The Health of the Nation includes a target for reducing population suicide rates. We have examined and quantified various high-risk and population-based strategies for prevention based upon a number of stated assumptions and hypothetical interventions.

The published literature was used to estimate the population attributable fractions for both high-risk and population-based strategies. The number needed to treat for the high-risk strategies was calculated, assuming an intervention that reduced suicide rates by 25%

Interventions that would reduce rates of suicide by 25% would reduce population rates by about 2.6% for those recently discharged from hospital and by up to 5.8% for those presenting to general hospital with deliberate self-harm. The population attributable fraction for unemployment was 10.9%

High-risk strategies will have only a modest effect on population suicide rates, even if effective interventions are developed. Evaluating interventions for deliberate self-harm patients seems worthwhile. The UK Government's target for suicide reduction is more likely to be achieved using population-based strategies. Reducing the availability of methods commonly used for committing suicide is the most practicable current policy, although more radical approaches, for example reducing unemployment, may also substantially reduce suicide rates.

It has been suggested that the increased rate of psychotic illness among African–Caribbeans living in Britain is due to an excess of pregnancy and birth complications (PBCs).

We therefore compared the frequency of PBCs in a group of White psychotic patients (n=103) and a comparable group of patients of African–Caribbean origin (n=61); the latter consisted of 30 first-generation (born in the Caribbean) and 31 second-generation (born in Britain) individuals.

White psychotic patients were more than twice as likely to have a history of PBCs as their African–Caribbean counterparts (odds ratio=2.34, 95% confidence interval (CI) 0.88–6.47, P=0.062). The same trend was observed among patients with a DSM–III diagnosis of schizophrenia (odds ratio=l.65, 95% CI 0.56–4.97, P=0.32). The rate of PBCs was similar among the first- and second-generation Caribbean psychotic patients.

The increased rate of psychotic illness that has been reported among the African–Caribbean population in Britain is not due to an increased prevalence of PBCs.

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.

The aim was to examine the longitudinal evolution of depression and anosognosia in patients with probable Alzheimer's disease (AD).

Sixty-two of a consecutive series of 116 AD patients that were examined with a structured psychiatric interview had a follow-up evaluation between one and two years after the initial evaluation.

At the initial evaluation 19% of the 62 patients had major depression, 34% had dysthymia, and 47% were not depressed. After a mean follow-up of 16 months, 58% of patients with major depression at the initial evaluation were still depressed, whereas only 28% of patients with initial dysthymia and 21% of the non-depressed patients were depressed at follow-up. During the follow-up period, all three groups showed similar declines in cognitive status and activities of daily living. At the initial evaluation, 39% of the patients had anosognosia, and there was a significant increment of anosognosia during the follow-up period.

While dysthymia in AD is a brief emotional disorder, major depression is a longer-lasting mood change. Anosognosia is another prevalent disorder among AD patients, and increases with the progression of the illness.

Currently the Mini Mental State Examination (MMSE) is widely used as a screening instrument for dementia syndrome. Diagnostic validity may be lowered in old age by normal age-related cognitive decline. Furthermore, visual impairment, occurring frequently in old age, leads to missing values which prevent an interpretation of the test result.

In the Berlin Ageing Study (n=516, age range 70–103 years) MMSE and clinical dementia diagnosis, made by a psychiatrist investigating all subjects by the Geriatric Mental State–A and History and Aetiology Schedule interviews, were investigated independently. The MMblind was analysed, an MMSE version for vision impairment in which all items requiring image processing are omitted. The study sample is population-based; dementia cases (DSM–III–R) were excluded on the basis of the clinical diagnosis.

Norms are reported for very old age regarding MMSE as well as MMblind. There is a considerable age effect on MMSE scores. In contrast to MMSE, sensitivity and specificity of the shorter MMblind version are not reduced.

The considerable age effect requires the adaptation of cut-off values for old age. The blind version of the MMSE seems to be a valid instrument improving the applicability of the MMSE in old age.

