Objective – To assess competing explanations for the universal preference of mothers to cradle infants on their left side and to propose a relation to hemispheric asymmetry for social attachment and communication behaviour. Methods – A review of observational, experimental, physiological, psychological, neuro-physiological, and neuro-psychological studies, including new findings on the cradling behaviour of mothers with auditory or visual impairments. Results – A significant left-cradling bias is observed in both right- and left-handed mothers which cannot adequately be explained by arguments based on handedness or closer contact to the soothing sound of the maternal heartbeat. Observations of primate behaviour have led to the suggestion that the left-cradling bias may be related to a left visual field (right hemisphere) advantage for monitoring an infant's facial expressions of distress. However, more than just monitoring, cradling subserves the mother's connection with the infant. For that reason, we have suggested that left cradling might be related to a right hemisphere specialisation for emotional communication, i.e. the speech melody, smiles, signals, and stroking which mothers use to interact with their infants. Studies of mother-infant interaction show that the sound of the mother's voice is more soothing when cradling on the left, more stimulating when cradling on the right. Cradling laterality may thus be related to emotional state and behavioural intent. There is also evidence to suggest that left cradling is linked to a special role of the right hemisphere in social attachment behaviour. This function may be disturbed in mothers with postnatal depression who show abnormal right hemisphere activity. Conclusion – Cradling embodies the symbiotic relationship between mother and infant; various lines of evidence support the suggestion that the universal preference of mothers to cradle infants on their left side is related to a right hemisphere dominance for social attachment and communication behaviour.

Objective – The assessment of outcome for any purpose is not undertaken routinely in European mental health services. This paper discusses the merits of using outcome data to inform the planning of mental health care for individual patients, and provides practical advice to support the implementation of this new approach to working. Method – The use of outcomes in North America and Europe is briefly reviewed. A conceptual basis is proposed for routine outcome assessment – the ongoing measurement and use of outcome data to inform decisions about whether to continue, change or curtail treatment. A cognitive psychology model is developed which indicates that the routine use of outcomes will improve mental health care. Perceived problems with routine outcome assessment are discussed, and principles for implementation are identified. Results – Outcomes are used mainly for generating local-level (rather than patient-level) data in North America, and rarely used in Europe. The use of outcome data routinely may facilitate reflective clinical practice, a model of decision-making which leads to a higher quality of clinical care than automated problem-solving. One issue relates to the use of standardised assessments designed for research purposes in clinical settings, and this is being addressed through the development of a new generation of outcome measures which are explicitly designed for clinical use. However, most clinicians remain unconvinced of the benefits of routine outcome assessment, and relevant research is currently underway across Europe which will address this concern. Scientific principles to maximise quality and pragmatic principles to maximise the chances of successful implementation are identified. Conclusions – The routine use of outcomes will become increasingly prominent in European mental health services. This provides clinicians with an opportunity to improve the quality of clinical care offered to patients.

Objective – In vivo structural magnetic resonance imaging (MRI) studies have evaluated the brain anatomy of various psychiatric disorders, allowing the investigation of putative abnormal brain circuits possibly involved in the patophysiology of psychiatric disorders. Here we reviewed the structural MRI literature in mood and anxiety disorders. Methods – All anatomical MRI studies evaluating mood and anxiety disorder patients were identified through a comprehensive Medline search conducted for the period from 1966 to January 2002, and a manual search of bibliographic cross-referencing complemented the Medline search. Results – Differential patterns of anatomical brain abnormalities appear to be involved in subtypes of mood disorders, with hippocampus and basal ganglia being abnormal in unipolar disorder, and amygdala and cerebellum in bipolar disorders, suggesting that these two mood disorders are biologically distinct. As for anxiety disorders, orbital frontal regions and basal ganglia have been reported to be anatomically abnormal in obsessive-compulsive disorder, temporal lobe was found to be abnormally reduced in panic disorder, and abnormal hippocampus shrinkage was shown in posttraumatic stress disorder. Conclusions – The structural MRI findings reviewed here suggest abnormalities in specific brain regions participating in proposed neuroanatomic models possibly involved in the pathophysiology of mood disorders and anxiety disorders. Nonetheless, available MRI studies have suffered from limitations related to relatively small patient samples and involvement of medicated patients, and were largely cross-sectional investigations. Therefore, longitudinal MRI studies involving more sizeable samples of drug-free patients, patients at first episode of illness or at high risk for mood or anxiety disorders, associated to genetic studies, are likely to be extremely valuable to separate state from trait brain abnormalities and to characterize further the pathophysiology of these disorders.

