Few formalised shared care schemes exist within psychiatry and the evidence base for sharing psychiatric care is weak.

To evaluate the utility of patient-held shared care records for individuals with long-term mental illness.

Cluster-randomised controlled parallel-group 12-month trial involving 90 patients with long-term mental illness drawn from 28 general practices.

Carrying a shared care record had no significant effect on mental state or satisfaction with psychiatric services. Compared with controls, patients in the shared care group were no more likely to be admitted (relative risk 1.2, 95% CI 0.86–1.67) and attend clinic (relative risk 0.96, 95% CI 0.67–1.36) over the study period. Uptake of the shared care scheme was low by patients and professionals alike. Subjects with psychotic illness were significantly less likely to use their records (relative risk 0.51, 95% CI 0.27–0.99).

Patient-held records may not be helpful for patients with long-term mental illness.

There is ample scope to devise forms of psychotherapy in consultation–liaison psychiatry, including the newly evolving area of psycho-oncology.

To highlight the development of psychotherapy in psycho-oncology, providing two illustrations.

We report on conceptual and clinical research in the context of oncology and palliative care, focusing on (a) an approach for families at risk of maladaptive bereavement; and (b) a group programme for women newly diagnosed with early-stage breast cancer.

We were able to introduce new forms of psychological treatment for specific clinical groups, and anecdotal evidence points to useful benefits for participants.

Psychotherapists should grasp the opportunity to bring their skills to the medical arena, but need to subject newly devised interventions to well-designed and methodologically rigorous research.

Whether individual differences in cortisol contribute to subsequent major depressive disorder (MDD) is unknown.

To determine whether premorbid levels of salivary cortisol and dehydroepiandrosterone (DHEA) were associated with subsequent MDD and how these related to psychosocial factors known to increase the risk for MDD.

Adult women (n=116) were recruited from general practices. None was currently depressed; 83 were ‘psychosocially vulnerable’ to MDD, 33 were not. Salivary steroids (cortisol and DHEA at 08.00 h and 20.00 h), recent life events, current mood and social support were assessed at entry. Onset of MDD was recorded during 13 months' follow-up.

There were no associations between salivary cortisol or DHEA and recent life events or vulnerability. Twenty-eight onsets of MDD occurred during the follow-up period. This was associated with: severe adverse life events and difficulties during the follow-up period; mean morning cortisol levels at entry; and the presence of any of three vulnerability factors.

Individual differences in morning salivary cortisol levels may represent an independent risk factor for subsequent MDD. The origin of these differences in cortisol is not yet understood.

Functional imaging studies indicate that delusions and hallucinations in schizophrenia are associated with overactivity of the left hippocampus and ventral striatum. Hippocampal neuronal firing modulates feedback to cortex via cortico–striato–thalamic loops.

To test the hypothesis that recovery from psychosis is associated with decrease in activity in cortico–striato–thalamic circuits, and, furthermore, that reduction in hippocampal activity predicts the degree of alleviation of delusions and hallucinations.

Positron emission tomography (PET) was used to measure the effects of the atypical antipsychotic, risperidone, on glucose metabolism in eight first-episode schizophrenia patients.

A single dose of risperidone produced decreases in metabolism in ventral striatum, thalamus and frontal cortex. The magnitude of decreases in left hippocampus predicted subsequent reduction in delusions and hallucinations. After six weeks' treatment with risperidone, the decreases in frontal metabolism were more extensive.

The mechanism of antipsychotic action of risperidone entails reduction of hippocampal activity together with reduced feedback via cortico–striato–thalamic loops.

The regional cerebral blood flow (rCBF) response to the Wisconsin Card Sort Test (WCST) has been used to assess the functional integrity of the prefrontal cortex in patients with schizophrenia.

In this study, patients were divided into two groups according to whether they had made few or many perseverative errors on a modified version of the WCST. A control group consisted of normal volunteers. The groups were then compared with respect to rCBF response to WCST activation.

rCBF was measured during administration of a modified version of the WCST and during a card sorting control task, using single photon emission computerised tomography (SPECT).

