to date have not allowed this suggestion to be properly evaluated.

The present study was designed to overcome these methodological weaknesses by using a sample of over 11 000 employees from 19 NHS trusts and a well-established measure of minor psychiatric disorder for which there are comparative data.

The findings show that 26.8% of the health service workers reported significant levels of minor psychiatric disorder, compared with 17.8% of people in the general population. Psychiatric morbidity was highest among managers, doctors, nurses and professions allied to medicine, with each of these groups recording higher rates than their professional counterparts outside the health service. It was lower among those in support occupations, such as administrative and ancillary staff. A feature of the findings was that female doctors and managers showed a much higher prevalence of minor psychiatric disorder than their male colleagues.

Studies are required to establish the organisational, occupational and individual determinants of minor psychiatric disorder among NHS employees.

Psychiatric morbidity studies in developing countries have used diagnostic procedures of low reliability, without a clinical definition of caseness, producing descriptive data with limited application for mental health planning.

A two-stage cross-sectional design (with a sample size of 6476) was conducted to estimate the prevalence of DSM–III psychiatric diagnoses in three metropolitan areas of Brazil (Brasília, São Paulo and Porto Alegre). All subjects were screened for the presence of psychopathology with a 44-item instrument (the QMPA) and a subsample was selected for a psychiatric interview.

Age-adjusted prevalence of cases potentially in need of care ranged from 19% (São Paulo) to 34% (Brasília and Porto Alegre). Anxiety disorders comprised the highest prevalences (up to 18%). Alcoholism yielded the most consistent prevalence levels, around 8% in all sites. Depression showed great variation between areas: from less than 3% (São Paulo and Brasília) to 10% (Porto Alegre)

Overall prevalences were high in comparison with previous studies conducted in Brazil. A female excess of non-psychotic disorders (anxiety, phobias, somatisation and depression) and a male excess for alcoholism were consistently found.

In a follow-up survey from Oslo, 503 persons were re-interviewed using the same questionnaire after 10 years.

The questionnaire includes questions about social support, social characteristics of the neighbourhood and mental health. Information about the neighbourhood was also gathered from key informants.

Of the five types of neighbourhoods surveyed, only one showed marked change over time with respect to social characteristics. This was an initially poorly functioning neighbourhood with poor mental health among the residents, where substantial improvement took place as part of the further development of the area. Parallel with the improvement in social environment there was a significant improvement in mental health among those who continued to live in the same area, as opposed to those who continued to live in the other areas. Selective migration could not explain this finding.

The findings support the environment stress hypothesis, implying that the quality of a neighbourhood has an impact on mental health. The implications for psychiatric prevention are discussed.

With few exceptions, evaluation of the capacity of general practitioners (GPs) to recognise psychiatric disorder in their patients has failed to consider the role of ethnic diversity in the consultation process and whether such knowledge can improve understanding of the degree to which psychiatric morbidity is recognised within GP settings.

This research was completed in five general practices representative of all those within an inner-city health district. Psychiatric morbidity in patients consecutively attending the practices was then assessed using the General Health Questionnaire; in addition, GPs were asked to complete a checklist of current problems identified during each consultation.

Analysis suggested that Asian and Black patients were less likely than White patients to have psychological problems identified; that social problems and a psychiatric history facilitated recognition; and that current physical illness hindered recognition.

GP recognition of psychological problems varies according to patient ethnicity but can be substantially masked by both the physical and social circumstances of patients at consultation.

The prevalence of the core ideational component of eating disorders among the at-risk population (11 – to 16-year-old girls) is not known.

A community survey of 11 – to 16-year-old girls was conducted to establish the prevalence of significant concerns about body weight and shape characteristics of eating disorders. A total of 1068 girls were screened and 368 interviewed using standardised measures.

Significant weight and/or shape concerns were estimated to be present in 14.5% of the 11-to 12-year-olds, 14.9% of the 13-to 14-year-olds and 18.9% of the 15-to 16-year-olds. Only among those aged 15 to 16 was the presence of such concerns associated with a significant level of concurrent behavioural and ideational disturbance.