Previous studies have shown higher rates of psychiatric admissions, compulsory admissions, and diagnosed schizophrenia in Black ethnic groups compared with other population groups.

In a point-prevalence study, demographic and clinical data were collected for adult acute and low-level secure psychiatric in-patients in all National Health Service and seven private psychiatric units in North and South Thames regions on 15 June 1994

A total of 3710 adult acute and 268 low-level secure psychiatric patients were surveyed; 75% of the patients were White, 16% were Black, and 4% were Asian. Analysis reveals that a high proportion of the Black population were admitted to a psychiatric unit; that Black patients are more likely to be admitted under Section; to be located in locked wards; have an inpatient diagnosis of schizophrenia; and not be registered with a general practitioner.

These findings demonstrate the over-representation of Black ethnic groups within current psychiatric provision. The complement of services to all minority ethnic groups should be examined in terms of access, appropriateness and quality of care. Racism awareness and staff training need to be incorporated into mental health service provision as a matter of priority.

Of 9156 patients admitted to psychiatric hospitals in Denmark between 1970 and 1987 and diagnosed for the first time as having schizophrenia, 508 committed suicide. The purpose of the study was to identify risk factors for suicide among patients with schizophrenia, particularly factors relating to hospitalisation.

From the cohort of all 9156 patients, the 508 who had committed suicide were individually matched to 10 controls from the same cohort, and data were analysed using conditional logistic regression.

Suicide risk was particularly high during the first 5 days after discharge, and increased risk was also associated with multiple admissions during the previous year, previous suicide attempts, previous diagnosis of depression, male gender, and previous admissions to general hospitals for physical disorders. After adjusting for these factors, no effect was found for age. There was some evidence of an excess of suicides during temporary leave from the psychiatric department.

The findings suggest that preventive measures could be focused on the first period after discharge, when closer monitoring and better social support may be needed. This may also apply to patients on temporary leave during a period of admission.

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.

We assessed the publication trends of papers on schizophrenia through an analysis of the articles published by three general psychiatric journals (Archives of General Psychiatry (AGP), the British Journal of Psychiatry (BJP), and the Australian and New Zealand Journal of Psychiatry (ANZJP) from three continents.

For each of the journals, we covered the period between 1980 and 1994. We carried out both a quantitative analysis, assessing the trends over time in the publication of papers on schizophrenia, and a qualitative analysis, classifying the articles into eight scientific fields.

During the study period a total of 943 articles dealing with schizophrenia were published in the three journals evaluated; the proportion of papers focusing on schizophrenia was higher in the AGP and in the BJP (18 and 15%) as compared with the ANZJP (5.6%). A substantially higher proportion of basic science articles was published in the AGP as compared with the BJP and the ANZJP, whereby a somewhat larger representation of epidemiological and psychosocial research was found in the latter journals.

Given the importance of schizophrenia in psychiatric research and practice, it will be useful to regularly monitor the research trends in this specific field.

Severe tardive dyskinesia (TD) represents a serious and potentially disabling movement disorder, yet relatively little is known about the incidence of and risk factors for severeTD.

We report the results of a longitudinal prospective incidence study of severeTD in 378 middle-aged and elderly neuropsychiatric patients. Psychiatric, neuropsychological, pharmacological and motor variables were obtained at intake and at regular intervals for 36 months.

The cumulative incidence of severeTD was 2.5% after one year, 12.1% after two years, and 22.9% after three years. Individual univariable Cox regression analyses were conducted to identify demographic, psychiatric, motor and pharmacological predictors of severeTD. Results indicated that higher daily doses of neuroleptics at study entry, greater cumulative amounts of prescribed neuroleptic, and greater severity of worsening negative symptoms were predictive of severeTD Conclusions These findings suggest that conventional neuroleptics may be prescribed to older patients only when necessary and at the lowest effective dosage. Additional caution is recommended in patients exhibiting negative symptoms.

Eighteen acute in-patient psychiatric units in Australia funded a syndicate to measure case-mix, disability and outcome of treatment. This syndicate included eight units in public general hospitals, five in stand-alone public psychiatric hospitals and five in private psychiatric hospitals.