Performance of the modified WCST was associated with a widespread and substantial increase in rCBF, particularly in the frontal region. The poorly performing group of patients with schizophrenia showed only a modest increase in rCBF in the left anterior cingulate region.

Subjects with schizophrenia are able to respond to specific neuropsychological challenge with activation of the frontal regions.

The mental health of populations can be represented by case prevalence rates and by symptom scales. Scales have the advantage of identifying sub-syndromal levels of distress, which may be common and associated with considerable disability.

To examine the distribution of common psychological symptoms and associated disablement in the Australian population.

A household sample of 10 641 individuals representative of the adult population of Australia was interviewed using the Composite International Diagnostic Interview and completed scales measuring recent symptoms and disablement.

Symptom scales showed similar associations with socio-economic variables as did diagnoses, although only a small amount of variance in symptom levels was explained by these variables. Considerable disablement was associated with symptom levels indicating distress but not reaching levels for formal diagnoses of anxiety or depression.

Symptom scales provide parsimonious measures of psychological distress and are appropriate for use in large-scale surveys of mental health and disablement.

Polarisation of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism. Current knowledge of the interaction between biology and psychology makes it possible to consider a truly integrative approach to treatment.

The aim of this overview is to consider conceptual models of how psychotherapy may affect the brain.

The literature discussing the mutual influence of genes and environment is surveyed. Relevant data involving the influence of psychotherapy on the brain are also reviewed.

Research findings suggest that the brain responds to environmental influence through the alteration of gene expression; that psychotherapy has specific measurable effects on the brain; and that implicit memory may be modified by psychotherapeutic interventions.

Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning. These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy can be designed to target specific sites of brain functioning.

Satisfaction with mental health services is an important quality and outcome variable. The Verona Service Satisfaction Scale (VSSS) is a well-established method for measuiring service satisfaction.

To report the development and reliability study of the European Version of the VSSS (VSSS–EU).

A sample of people with schizophrenia on the case-load of local mental health services in the five European participating countries was assessed. The VSSS–EU was administered at one site in each country at two points in time. Internal consistency and test–retest reliability were assessed and compared between the five sites.

The α coefficient for the VSSS–EU total score in the pooled sample was 0.96 (95% CI 0.94–0.97) and ranged from 0.92 (95% CI 0.60–1.00) to 0.96 (95% CI 0.93–0.98) across the sites. Test–retest reliability for VSSS–EU total score, pooled over sites, was 0.82 (95% CI 0.78–0.85) and ranged from 0.73 (95% CI 0.6–0.86) to 0.93 (95% CI 0.89–0.97) across the sites.

VSSS–EU is a reliable instrument for measuring service satisfaction in people with schizophrenia, for use in comparative cross-national research projects and in routine clinical practice in mental health services across Europe.

Mental health provider trusts in England were required in 1994 to establish local Supervision Registers of patients at risk.

To identify the factors associated with registration, and obtain clinicians' views on its effectiveness.

At a random sample of 14 trusts data were collected from case notes, keyworkers and responsible medical officers.

A sample of 133 registered patients were more disabled and had more extensive histories of violence and self-harm than 126 comparison patients on the upper tier of the Care Programme Approach (CPA). Those registered were a heterogeneous group. For some there was little evidence of risk. In most cases clinicians did not believe registration had improved care.

The Supervision Register policy has not resulted in the identification of a well-defined group. Its effectiveness is limited by the lack of operationalised measures of risk.

Selective action at limbic cortical dopamine D2-like receptors could mediate atypical antipsychotic efficacy with few extrapyramidal side-effects.

To test the hypothesis that quetiapine has ‘limbic selective’ D2/D3 receptor occupancy in vivo.

The high-affinity D2/D3 ligand [123I]-epidepride and single photon emission tomography were used to estimate D2/D3 specific binding and an index of relative percentage D2/D3 occupancy in striatal and temporal cortical regions for quetiapine-treated patients (n=6). Quetiapine-, and previously studied typical-antipsychotic- and clozapine-treated patients were compared.

