There is underdiagnosis of and low use of specialist services for attention-deficit hyperactivity disorder (ADHD).

To quantify the filters in the help-seeking pathway through primary care and to investigate factors influencing progress for children at risk of ADHD.

A total of 127 children (5–11 years old) with pervasive hyperactivity who passed each filter (primary care attendance and general practitioner (GP) recognition of disorder) were compared with those who had not.

Primary care attendance was only associated with parental perception of the behaviour as problematic (OR 2.11; 95% CI 1.11-4.03). However, GP recognition was related to both parent and child factors – parental request for referral (OR 20.83; 95% CI 3.05-142.08) and conduct problems (OR 1.48; 95% CI 1.04-2.12). GP non-recognition was the main barrier in the pathway to care; following recognition, most children were referred.

Parents can be regarded as the main gatekeepers for access to specialist services.

In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.

The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.

Structured interviews were conducted with the manager of each NHRF.

On 31 May 2000 there were 1370 NHRFs with 17138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.

There is marked variability in the provision of residential places between different regions; discharge rates are generally low.

Little is known about the effect of pharmacotherapy in the prevention of post-traumatic stress disorder (PTSD) relapse.

To assess the efficacy and tolerability of fluoxetine in preventing PTSD relapse.

This was a double-blind, randomised, placebo-controlled study. Following 12 weeks of acute treatment, patients who responded were re-randomised and continued in a 24-week relapse prevention phase with fluoxetine (n=69) or placebo (n=62). The primary efficacy assessment was the prevention of PTSD relapse, based on the time to relapse.

Patients in the fluoxetine/fluoxetine group were less likely to relapse than patients in the fluoxetine/placebo group (P=0.027). There were no clinically significant differences in treatment-emergent adverse events between treatment groups.

Fluoxetine is effective and well tolerated in the prevention of PTSD relapse for up to 6 months.

Studies have consistently found that many individuals with first-episode psychosis experience significant delays before receiving treatment. Current research investigating treatment delays has focused on the relationship between demographic factors and duration of untreated psychosis (DUP). However, treatment-seeking behaviours in this group have not been investigated.

To examine psychological processes that influence the decision-making process to contact primary care, in individuals with emerging psychosis.

The influence of coping style, health locus of control and past health help-seeking behaviour on DUP was investigated in clients with a first episode of psychosis. This involved scrutiny of general practitioner (GP) records in an average of 6 years before the first treatment.

Shorter DUP was associated with more frequent GP attendance in the 6 years before the onset of psychosis and lower health threat avoidant coping scores.

Patients with short DUP have a history of higher contact with their GP and, as a group, tend not to avoid health threats. The study underlines the importance of engaging young people and their families with primary care as one of a series of strategies to reduce DUP.

There is interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients.

To identify individuals at high risk of transition to psychosis, and psychological characteristics relevant to the development of psychosis in this group.

The design of a randomised controlled trial of cognitive therapy for the prevention of psychosis in people at high risk (meeting operational criteria of brief or attenuated psychotic symptoms, or first-degree family history with functional decline) is outlined. The first patients recruited are compared with non-patient samples on cognitive and personality factors; an interim analysis of transition rate is reported.

Cases (n=31) were recruited mainly from primary care. Of the 23 high-risk patients monitored for 6–12 months, 5 (22%) made the transition to psychosis. The high-risk group scored significantly higher than non-patients on measures of schizotypy, metacognitive beliefs and dysfunctional self-schemas (sociotropy).

The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.

Community-based epidemiological data on post-partum depression from developing countries are scarce.

To determine the incidence of and risk factors for developing post-partum depression in a cohort of women living in rural south India.

We assessed 359 women in the last trimester of pregnancy and 6–12 weeks after delivery for depression and for putative risk factors.

The incidence of post-partum depression was 11% (95% CI 7.1–14.9). Low income, birth of a daughter when a son was desired, relationship difficulties with mother-in-law and parents, adverse life events during pregnancy and lack of physical help were risk factors for the onset of post-partum depression.

Depression occurred as frequently during late pregnancy and after delivery as in developed countries, but there were cultural differences in risk factors. These findings have implications for policies regarding maternal and child-care programmes.

Antipsychotic drugs are associated with sexual dysfunction but the mechanisms are poorly understood.