Significant concerns about weight or shape are present in almost one in five 15-to 16-year-old girls, many of whom evidence high levels of ancillary disturbance.

This study investigates the outcome of anorexia nervosa in adolescents in relation to precipitating life events and changes in family functioning over time.

Thirty-five adolescents with anorexia nervosa and their mothers were administered measures of life events and family functioning at initial assessment and 1 and 2 year follow-up, when outcome was also assessed.

Fifty-five per cent of patients had a good outcome. Patients from initially well-functioning families or those with precipitating life events improved more in the first year, than those with dysfunctional families or without events. Subjects perceived a deterioration in family functioning at 1 year follow-up but an improvement at 2 years. Mothers reported no changes.

Approximately half of a series of early onset cases of anorexia nervosa can be expected to recover by 2 years. Healthy family functioning and presence of a precipitating life event predict good short-term outcome. The relationships between subjects' perceptions of family functioning and their recovery from anorexia nervosa is discussed.

Correlates and predictors of mood disturbance at 3 days and 6 weeks postpartum were assessed in Irish mothers and their partners.

The Edinburgh Postnatal Depression Scale (EPDS) and the Highs Scale were used to assess 370 mothers and their partners. Socio-demographic, clinical and obstetric data were collected at patients' first antenatal visit. Factors associated with EPDS scores of ≥ 13 and Highs scores of ≥ 8 were examined.

On the EPDS 11.4% of mothers scored ≥ 13 at 3 days postpartum and 11% at 6 weeks, while 18.3% of mothers scored ≥ 8 on the Highs Scale at 3 days and 9% at 6 weeks. Scores on the EPDS and Highs Scale were interrelated. Factors associated with EPDS scores of ≥ 13 at 6 weeks were single status, unemployment, unplanned pregnancy, public status and bottle-feeding. The best predictors of EPDS ≥ 13 at 6 weeks were mothers' scores on the EPDS and the Highs Scale at 3 days. Three per cent of partners scored ≥ 13 on the EPDS at 3 days postpartum and 1.2% at 6 weeks.

Factors associated with mothers' mood disturbance were readily identifiable and collected routinely at antenatal intake. Mothers' mood within 3 days of delivery was the best predictor of later postnatal depression. Paternal mood disturbance was rare. Certain women may be at increased risk for postnatal mood disturbance and may be amenable to early identification and intervention.

Deliberate self-harm (DSH) has been a major health problem in the UK for nearly three decades. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and suicide prevention.

Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends in DSH between 1985–1995

There was a substantial increase in DSH rates during the 11-year study period, with a 62.1% increase in males and a 42.2% increase in females. The largest rise was in 15–24-year-old males (+194.1%). Changes in DSH rates correlated with changes in national suicide rates in both males and females in this age group. Rates of repetition of DSH increased in both genders during the study period. Paracetamol self-poisoning has continued to increase, half of all overdoses in 1995 involving paracetamol, and antidepressant overdoses have become more common.

The increase in DSH, especially in young males, has important implications for general hospital DSH and medical services. It may herald a reversal of recent progress towards achievement of national suicide targets.

Rapid changes in styles of clinical practice mean that we should carefully monitor the way suicides occur among psychiatric patients both in hospital and in the wider community.

Patients who had died through suicide either while receiving in-patient care or within 2 months of discharge from hospital were compared with a similar series reported 10 years previously. Clinicians' perceptions of patients' behaviour were compared with concurrent controls.

Patients in the more recent study were younger, more often male, and a greater proportion had been discharged from in-patient status. Hazards which complicated risk assessment included short-lasting misleading clinical improvements, variability in degree of distress, and a reluctance to discuss suicidal ideas. Over a range of perceived behaviours it was not possible to distinguish suicides from controls.

In assessing suicide risk paramount importance should be attached to monitoring suicidal ideation and addressing the several hazards which might complicate this procedure.