Mean (s.d.) relative percentage D2/D3 receptor occupancy by quetiapine was 32.0% (14.6) in striatum and 60.1% (17.2) in temporal cortex (mean daily dose 450 mg: range 300–700 mg/day). Quetiapine treatment resulted in limbic selective D2/D3 blockade similar to clozapine and significantly higher than typical antipsychotics.

Preliminary data suggest that limbic selective D2/D3 receptor blockade is important for atypical drug action.

Recent work has reported a decline in the incidence of schizophrenia, but it is unclear if these findings reflect a true decrease in its incidence or are an artefact arising from methodological difficulties.

To take account of these methodological difficulties and report service-based incidence rates for schizophrenia in Dumfries and Galloway in south-west Scotland for 1979–98.

Using both clinical diagnoses and diagnoses generated from the Operational Checklist for Psychotic Disorders (OPCRIT) computer algorithm for ICD–10 and DSM–IV schizophrenia, we measured change in the incidence rates over time. We used indirect standardisation techniques and Poisson models to measure the rate ratio linear trend.

There was a monotonic and statistically significant decline in clinically diagnosed schizophrenia. The summary rate ratio linear trend was 0.77. However, using OPCRIT-generated ICD–10 and DSM–IV diagnoses, there was no significant difference over time.

OPCRIT-generated consistent diagnoses revealed no significant fall in the incidence of schizophrenia. Changes in diagnostic practice have caused the declining rates of clinically diagnosed schizophrenia in Dumfries and Galloway.

Generalisability of existing studies on the naturalistic history of major depression is undermined by overrepresentation of in-patients and tertiary care academic centres, inclusion of patients already on treatment and/or incomplete follow-up.

To report the time to recovery of an inception cohort of unipolar major depressive episodes.

A multi-centre prospective follow-up study of patients with a mood disorder, who had been selected to be representative of the untreated first-visit patients at 23 psychiatric settings from all over Japan.

The median time to recovery of the index episode after treatment commencement was 3 months (95% CI 2.5–3.6): 26% of the cohort reached asymptomatic or minimally symptomatic status by I month, 63% by 3 months, 85% by 12 months and 88% by 24 months.

Our estimate of the episode length was 25–50% shorter than estimates reported in the literature.

This paper, part of the European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study, reports the development, reliability and internal consistency of the Lancashire Quality of Life Profile – European Version (LQoLP–EU) in a representative sample of people with schizophrenia from five European sites.

The LQoLP–EU was administered to a total sample of 404 patients to check its internal consistency, and a sub-sample of 294 patients was interviewed a second time within 7–15 days to verify its test–retest reliability.

Internal consistency of the total domains, perceived QoL scale (Life Satisfaction Scale, LSS) was good at 0.87. Of the nine subjective QoL domains Work and Leisure showed the lowest internal consistency (0.30 and 0.56 respectively), the values of the remaining sub-scales ranging between 0.62 and 0.88. The pooled ICC score for LSS was 0.82, and for the nine subjective QoL domain sub-scales it ranged from 0.61 (Safety) to 0.75 (Living Situation). There were significant differences between the sites in α and ICCs for sub-scales, but not for the LSS.

The LQoLP-EU has good internal consistency and reliability in the five European centres.

It is unclear what determines duration of untreated psychosis (DUP) in schizophrenia and why long DUP predicts poor outcome.

First, to test the hypothesis that specific patterns of symptoms and social functioning acting before treatment prolong DUP. Second, to clarify the mechanisms linking DUP with recovery after treatment.

Two hundred and forty-eight consecutive first admissions with schizophrenia were interviewed to assess DUP, symptoms and social functioning at admission, and symptoms were re-assessed after 6–12 weeks.

Median DUP was 12 weeks. Long DUP was predicted by poor insight, social isolation and preserved coping skills, but not by demographic factors. Even allowing for all these variables, long DUP predicted poor outcome.