Objective – Two forms of early intervention in psychosis are currently being proposed — intervention before the onset of illness with at-risk individuals and intervention after the onset of psychosis. Method – The risks and potential benefits associated with these two approaches were examined using published data and Bayes probability theorem. Results -Claims for benefits from early intervention in established psychosis go back more than two hundred years to the nineteenth-century advocates for asylum construction. Theoretical support for early intervention in psychosis rests on data suggesting that a longer duration of untreated psychosis (DUP) is associated with poor outcome. The association of DUP with outcome, however, appears to be inseparable from the confounding influence of the good outcome expected in recent-onset psychosis. Although some researchers advocate treating people with premorbid features of psychosis or other high-risk indicators, adequate screening measures and effective interventions are not yet available. The most promising current screening measure, if applied to the general population, would be accurate only two percent of the time. The accuracy of these measures can be improved by screening only those patients who are referred to a clinic, but this strategy will result in many cases in the population-at-large being overlooked. Discussion – The risks and potential benefits associated with the two early intervention approaches are very different. The provision of optimal treatment early in psychosis could produce benefits, but people with brief, good-prognosis psychotic episodes are likely to receive unnecessary treatment. Screening the general population or patients referred to a clinic will have little public health impact on the incidence of schizophrenia. There is likely to be considerable negative impact on those who are inaccurately labeled as being at imminent risk of psychosis and are treated accordingly.

Objective – This article critically reviews the European Agency for the Evaluation of Medicinal Products (EMEA) recommendations on the conduct of clinical trials in psychiatry. The EMEA is a regulatory body which provides the institutions of the European Community with the best possible scientific advice on the quality, safety, and efficacy of medicinal products. Method – Systematic review of recommendations, guide-lines and official documents available in the EMEA web site. Results – Out of nearly 400 documents, we identified 4 documents on the conduct of clinical trials in specific psychiatric disorders and 5 on the use of placebo or active comparator in evaluating a new drug's efficacy and on methodological issues in establishing difference and equivalence of effect. The EMEA recommends clinical trials to detect a difference between the compound under investigation and placebo, and to assess at least non-inferiority against an active comparator. A placebo arm is intended to validate the study. The EMEA supports the use of placebo only when there is no serious risk for the patient. In schizophrenia, depression and bipolar disorder the Agency suggests that a three-arm study is the design of choice, to demonstrate superiority against placebo and a similar balance against an active comparator. Conclusions – Despite the many effective therapeutic options available for the pharmacological management of psychiatric disorders, the EMEA regulatory process still relies on the demonstration of efficacy in absolute terms, against a placebo. We discuss this position and put at issue the possibility of developing a new generation of trials to demonstrate superiority of effect of new compounds over reference ones.

Closing the gap between research and clinical practice is nowadays considered a priority in outcome studies. Survey studies in community settings having as their main aim the multidimensional measure of outcome of mental health care interventions, including the use of standardised instruments administered as part of the routine clinical activities in mental health services, have recently started to be planned in various countries, but have encountered several difficulties. A naturalistic, longitudinal study aimed to assess the outcome of care provided by a community-based mental health service, the South Verona Outcome Project, has been conducted in Italy starting from the beginning of the 90's and is running since then. This paper: a) describes a series of methodological aspects of the South Verona Outcome Project, such as instruments, study design, inclusion and exclusion criteria, training of the staff, and focuses on strategies used so to ensure feasibility of the assessment and good quality of the data; b) summarises some results of the study, characteristics of feed-back provided, and outputs; c) discusses the problems faced, the impact of this approach on service provision, its limitations and future perspectives.

