Current acceptance of the need for a wide range of treatments and growing pressure for cost-effectiveness suggest the need for a more discriminating approach to assessment of psychotherapy.

Medline and manual literature searches, and personal experience of over 1000 assessments in a district psychotherapy service.

There is substantial evidence for the general efficacy of psychotherapy; differential benefits are beginning to be identified. Short-term treatments are appropriate in a wide variety of situations and can be surprisingly effective. Chronic/complex psychopathology is likely to need longer term therapy.

Effective use of scarce psychotherapy resources requires knowledge of the research evidence of treatment effectiveness, careful assessment of the patient and a logical and collaborative approach to treatment planning.

The prevalence rate of behaviour problems and maternal mental disturbance was estimated using a sample of 1047 families with a 3-year-old child from a mixed urban/rural area.

Parents completed the Child Behaviour Checklist, EAS Temperament Questionnaire, Weiss–Werry–Peters Activity Scale and the GHQ–30.

The rate of behaviour problems (13.2%) was similar to that obtained in studies of urban children. The rate of maternal disturbance (27.6%) was lower than in other population samples. Few differences were found in the prevalence rates in the urban and rural areas.

Preschool children and their parents living in non-urban areas had the same rates of problems as those in conurbations. The service needs of such families are similar regardless of locality.

The extent to which certain maternal, child and family characteristics are associated in families with a 3-year-old child were examined.

A total population of families with a 3-year-old child and living in the New Forest were identified. Measures of child behaviour and the maternal GHQ-30 were obtained.

Whereas behaviour problems were found to be significantly associated with all maternal and family factors (except social class), difficult temperament was only related to mother's recall of their own childhood as unhappy and overactivity was only significantly associated with maternal disturbance.

The results are consistent with maternal disturbance and difficult temperament acting independently and additively to influence the development of behaviour problems in preschool children.

There is a lack of clear and explicit models of the way various family and social influences on children's behaviour interact with factors such as temperament to produce behaviour disturbance in young children.

The following measures had been obtained on a total population sample of 1047 families with a 3-year-old child: the child's perceived cuddliness, difficult temperament, mother's unhappy childhood, maternal disturbance, social class, behaviour problems and overactivity. A latent variable analysis using the LISREL 7 program was applied to the data.

A model that allowed the latent variables child ‘temperament’ and ‘mother's mental state’ to have separate additive effects on ‘child adaptation’ proved an excellent fit (goodness of fit index = 0.956). This model suggests that there is a common factor (‘child adaptation’) underlying behaviour problems and overactivity. Using this model 72% of child adaptation in boys could be explained. For girls however temperament and mother's mental state accounted for only 30% of the variance in child adaptation.

There is a need to investigate different mechanisms for the origins of behaviour problems in preschool boys and girls.

The Adolescent to Adult Personality Functioning Assessment (ADAPFA) a modification of the Adult Personality Functioning Assessment (APFA) is described. It may be used to assess specific and general social dysfunction in the transition from childhood to adult life.

Two raters independently rated 38 audiotaped interviews to test the interrater reliability of the instrument. The relationship between dysfunction in specific domains and overall psychosocial dysfunction was examined.

Interrater reliabilities for the total ADAPFA score and for the majority of the domains were high. Agreement on type of dysfunction and on categorical ratings indicating the presence of personality disorder were good.

The ADAPFA is a useful measure of interpersonal and social role performance in the transition between adolescent and adult life.

The features of adolescents who had taken an overdose were assessed to determine the focus for a treatment trial.

Overdose cases were compared with psychiatric and community controls who had not taken an overdose in respect of mental disorders and family background.

Overdose cases had high rates of major depression, but most of them recovered from depression within six weeks of the overdose. There was a specific association between taking an overdose and family dysfunction.

Family dysfunction could be a useful focus in a clinical trial of the aftercare of adolescents who have taken an overdose.

Paracetamol is now the most common drug used for self-poisoning in the UK and is associated with potentially fatal liver damage. Patients admitted to hospital because of paracetamol overdoses were studied in order to determine their characteristics and factors which might have deterred them from taking paracetamol or reduced the dangers of the overdose.

Eighty patients were studied in hospital using a structured interview schedule, measures of depression and suicidal intent, information collected through the Oxford Monitoring System for Attempted Suicide, and the results of liver function tests.

Acute liver dysfunction (25 patients) was associated with consumption of more than 25 tablets (odds ratio 4.46, 95% CI 1.31 to 17.41, P = 0.014). The proportionate use of tablets from blister packs (60%) and loose preparations (46%; 5 patients using both types) reflected their general availability. More of those who took tablets from a loose preparation consumed 25 or more tablets (69%) than those who used a blister-pack preparation (40%; odds ratio = 3.0, 95% CI 1.12 to 9.95, P = 0.028). Only 20 patients thought that any type of warning label would have deterred them from taking a paracetamol overdose.

Establishing a maximum number of tablets (e.g. 25) that can be available in individual preparations is likely to reduce the dangers of paracetamol self-poisoning. The potential effects of other measures are uncertain.