Up to 100 in-patients admitted consecutively to each hospital (1359 in all) were assigned to a Diagnosis-Related Group (DRG), rated on the Health of the Nation Outcome Scales (HoNOS) and asked to complete the Medical Outcomes Trust Short Form 36 (SF36). These scales were administered again at discharge. Demographic information and length of stay were also recorded. Disability was measured by scores on the HoNOS and SF36 at admission, and outcome was assessed by the change in scores between admission and discharge.

The public hospitals treated significantly more patients with schizophrenia and fewer with affective disorders, and their case load on admission was more disabled, on the whole, than that of the private hospitals. They achieved the same outcome or health gain as the private hospitals, but needed a shorter length of stay to do so. The addition of disability scores to DRG moderately increased the ability to predict length of stay.

Routine outcome assessment using reliable and valid instruments is practical, and could lead to improvements in the quality of care for psychiatric patients.

Little is known about seasonal fluctuations in psychological well-being among elderly people.

Over a period of 21 months, 1466 elderly people completed the General Health Questionnaire and the Leeds Scales for Depression and Anxiety. Scores during the winter months (December to February) were compared with those during other months of the year.

Scores on all scales were significantly higher during the winter months, but there was no difference in rates of caseness. Unlike younger populations, elderly women did not exhibit greater seasonality in well-being than did elderly men.

Elderly people exhibit a small seasonal fluctuation in psychological well-being, which is probably of little clinical importance, and there is no gender difference. The findings support the contention that seasonal mood changes are most pronounced among females of reproductive age.

There has been no published study that considers actual costs in a representative sample of people aged ???? 65 years. The present study describes the financial cost of formal community services for elderly people with dementia, depression, anxiety disorders or physical disability.

Psychiatric morbidity, physical disability and services received were assessed by standardised questionnaire in randomly selected Islington enumeration districts. Subjects were interviewed at home (.=700).

Dementia was the most expensive disorder per sufferer in terms of formal services. Those with depression were also high users of health services. Despite presenting to health services, 90% were not treated with appropriate drugs. In contrast, social services were received by people who were activity-limited or with dementia. The highest service cost for the population as a whole was for the physically disabled. In multivariate analysis the significant predictors of high service costs were living alone, being physically ill, depression, dementia and increasing age.

Failure to detect and treat depression and the anxiety disorders in older people, despite their presentation to medical services, may have major economic consequences as well as contributing to individual suffering.

The study aimed to define the characteristics and assess the clinical predictability and possible prevention of psychiatric in-patient suicides.

The coroner's files on all suicides in the Greater Montreal Region from 1 April 1986 to 31 March 1991 were examined. The medical records of each case of suspected in-patient suicide were then reviewed and rated for predictability and preventive measures taken.

A total of 3079 suicides were recorded over this five-year period (mean annual rate of 16.4 per 100 000 inhabitants). Of these, 104 (3.4%) involved hospital in-patients. Nearly half (48%) of these in-patient suicides occurred outside the hospital setting. The methods most frequently employed were hanging (36%) and jumping from high places (24%). Patients suffering from an affective disorder (45%) or schizophrenia (35%) comprised the majority of the sample. Suicides were significantly more predictable in general hospital psychiatric wards. Suicide prevention measures did not differ significantly across settings.

The majority of in-patient suicides were not highly predictable. For highly predictable suicides, the results underline the importance of actively treating and protecting these patients.

While executive (frontal lobe) dysfunction appears to be a core feature of schizophrenia, its relationship to psychopathology, age and duration of illness has yet to be explored systematically between the genders.

Executive dysfunction, positive and negative symptoms were evaluated in 27 male and 21 female in-patients who were unusually well-matched on numerous demographic and clinical measures.

Measures of executive dyscontrol and negative symptoms were highly associated in both genders. However, while both executive dyscontrol and negative symptoms increased prominently with age/duration of illness among women, no such relationship was evident among men.