Objective – The analysis aims to study the packages of care in the public Departments of Mental Health by diagnosis and service utilisation intensity. Design – Data on community, hospital and residential contacts were provided by the Regional Psychiatric Information System. The sample has been composed by 55518 patients residents in Lombardy and treated in public Departments of Mental Health. Setting – The public Departments of Mental Health in Lombardy. Main outcome measures – Fifteen packages of care were defined according to researchers' experience; the package “community care only” has been divided in five sub–packages; for every package the care weight has been attached. Results – Four packages of care (“community care only”, “hospital care plus community care”, “hospital care only” “community care plus day centre care”) represented 95% of the patients. Three quarter of the patients were treated only in the community setting, without hospital, residential and day centre contacts in the year. Heavier patients (patients with more than 5000 care weight) represent only 4%. Residential care is the heavier setting (36% of the total weight), while schizophrenia is the diagnosis with mayor impact on the community services (59% of the total weight). Of the patients treated only in the community setting one third receives only psychological and psychiatric visits, while two thirds integrated community care. Conclusions in community care the mixed packages represent the exception not the rule. More complex or heavier packages are addressed to severe mental illness patients.

Objective – To evaluate potential differences in socio-demographic and clinical characteristics (obsessivecompulsive symptomatology, axis I and II comorbidity) between OCD adults with an early age at onset (≤18 years) and later onset, (≤18 yrs). Design – Clinical controlled study. Setting – Anxiety and Mood Disorders Unit, Department of Neuroscience, University of Turin. Methods – We included 149 subjects with a principal diagnosis of OCD (DSM-IV) and a Y-BOCS total score ≤ 16 All patients underwent a semistructured clinical interview aimed at investigating sociodemographic characteristics and clinical features of the disorder. Lifetime Axis I comorbidity, according to DSM-IV criteria, was investigated with a structured interview following Othmer & Othmer guidelines (1994; 1999). Personality disorders were assessed using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). Results – 39 patients referred age at onset of OCD before 18 years (earlyonset group) and 110 patients at 18 years or later (later-onset group). Significant differences were found between the two groups: early-onset subjects are characterized by a preponderance of males, a chronic course of illness and a strong association with Schizotypal Personality Disorder. Discussion – When subtyping OCD according to age at onset we found significant differences which suggest a possible heterogeneity of the disorder. Our results seem to confirm that early-onset OCD may represent a more severe subgroup, with clinical characteristics such as the chronic course and the high association with Schizotypal PD which are significant in order to apply specific therapeutic strategies.

Objective – Description of the opinions about causes and psychosocial consequences of schizophrenia in a sample of psychiatric professionals, recruited in 29 Italian Mental Health Centres (MHC). Design – Each professional was asked to read a case-vignette describing a patient who met the ICD-10 criteria for schizophrenia. Referring to case-vignette, he/she was asked to fill the Questionnaire on the Opinions about Mental Illness – Professionals' version (QO-P). Professionals' opinions were explored in relation to: a) their socio-demographic variables and professional background; b) geographic location of the MHC. Setting – 29 MHC stratified by geographic area (Northern, Central, Southern Italy) and population density of their catchment areas (> 100000 inhabitants; between 100000 and 25000 inhabitants; < 25000 inhabitants) and randomly selected. Results – Data on 465 professionals were collected. 75% of the sample identified in the vignette a case of schizophrenia, 22% of depression/anxiety disorder. Factors most frequently mentioned as causes of the detected disorder were heredity (68%), stress (61%), family difficulties (46%). More pessimistic opinions about psychosocial consequences of schizophrenia were found among nurses and among professionals of Southern Italy, among those with lower educational level, older age and among those working longer in psychiatry. No statistical difference in the opinions about psychosocial consequences of schizophrenia was found among staff who referred the case-vignette to schizophrenia and those who did not. Conclusions – The results of this study outline the need to: a) include issues such as disability and psychosocial consequences of mental disorders in the basic training of professionals; b) increase the number of professionals trained in evidence-based psychosocial interventions.

Objective – To evaluate the prevalence of dementia among persons born in the year 1930 or before, who were living in Granarolo, Ravenna province, on December 31, 1991. Design – Population study, carried out in two phases: in the first was phase all persons were administered two screening tests for dementia. In the second phase, persons who screened positive underwent detailed clinical and cognitive assessments. Main outcome measures – The Mini Mental State Examination (MMSE) and the Global Deterioration Scale (GDS) were administered as screening tests. In the second phase the screened-positive subjects underwent a general and neurological examination, and a detailed neuropsychological assessment. Results – Of the 557 participants, 56 were clinically diagnosed as demented. Twenty-nine persons were diagnosed as affected by Alzheimer's disease (AD) and 14 patients by vascular dementia (VaD). The crude prevalence ratios for dementia were 9.1% (95% C.I.= 5.29−12.89) for men and 12.7 % (95% C.I.= 8.84−16.6) for women. The prevalence of all dementias, as well as AD, increased steeply every five years of age for both men and women up to 90 years of age. Women had higher prevalence of all dementias and AD than men, more evident in the advanced ages. Conclusions – Our findings are in agreement with similar studies carried out in European populations, showing that prevalence of dementia increases with increasing age. If we consider that in Italy the oldest (those 80 years and older) are the fastest growing part of the elderly population, we can expect that dementia will be a major emerging public health problem, as it is one of the most common diseases in the very elderly and a major cause of disability and mortality.