To ascertain the frequency of sexual dysfunction in patients taking conventional antipsychotics and to determine the possible underlying mechanisms.

Sexual dysfunction was assessed in 101 patients receiving conventional antipsychotic medication, 57 normal controls and 55 controls attending a sexual dysfunction clinic.

Sexual dysfunction occurred in 45% of patients taking antipsychotic medication, 17% of normal controls and 61% of controls attending a sexual dysfunction clinic. Sexual dysfunction was associated with autonomic side-effects in normoprolactinaemic males, but the presence of hyperprolactinaemia overrode other causes of sexual dysfunction. For women, hyperprolactinaemia was the main cause of sexual dysfunction.

Conventional antipsychotic medications cause significant levels of sexual dysfunction. Clinicians should routinely enquire about sexual symptoms prior to the prescription of antipsychotics and on follow-up.

Previous short-term work reported fewer suicides among elderly users of a telephone helpline and emergency response service (the Tele Help–Tele Check Service).

To examine long-term effects of the service on suicide in an elderly population of northern Italy.

The service provided twice-weekly support and needs assessment telephone calls and a 24 h emergency alarm service. Data from 1988 to 1998 allowed comparison of 18 641 service users with a comparable general population group of the Veneto region in Italy.

Significantly fewer suicide deaths (nOBSERVED=6) occurred among elderly service users (standardised mortality ratio (SMR) 28.8%) than expected (nEXPECTED=20.86; χ2=10.58, d.f.=1, P < 0.001) despite an assumed overrepresentation of persons at increased risk. The service performed well for elderly females (nOBSERVED=2, SMR=16.6%, nEXPECTED=12.03; χ2=8.36, d.f.=1, P < 0.001).

The study confirms the initial promise of the Tele Help–Tele Check service over a much longer time period. Further research will clarify the apparent lack of benefit for elderly males.

Depressive symptoms are associated with cognitive decline in elderly people, but the nature of their temporal relationship remains equivocal.

To test whether depressive symptoms predict cognitive decline in elderly people with normal cognition.

The Center for Epidemiologic Study depression scale (CES – D) and the Mini-Mental State Examination (MMSE) were used to evaluate depressive symptomatology and cognitive functioning, respectively. A sample of 1003 persons aged 59–71 years and with a MMSE score of 26 or over was selected. Cognitive decline was defined as a drop of at least 3 points on the MMSE at 4-year follow-up.

Baseline high levels of depressive symptoms predicted a higher risk of cognitive decline at 4-year follow-up. The MMSE score of participants with depression was more likely to fall below 26 at 2-year follow-up and to remain below at 4-year follow-up than the MMSE score of those without depressive symptoms. Persistent but not episodic depressive episodes were associated with cognitive decline.

High levels of depressive symptoms, when persistent, are associated with cognitive decline in a sample of elderly people.

Spontaneous dyskinesia and parkinsonism have been reported in never-medicated patients with schizophrenia but there has been no previous study of the natural history of these conditions.

To determine the prevalence of spontaneous dyskinesia and parkinsonism in a group of never-medicated, chronically ill patients with schizophrenia on two occasions separated by an 18-month interval.

Dyskinesia was assessed by the Abnormal Involuntary Movements Scale using Schooler and Kane criteria for its presence; parkinsonism by the Simpson and Angus scale; and mental state by the Positive and Negative Syndrome Scale for schizophrenia.

Thirty-seven patients were examined on two occasions. Nine (24%) had dyskinesia on both occasions, 12 (33%) on one occasion and 16 (43%) on neither occasion. Twenty-one (57%) had dyskinesia on at least one occasion. Thirteen patients (35%) had parkinsonism on at least one occasion.

Spontaneous dyskinesia and parkinsonism fluctuate over time. The former was found on at least one occasion in the majority of patients. It is an integral part ofthe schizophrenic disease process.

Specialised services should be developed to help people with schizophrenia and associated substance misuse. The extent of the problem therefore needs to be known.

To determine the use of drugs, alcohol and tobacco by people with schizophrenia drawn from rural, suburban and urban settings, and to compare use by general population control subjects.

People with schizophrenia (n=316) and general population controls of similar gender distribution, age and postcode area of residence (n=250) were identified in rural, urban and suburban areas of Scotland. Use of drugs and alcohol was assessed by the Schedules for Clinical Assessment in Neuropsychiatry, and use of tobacco by a questionnaire.