We set out to determine whether and to what degree life events independent of illness increase the risk of relapse in schizophrenia following withdrawal from medication in the previous 6 months, either by triggering a relapse in the following 4 weeks or by acting cumulatively over time.

Seventy-one patients fulfilling DSM–III–R criteria for schizophrenia with chronic illness were followed for 48 weeks and assessed on the LEDS scale. Half were treated with regular neuroleptic medication and half had been recently withdrawn from medication. A subgroup was randomised double-blind to treatment or placebo.

A proportional hazards regression model showed that life events made a significant cumulative contribution over time (P < 0.05) to the risks of relapse and that ceasing medication made an independent contribution. The risk of relapse increased in proportion to the number of life events but no interaction between medication status and events could be detected, i.e. life events were not more closely associated with relapse on medication than off medication. For those of the sample exposed to the mean rate of life events during the study period, it was estimated that 23% of the relapse risk could be attributed to life events, and for those with twice the mean rate of events, 41%. In contrast, patients who continued on regular medication had 80% less risk of relapse than those who had been withdrawn from medication either by choice or under double-blind controlled conditions.

A contribution of life events to the risk of relapse in schizophrenia was confirmed by this study but the hypothesis that life events trigger relapse was not supported, nor was the hypothesis that life events are more relevant to relapse in patients on maintenance medication than in patients off medication.

We wished to investigate central serotonergic function in untreated schizophrenia.

Thirteen drug-naive, DSM–III–R schizophrenic patients were compared with sex, race, age, weight and menstrual phase matched controls. Plasma prolactin and cortisol responses to a specific serotonergic probe, d-fenfluramine, were measured along with BPRS ratings.

Prolactin responses were enhanced in schizophrenic patients compared to controls (P < 0.05) and were correlated positively with BPRS items for depression, anxiety and guilt. Baseline cortisol was also raised in those with schizophrenia (P < 0.001).

Central serotonergic tone may be raised in acute, drug-naive schizophrenia and may be associated with the presence of affective symptomatology.

Studies of schizophrenics with persecutory delusions have shown cognitive biases in subjects who are deluded. It has been suggested that their delusions defend against depression. This study challenges the assumption that delusional disorder (DD) patients are covertly depressed.

Clinical and demographic data and responses to questionnaires designed to assess schizotypy, depression, dysfunctional attitudes, attributional and attention biases were collected from 29 patients satisfying DSM–III–R criteria for DD. These were compared with 20 matched normal controls and results from published studies of schizophrenics.

DD subjects did not show abnormal levels of overt or covert depression or schizotypy. They showed high levels of dysfunctional attitudes (P < 0.0001), a distinctive attributional style (P = 0.01), and increased attention to threat-related stimuli (P = 0.01).

DD is a distinct disorder predicated upon sensitivity to threat and biases of attention and attribution. These findings may have implications for the cognitive therapy of these disorders.

We examined relationships among positive, negative, and depressive symptoms in schizophrenia and major depression with psychosis.

Patients with schizophrenia (n = 17) and major depression and psychotic features (n = 25), with no prior psychopharmacologic treatment were assessed on scales measuring positive psychotic, negative, and depressive symptoms.

Analyses revealed that depressive symptoms positively correlated with anhedonia/asociality and avolition/apathy in both patient groups. Positive psychotic symptoms significantly correlated with depressive symptoms in the schizophrenic group.

Several specific symptoms used in defining both depressive and negative syndrome constructs appear to be shared. The relationship between positive symptoms and depression in schizophrenia and not psychotic depression suggests the severity of depression may be involved in this relationship.

This study examines the validity and screening properties of the Borderline Syndrome Index – BSI (developed in the USA) for categories of the Personality Assessment Schedule – PAS (developed in the UK).

Patients were recruited by case control sampling. Chance corrected agreement between instruments and screening properties of the BSI were calculated.

The BSI proved a moderately sensitive but non-specific screen. Questionnaire scores were highly correlated with symptom measures.

The results do not support the validity of the BSI or its use as a screening instrument. BSI scores may be distorted by current symptoms.

Depression affects a significant proportion of the expanding elderly population in the UK. Reports of a poorer prognosis for older than for younger adult patients have been challenged by recent papers.

The casenotes of 56 adults (mean age 47.8 years) and 54 elderly (mean age 72.9 years) patients with primary depression were assessed one year after receiving hospital treatment. Outcome measures were compared with earlier reported findings and factors possibly influencing outcome were explored.

The pattern of outcome in both age groups was broadly similar, thus: adults v. elderly: recovered 44.6% v. 44.4%; relapsed and recovered 23.2% v. 24%; residual symptoms 19.6% v. 13% and chronic depression 7.1% v. 5.5%. In the adults there were two natural deaths and one suicide. In the elderly there were two cases of dementia and five natural deaths, which was double the expected death rate. Predictors of poor outcome were melancholic depression in adults and longer duration of illness at intake and an increasing number of previous episodes of affective disorder in the elderly.

The outcome of treated depressive illnesses appears similar in elderly and adult patients. Associated physical ill health did not adversely affect outcome in the elderly group.