This paper examines two questions. Do staff and service users agree when rating the needs of those with severe mental illness? If not, what is the meaning of these differences? To put these questions in context, we shall define needs, examine one particular way in which needs can be measured in a standardised way, using the Camberwell Assessment of Need, and shall discuss three somewhat similar studies which have compared user and staff rated needs.

Objective – Cognitive Behavioural Therapy for the treatment of Social Phobia has proved effective through several controlled trials and meta-analyses. In spite of this the CBT has not spread in clinical field yet. Therefore our aim was to verify the effectiveness of the CBT in a public mental health service and to compare our results with those described by experimental research. Design and setting – Partecipants were 11 public mental health center clients, with a primary diagnosis of Social Phobia (according to DSM-IV criteria). The transportability of CBT to a common clinical setting was examined comparing treatment outcome data, at the end of the treatment and at a six months follow up, with results described in controlled efficacy studies. We employed self completion rating scales relating to both general health conditions and life satisfaction (SF36) and trend of symptoms (LSPS). Moreover we recorded the Clinical Global Impression (CGI) and Patient's Global Impression (PGI). Results – Despite differences in setting, clients and treatment providers, both the magnitude of change from pre treatment and maintenance of change at a six months follow up were comparable with the parallele findings in the efficacy studies. Conclusions –. The results attest the effectiveness of CBT even in a public mental health center setting so, in consideration of the fact that social phobia is a very common disease and involve high degree of severity, chronicity and disability, we hope that this effectual and relatively cheap therapy will be routinely applied in public mental health services.

Objective – Many different factors, both related to the individual and illness (“intrinsic” factors) and to the environment (“extrinsic” factors), contribute in different ways to the development of disability. Basing on data of literature, this review focuses the main “intrinsic” factors predicting disability in schizophrenia. Method – A systematic search on Mediline of all papers published during the period 1965-2001 was performed, using “schizophrenia”, “outcome”, “psychosocial outcome”, “social disability” and “social adjustment” as key words. Only papers reporting specifically data about predictive factors and psychosocial outcome variables were considered; prospective follow-up studies were considered, but retrospective and cross-sectional studies were also taken into account when data deriving from prospective studies were inconsistent. Results – Male sex predicts a higher disability among demographic factors; lower social and occupational adjustment are premorbid personality factors associated with higher disability; among factors related to illness, younger age at onset of illess, “nuclear”, “non paranoid” and in particular “deficit” forms of schizophrenia seem to predict more disability. The latter seems to be predicted also by higher levels of negative symptoms and neuropsychological deficits ; the role of depressive symptoms seems to be less supported by follow-up data; a continuous course of the illness predicts more disability, although some evidences show a progressive reduction of disability, at least in the long term. Conclusions – Disability shows a largely autonomous course respect to symptoms and has to be considered an independent parameter of outcome. Few intrinsic factors show a predictive role also in the long term.

This paper is concerned with issues in the routine measurement of quality of life in a mental health context. It is in three parts. In the first part the first author reviews briefly, lessons from a decade of experience in the use of data produced by routine measurement using the Colorado Client Assessment Record (CCAR) in the Mental Health Centre of Boulder County (MHCBC) in Colorado, USA. In the second part, the specific issues surrounding quality of life assessment as a routine outcome measure are considered. Evidence is presented to counter some of the commonly held beliefs about QoL measurement problems. Finally, general problems that affect QoL and all other routine measures are described and analysed using a framework devised by Peterson (1989).