More patients than controls reported problem use of drugs in the past year (22 (7%) v. 5 (2%)) and at some time before then (50 (20%) v. 15 (6%)) and problem use of alcohol in the past year (42 (17%) v. 25 (10%)) but not at sometime previously (99 (40%) v. 84 (34%)). More patients were current smokers (162 (65%) v. 99(40%)).

Problem use of drugs and alcohol by people with schizophrenia is greater than in the general population, but absolute numbers are small. Tobacco use is the greatest problem.

Subjects recovered from depression have a substantial risk for recurrence of depression, suggesting persistent abnormalities in brain activity.

To test whether women recovered from depression show abnormal brain activity in functional magnetic resonance imaging (fMRI) during a conditioning paradigm with a noxious pain stimulus.

Ten unmedicated women who had recovered from major depression and eight healthy control women each received either noxious hot or non-noxious warm stimuli, the onset of which was signalled by a specific coloured light during 3-tesla echo planar imaging-based fMRI.

Similar patterns of brain activation were found during painful stimulation for both patients and healthy controls. However, relative to healthy controls, subjects recovered from depression showed a reduced response in the cerebellum during anticipation of the noxious stimulus compared with anticipation of the non-noxious stimulus.

Our data suggest that abnormal cerebellar function could be a marker of vulnerability to recurrent depression. This could provide a new target for therapeutic interventions.

Neurasthenia imposes a high burden on primary medical health care systems in all societies.

To determine the prevalence of ICD-10 neurasthenia and associated comorbidity, disability and health care utilisation.

Utilisation of a national sample of Australian households previously surveyed using the Composite International Diagnostic Interview and other measures.

Prolonged and excessive fatigue was reported by 1465 people (13.29% of the sample). Of these, one in nine people meet current ICD-10 criteria for neurasthenia. Comorbidity was associated with affective, anxiety and physical disorders. People with neurasthenia alone (< 0.5% of the population) were less disabled and used less services than those with comorbid disorders.

Fatigue is frequent in the Australian community and is common in people attending general practice. Neurasthenia is disabling and demanding of services largely because of its comorbidity with other mental and physical disorders. Until a remedy for persistent fatigue is provided, doctors should take an active psychological approach to treatment.

There is great potential demand for treatment of bulimia nervosa and binge eating disorder. Skilled therapists are in short supply. Self-help and guided self-help based upon books have shown some promise as an economical alternative to full therapy in some cases.

To investigate the efficacy and effectiveness of self-help with and without guidance in a specialist secondary service.

A randomised controlled trial comparing three forms of self-help over 4 months with a waiting-list comparison group and measurement of service consumption over the subsequent 8 months.

Self-help delivered with four sessions of face-to-face guidance led to improved outcome over 4 months. There is also some evidence to support the use of telephone guidance. A minority of participants achieved lasting remission of their disorder in relation to self-help, but there was no significant difference in final outcome between the groups after they had progressed through the stepped care programme. Patients initially offered guided self-help had a lower long-term drop-out rate.

Guided self-help is a worthwhile initial response to bulimia nervosa and binge eating disorder. It is a treatment that could be delivered in primary care and in other non-specialist settings.

Assessment of neurocognitive dysfunction in schizophrenia is hampered by the multitude of tests used in the literature.

We aimed to identify the main dimensions of an assessment battery for patients with first-episode psychosis and to estimate the relationship between dimension scores and gender, age, education, diagnosis and symptoms.

Eight frequently used neuropsychological tests were used. We tested 219 patients 3 months after start of therapy or at remission, whichever occurred first.

We identified five dimensions: working memory (WM); verbal learning (VL); executive function (EF); impulsivity (Im); and motor speed (MS). Significant findings were that the MS score was higher for men, and the WM and VL scores were correlated with years of education.

Neurocognitive function in first-episode psychosis is described by at least five independent dimensions.

Post-natal depression is a common condition that can result in distress for the mother and deleterious effects on the development of the infant.

To estimate the economic costs of post-natal depression in a geographically defined cohort of women at high risk of developing the condition.

Unit costs were applied to estimates of health and social care resource use made by 206 women recruited from antenatal clinics and their infants. Net costs per mother–infant dyad over the first 18 months post-partum were estimated.