The similarly prominent levels of current executive dyscontrol and negative symptoms in male and female patients appear to have emerged via processes that differ fundamentally between the genders; among males these deficits appear to emerge and become ‘locked in’ earlier in the course of illness and to show little subsequent increase, while among females these same deficits appear to be less evident early in the course but to increase in prominence thereafter.

Recent findings indicate that the established association between social indicators of deprivation and psychiatric admission rates may not hold across all diagnoses.

Admission rates in individuals aged 16–64 years for 71 electoral wards in North Staffordshire were calculated for six diagnostic groups using data from the Korner Episode System for 1987–1993. These were correlated with selected individual census variables, Townsend and Jarman indices. The ability of regression models to predict admission rates was tested.

The strongest correlations were found for total admissions (r 0.44–0.79). Strong correlations were found for neurotic disorders/depression (r 0.29–0.62), schizophrenia (r 0.24–0.59), all non-psychotic disorders combined (r 0.41–0.71) and all psychotic disorders combined (r 0.33–0.67). Predicted admission rates for total admissions, psychotic and non-psychotic admissions using regression models showed strong positive correlations with observed admission rates.

The strong correlations between social indicators of deprivation and total psychotic admission rates are consistent with the results of previous studies. The strong associations between social indicators and admissions for non-psychotic disorders is contrary to previous findings and may be partly explained by the relatively high admission rates for neurotic disorders.

Cognitive impairment, frequently found in patients with schizophrenia, may be associated with negative symptoms and dyskinesia. However, antipsychotic medication may be a confounding variable. These putative associations may be clarified by examining never-treated patients.

Never-treated elderly schizophrenic patients (n=19) living in south-east India were compared with treated patients (n=25) and normal subjects (n=55). Memory was assessed by the Wechsler Memory Scale, negative symptoms by the Positive and Negative Syndrome Scale, and dyskinesia by the Abnormal Involuntary Movements Scale.

Normal subjects had a higher mean memory quotient than patients. There were no significant differences between never-treated and treated patients. Negative symptoms were associated with a poorer memory in the never-treated group. There was no association between memory and dyskinesia.

There is an association in never-treated patients between a poorer memory and negative symptoms, but not between a poorer memory and dyskinesia.

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.

The aim of this study was to provide information on patients' current service use which could inform future decisions on service planning and resource allocation.

Individuals with a diagnosis of schizophrenia, who had received in-patient care in the previous five years, were identified from the Lothian Case Register. Information was obtained from 193 subjects. Patients' service use over a six-month period was examined. The costs incurred in service provision were determined.

Patients differed markedly in their use of services. This was not found to be related to their mental state. Average care costs were high. In-patient care accounted for most of the overall expenditure.

There is considerable variation in the services used by patients with schizophrenia and in the costs incurred in service provision. When planning services it is therefore important that detailed information on the patient population is available if resources are to be allocated cost-effectively.

Small group homes operating according to the principles of supported housing have, during the past five years, become a cornerstone of the housing services for the long-term mentally ill in Copenhagen.

During a 2.5-year period, 47 long-term mentally ill persons were examined at the time of entry to a group home programme. Residents' psychopathology, social integration, mastery and quality of life were measured by structured interviews, including the Present State Examination (PSE–10); and their social functioning was recorded by interview with the staff. Forty-four of the residents were re-examined at follow-up after a mean of 1.1 years using the same instruments. Data on hospitalisation were obtained through the Danish Psychiatric Case Register.

Eighty-three per cent of the residents remained in the programme during the first year. They showed a significant improvement in subjective quality of life, PSE total score, social integration, functioning and hospitalisation index. The number of reciprocal supportive contacts in the social network increased. Lower baseline PSE total score was associated with adherence to the programme, and the improvement in quality of life during their stay was predicted by reduction in symptoms and improvement in social integration.

A rehabilitation strategy of supplementing standard psychiatric treatment with a programme of small supportive group homes improves the quality of life, psychosocial functioning and community tenure of the long-term mentally ill.