Longer DUP results partly from a pattern of symptoms and social functioning which reduces concern by the sufferer and relevant others. DUP's relationship to outcome is strongest in the initial months of psychosis. This has implications for targeting early intervention.

Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice.

To review the developments in measurement relevant to psychotherapy.

Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skilfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement.

Modern methods of measurement can support ‘evidence-based practice’ for psychological treatments. They also support ‘practice-based evidence’, a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs).

Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.

We present a revised Beliefs About Voices Questionnaire (BAVQ–R), a self-report measure of patients' beliefs, emotions and behaviour about auditory hallucinations.

To improve measurement of omnipotence, a pivotal concept in understanding auditory hallucinations, and elucidate links between beliefs about voices, anxiety and depression.

Seventy-one participants with chronic auditory hallucinations completed the BAVQ–R, and 58 also completed the Hospital Anxiety and Depression Scale.

The mean Cronbach's α for the five sub-scales was 0.86 (range 0.74–0.88). The study supports hypotheses about links between beliefs, emotions and behaviour, and presents original data on how these relate to the new omnipotence sub-scale. Original data are also presented on connections with anxiety and depression.

The BAVQ–R is more reliable and sensitive to individual differences than the original version, and reliably measures omnipotence.

Those with schizophrenia often give a history of premorbid non-psychotic psychiatric disorder.

To investigate the association between non-psychotic psychiatric disorders and the later development of schizophrenia.

Men aged 18 or 19 years, conscripted to the Swedish army in 1970 (n=50 054) were linked to the Swedish National Psychiatric Case Register.

There was an increased risk of schizophrenia in those with ICD–8 diagnoses of neurosis (OR=4.6,95% CI 3.2–6.9), personality disorder (OR=8.2, 95% CI 5.4–12.3), alcohol abuse (OR=5.5, 95% CI 1.7–17.5) or substance abuse (OR=14.0, 95% CI 7.8–25.0) at age 18. Of those who developed schizophrenia, 38% (95% CI 32–45) received a diagnosis of non-psychotic psychiatric disorder at age 18. Only those with personality disorder had a significantly increased risk of schizophrenia (OR=2.4, 95% CI 1.1–5.2) with onset after age 23.

Personality factors could represent an underlying vulnerability to schizophrenia. Other diagnoses occurring before schizophrenia may reflect a prodromal phase of the illness.

The association between depression and increased mortality risk in older persons may depend on the severity of the depressive disorder and gender.

To investigate the association between major and mild depressive syndromes and excess mortality in community-living elderly men and women.

Depression (Geriatric Mental State AGECAT) was assessed in 4051 older persons, with a 6-year follow-up of community death registers. The mortality risk of neurotic and psychotic depression was calculated after adjustment for demographic variables, physical illness, cognitive decline and functional disabilities.

A total of 75% of men and 41% of women with psychotic depression had died at follow-up. Psychotic depression was associated with significant excess mortality in both men and women. Neurotic depression was associated with a 1.67-fold higher mortality risk in men only.

In the elderly, major depressive syndromes increase the risk of death in both men and women, but mild depression increases the risk of death only in men.

Many patients suffering from psychosis are unaware of their disorder and symptoms.

To investigate whether insight changes with time, and how it relates to patients' psychopathology, and to examine the correlations between insight scales in patients with psychoses.

Seventy-five consecutively admitted in-patients with schizophrenia, affective disorder with psychotic symptoms, or schizoaffective disorder were examined after remission of an acute episode and at follow-up (>6 months). Three different scales were used to assess insight.

To some extent, insight into past episodes improved over time in patients with psychosis, regardless of diagnosis. Few significant relationships between insight and psychopathology remained stable at follow-up. The higher the negative and disorganisation dimensions at baseline, the less did attitudes to treatment vary when tested at follow-up. No predictive value for variability of psychopathological dimensions was found for insight dimensions. The insight scales used were highly intercorrelated, suggesting that they measure the same construct.

Insight and psychopathology seem to be semi-independent domains.