Mean mother–infant dyad costs were estimated at £2419.00 for women with post-natal depression and £2026.90 for women without post-natal depression, a mean cost difference of £392.10 (P=0.17). The mean cost differences between women with and without post-natal depression reached statistical significance for community care services (P=0.01), but not for other categories of service. Economic costs were higher for women with extended experiences of the condition.

The results of this study should be used to facilitate the effective planning of services by different agencies.

Subtle formal thought disorders are difficult to quantify. Their relationship to florid thought disorder is unknown.

To assess the interrater reliability, sensitivity and factor structure of a new assessment instrument, the Thought and Language Index (TLI), and to determine if minor aberrations detectable in the speech of healthy individuals are related to the more severe formal thought disorders characteristic of schizophrenia.

Interrater reliability was evaluated by determining the intraclass correlation for the ratings by five assessors. Factor analysis of the TLI scores of 87 patients was performed, and TLI scores in matched patients and controls were compared.

The intraclass correlation was good for individual TLI items, and excellent for sub-scale scores. Factor analysis identified three groups of approximately orthogonal disorders. Mild speech aberrations were observed in healthy participants and in patients with schizophrenia. The prevalence of mild aberrations was correlated with the prevalence of definite formal thought disorders.

The TLI is reliable and capable of detecting subtle disorders. Some mild aberrations occurring in the speech of healthy individuals appear to be attenuated forms of the florid disorders characteristic of schizophrenia.

Magnetic resonance imaging (MRI) has demonstrated abnormalities of brain structure, particularly of the temporal lobes, in schizophrenia. These are thought to be neurodevelopmental in origin, but when they become evident is unknown.

To determine iftemporal lobe volumes reduce during the development of symptoms of schizophrenia in initially well people at high riskofthis disorder.

A group of 66 people who had at least two first— or second-degree relatives with schizophrenia and a control group of 20 healthy people had a structural MRI scan ofthe whole brain which was repeated after approximately 2 years. Regions of interest, specifically the amygdala-hippocampus complex and the temporal lobes, were traced semi-automatically by three masked raters with good inter— and intrarater reliability

Regional brain volume changes over 2 years did notdiffer between high-risk and healthy participants. Within the high-risk group, the 19 people with psychotic symptoms (12 at first assessment) had a mean reduction of 2163 mm3 intherighttemporal lobe compared with 97 mm3 in the 47 without symptoms (P⩵0.02).

Our findings suggest that people at high risk of schizophrenia with psychotic symptoms show reductions in temporal lobe volumes.

Trials in community psychiatry must balance rigour with generalisability. The UK700 trial failed to find a significant effect on hospitalisation, but its sample population contained significant heterogeneity of exposure to case management in the two groups.

To test whether patients successfully exposed to a minimum of 12 months' intensive case management over the 2-year follow-up period achieved reduced hospitalisation.

Of 679 participants with hospitalisation data, 84 were identified as having < 12 months' exposure owing to prolonged hospitalisation, imprisonment or a combination of the two. These patients were excluded and outcomes tested for the remaining 595 patients.

Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers. Age, previous hospitalisation and source of recruitment to the study all correlated with outcome.

Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis. Baseline patient characteristics (in particular length of previous hospitalisation and recruitment from in-patient care) have a significant influence and should be allowed for in power calculations. Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies.

The results of one randomised control trial testing a psychological rehabilitation programme aimed at information processing strategies showed improvements in cognition post-treatment.

To determine whether there are concomitant brain activation changes as a result of engaging in cognitive remediation therapy (CRT).

Three groups (patients receiving control therapyor CRT and a healthy control group) were investigated in a repeated measures design using the two-back test. Functional magnetic resonance imaging (fMRI) data and a broad assessment of executive functioning were completed at baseline and post-treatment. Brain activation changes were identified after accounting for possible task-correlated motion artefact.

fMRI analyses indicate that the control group showed decreased activation butthetwo patient groups showed an increase in activation over time. The patient group that received successful CRT had significantly increased brain activation in regions associated with working memory particularly the frontocortical areas.

This isthefirsttimethat brain activation changes in a seriously disabled group of patients with schizophrenia can be associated clearly with psychological rather than pharmacological therapy.