Amisulpride is a potent substituted benzamide antipsychotic drug claimed to improve the negative symptoms of schizophrenia, particularly at low dosage.

Sixty long-term in-patients with schizophrenia and selected for predominant negative symptoms were randomised to receive either haloperidol or amisulpride. Over a year there was systematic dose reduction, as symptoms allowed.

There were no significant differences between the treatment groups in the proportion receiving low-dose treatment, the control of positive symptoms, or ratings of social behaviour, side-effects or tardive dyskinesia. For negative symptoms, there were consistent but non-significant trends in favour of amisulpride. The amisulpride patients required significantly less anticholinergic medication.

In chronically-hospitalised in-patients with schizophrenia characterised by persistent negative symptoms, amisulpride was a well-tolerated maintenance antipsychotic medication. The drug had only a limited effect in reducing negative symptoms, which were relatively stable, enduring phenomena in this sample, despite dosage reduction.

We hypothesised that a combined regimen of clozapine, a relatively weak D2-dopaminergic antagonist, and sulpiride, a selective D2 blocker, would demonstrate a greater antipsychotic efficacy by enhancing the D2 blockade of clozapine.

Twenty-eight people with schizophrenia, previously unresponsive to typical antipsychotics and only partially responsive to current treatment with clozapine, received, double-blind, 600 mg/day sulpiride or placebo, in addition to an ongoing clozapine treatment. The clinical status was evaluated before, during, and at the end of 10 weeks of sulpiride addition using the Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms, and Hamilton Rating Scale for Depression.

The clozapine–sulpiride group exhibited substantially greater and significant improvements in positive and negative psychotic symptoms. About half of them, characterised by a younger age and lower baseline SAPS scores, had a mean reduction of 42.4 and 50.4% in their BPRS and SAPS scores, respectively.

A subgroup of patients with chronic schizophrenia may substantially benefit from sulpiride addition to clozapine.

Previous in vivo studies of schizophrenia with dopamine D2 receptor radioligands have yielded contradictory results. No prior study has used multiple scans to examine within-subject clinical change.

Twenty-one patients were studied with [1231]-iodobenzamide single photon emission computed tomography about two weeks after neuroleptic withdrawal. Thirteen of the 21 completed a second scan about four weeks after neuroleptic withdrawal. Sixteen controls were scanned for comparison.

There was no significant difference between groups in [1231]-iodobenzamide uptake at either scanning session. No significant correlations with demographic variables (age, illness duration, drug-free period), or clinical ratings (positive and negative symptoms, movement disorder) were observed at either scanning session. There was a significant correlation between change in [1231]-iodobenzamide uptake and change in negative symptom ratings for the subjects who underwent two scans (r=0.72, P < 0.05)

Worsening of negative symptoms may be associated with increased availability of striatal D2 receptors, perhaps because of decreased concentrations of endogenous dopamine.

There have been several reports of linkage between genetic markers on the X chromosome at Xq26.3-28 and bipolar affective disorder in family samples obtained from distinct ethnic and geographical origins. As part of a genome search in a series of 23 UK and Icelandic families, specifically selected for their large size and power to resolve the issue of linkage heterogeneity, we have tested the hypothesis that there is a locus for a genetic subtype of bipolar affective disorder which is linked to this region.

In families selected on the basis of absent male to male transmission for affective disorder, we performed two-point and FASTMAP multipoint linkage analyses with markers spanning the region between the genetic loci DXS102 and F8

We found negative lod scores for several models of affection status in families selected under stringent and relaxed criteria for the absence of male to male transmission.

In the family sample we have obtained, our study provides no support for the presence of a locus increasing genetic susceptibility to bipolar affective disorder in this region of the X chromosome. It is likely that our finding reflects heterogeneity of linkage for bipolar and genetically related unipolar disorder that exists in specific ethnic populations. Alternatively the X-linked subtype of the disorder may have been present only in a few of our small families resulting in loss of power to detect the Xq26.3-28 linked subtype.