Objective – The study aims to identify the predicting factors of hospitalization in patients who come in Emergency Room with psychiatric symptoms. Method – Cross-sectional study using data collected by E.R. of S.Gerardo Hospital in Monza from 1st of June 1995 to 31 May 1997. Inclusion criteria were age older than 18 and the need for psychiatric evaluation. The influence on disposition decision of demographic, clinical and service variables were assessed. Main outcome measures – Data were collected by a questionnaire designed for the study and administered by a trained psychiatrist. Statistical analysis was performed by univariate analysis and logistic regression. Results – 2076 cases were evaluated. Univariate analysis yielded higher odds of hospitalization for patients between 39 and 48 years of age, unmarried, unemployed, affected by schizophrenia, mood disorders or personality disorders. A linear trend was reported between hospitalization and severity of illness, siucide risk and aggressivness. While anxiety proved to be a protective factor, hallucination, delusion, lack of insight, psychomotor inhibition, agitation, confusion, destructive behaviour, odd behaviour, abnormal consciousness and previous hospitalization increase inpatient disposition. On Monday and Friday higher frequency of hospitalization was observed. Logistic regression confirm the role of age, symptoms, aggressive behaviour, severity of illness, suicide risk, and, among services variables, days of the week. Conclusion – Clinical variables proved to be the main predictors of hospitalization, and an important role is played by the availability of outpatients services: hospitalization was more frequent in the days closer the week-end, when the outpatient services are closed.

Three issues characterise the background to the MECCA study: A) Throughout Europe, most patients with severe forms of psychotic disorders are cared for in the community. The challenge now is to make processes in community mental health care more effective. B) There are widespread calls to implement regular outcome measurement in routine settings. This, however, is more likely to happen, if it provides a direct benefit to clinicians and patients. C) Whilst user involvement is relatively ?" easy to achieve on a political level, new mechanisms may have to be established to make the views of patients feed into individual treatment decisions. The MECCA study is a cluster randomised controlled trial following the same protocol in community mental health teams in six European countries. In the experimental group, patients' subjective quality of life, treatment satisfaction and wishes for different or additional help are assessed in key worker-patient meetings every two months and intended to inform the therapeutic dialogue and treatment decisions. The trial tests the hypothesis that the intervention – as compared to current best standard practice – will lead to a better outcome in terms of quality of life and other criteria in patients with psychotic disorders over a one year period. This more favourable outcome is assumed to be mediated through different treatment input based on more appropriate joint decisions or a more positive therapeutic relationship in line with a partnership model of care or both. Moreover, the study will hopefully reveal new insights into how therapeutic processes in community mental health care work and how they can be optimised.

Objective – The aim of the present study is to provide an epidemiological study about suicide in Verbano-CusioOssola province, between January 1990 and December 2000. Design – The present study is based on the acquisition of data through the examination of model 45, that registers all the cases of violent death and suicide, filed in Verbania Republic Procuration. Setting – The Verbano-Cusio-Ossola province extends 2,255 Km2 and counts 161,248 inhabitants. The Procuration in Verbania has territorial jurisdiction on the whole province of our study. Main outcome measures – The data obtained were presented in terms of descriptive analysis, evaluation of standardised rates of the province of Verbano-Cusio-Ossola. In order to appreciate the differences in comparison with the mean rates of northern Italy, Standardised Mortality Rates (SMRs) with the confidential intervals (IC 95%) have been used. Results – In the eleven years period considered, 297 cases of suicide were notified at the Court with a rate of 16.74 per 100,000 inhabitants. The trend of suicide in the period examined is heterogeneous with significant differences between males and females. The analysis of SMRs points out that the incidence of suicide is higher in the province of VCO than in Italy in the same decade and that this difference is mostly due to an higher rate of suicide among women. The analysis of social-demographic parameters of the examined population confirms the data from international literature: suicide is more present in elderly, in widowers and in the retired. Conclusions – The present study means to provide a description of the suicide phenomenon, in a specific geographical and cultural context, in order to point out the problematic sides in a diagnostic-clinical point of view that may be an incentive to a larger preventive care.

Aims – Taking the scientific literature on psychotherapy as a starting point, the paper suggests a few remarks for the debate over psychological treatments in the mental health services in Italy. Methods – A survey of reviews and papers on process and outcome of psychological treatments and on psychotherapeutic practice in mental health services. Results – The paper examines some organizing hypotheses in order to increase psychological treatments supplies. Conclusion – The practicability of such solutions requires on the one hand more attention for empirically supported psychological treatments in mental health professionals training and, on the other hand, that various health services become able to be different in their treatments supply.