This study surveyed all residents in a hostel for homeless women. Demographic data, and information on past and present psychiatric and social morbidity and current and premorbid cognitive functioning were collected.

A four week prevalence study using: SCID–PD; a semi-structured interview; GHQ; SBS; Manchester Scale; MMSE; and NART; the data were analysed using SPSS.

The women originated from across the social spectrum and disruption of early family life was common. Fifty per cent had a ‘severe mental illness’ and most were not receiving drug treatment. High levels of active psychotic symptoms were present. Women with psychosis had suffered a greater intellectual decline from their premorbid levels of functioning than those without psychosis.

The study affirmed findings of earlier studies employing case-series methodology. Women with high levels of psychiatric morbidity and social dysfunction were being managed by care workers in a way that may promote stability rather than a drift into street-life.

Clinical practice suggests that partners of psychotherapy patients often have powerful feelings about the therapy and therapist. The repercussions of psychotherapy on those close to the patient are rarely considered. A small exploratory study was therefore conducted.

All patients who had completed at least two months of weekly psychodynamic psychotherapy in 1990 at an out-patient unit of a psychiatric hospital (n = 35) and had a partner with whom they were living at the time of starting therapy (n = 23) were contacted. Eight gave permission for their partner to be contacted directly. All eight partners agreed to participate in a semi-structured interview exploring their perceptions of the effects of the therapy on a number of family relationships. The impact of the process of the study was also investigated by means of a questionnaire sent to all partners some weeks after the interview.

Considerable changes were perceived to have taken place in association with therapy affecting not only the relationship between the couple but also their parenting relationship, the children, and at times members of the extended family. Partners' views about the direction of such changes seemed to influence other perceptions about the therapy.

The repercussions of individual psychotherapy may well spread extensively within a family. This further blurs the boundary between individual and family therapy, both theoretically and clinically. Research procedures are themselves a major intervention and may have a considerable emotional impact on participants.

The aim of this study was to evaluate the effectiveness of a stepped care approach to the treatment of bulimia nervosa: a self-care manual followed, if necessary, by a course of attenuated cognitive behavioural treatment (CBT) in comparison with standard CBT.

One hundred and ten patients, presenting at a tertiary referral centre with ICD–10 bulimia nervosa or atypical bulimia nervosa, were randomly assigned to one of two treatment conditions; a) a sequential treatment group: 8 weeks with a self-care manual followed by up to eight sessions of CBT (if still symptomatic) or b) 16 sessions of CBT.

Bulimic symptoms improved significantly in both groups with no significant differences between the two groups on any of the measures at the end of treatment or at 18 months follow-up. At end of treatment 30% (95% CI: 18–46%) of the sequential group and 30% (95% CI: 17–47%) of the standard treatment group were free from all bulimic symptoms. Sixteen of those in the sequential group improved significantly with self-care and did not require additional treatment. The median number of sessions taken by the sequential group was three (95% CI: 0–6). At 18 months follow-up 40% (95% CI: 23–59%) of the sequential group and 41% (95% CI: 25–59%) of the CBT group were symptom free.

A sequential approach to the treatment of bulimia may be as effective as standard CBT and can considerably reduce the amount of therapist contact required.

The ‘Young Persons Unit’ (YPU) at Broadmoor Hospital offers psychotherapeutic treatment for young adult male patients. The study objective was to report background details, treatment and outcome of the ward's personality disordered patients.

The sample consisted of 49 patients, with the legal classification of psychopathic disorder, treated on the unit for at least one year. Data were collected from existing case records. Outcome was recorded until discharge from statutory supervision. Outcome measures were recidivism and a variety of social factors.

At follow-up 10 patients had reoffended, with four having committed serious violent or sexual offences. Two patients had died. A history of sex offending was the strongest predictor of subsequent reoffending. No patients with good social outcome reoffended.

Young patients with personality disorder can be successfully treated on the YPU. The management of sex offenders in this group requires further attention. Successful social integration within the community after discharge may help prevent future reoffending.

It has been suggested that the key variable in reduced plasma immunoreactive β-endorphin concentrations in autistic subjects may be concomitant self-injurious behaviour.

We studied morning levels of plasma β-endorphin in 33 learning disabled people with self-injurious and/or autistic behaviour.

The β-endorphin level of the subjects with severe self-injurious behaviour proved to be significantly lower than that of autistic subjects without severe self-injurious behaviour (3.6 (1.4) pmol/l v. 5.8 (4.3) pmol/l; t-test: P = 0.045. Replication: 3.7 (1.1) pmol/l v. 5.7 (3.8) pmol/l; t-test P = 0.043). Individuals with mild and occasional self-injurious behaviour were found to have β-endorphin levels comparable to those without self-injurious behaviour. Further, subjects being treated with neuroleptics had lower β-endorphin levels than untreated subjects.

These results stress that in any study of opioid systems of learning disabled people, it is very important to differentiate between people with and without severe self-injurious behaviour. The results support the idea that severe self-injurious behaviour may be related to functional disturbances in the endogenous opioid system.