The present study, conducted in collaboration between the Departments of Psychiatry in Swiss Universities and the World Health Organization, had two main goals: to develop assessment methods which could subsequently be used in the Swiss centres in a standard manner; and to make arrangements for continuing collaboration between the centres in Switzerland and the acquisition of new knowledge about the distinctions between depression and cognitive impairment. For this aim, three different groups of elderly patients of either sex were selected during the period of November 1989 to July 1991 for inclusion in the study. The first two groups included the first ten patients of either sex over 60 years of age consecutively contacting the participating institutions and showing depression with or without clinically significant symptoms of cognitive impairment; the control group included patients showing no depression or clinically significant symptoms of cognitive impairment. A total of 125 patients were included in the initial evaluation, 69 of which were reassessed at a seven-month follow up (on average). Each patient was administered a number of clinician-rated or self-report instruments for the assessment of depression, cognitive impairment, disabilities, physical status and onset of disorders. The study has shown that a variety of instruments can be used for the reliable assessment of depression or cognitive impairment in the elderly; but the instruments for the assessment of depression differentiate only poorly between patients with or without cognitive impairment. Because of the importance of identifying both depressed and cognitively impaired patients among the elderly, different assessment instruments targeted at the different symptom clusters need to be administered simultaneously.

Biological depression research can boast of a number of significant achievements over the past 35 years. Yet, in spite of those achievements, the field is in danger of desiccation. Five reasons are discussed herein: 1) short-comings of the DSM-based depression classification; 2) the ever increasing number of, generally poorly validated, diagnostic categories; 3) desubjectivation of psychiatric diagnosing; 4) the lack of a dimensional (better: functional) component in diagnosing depression; and 5) horizontalism, ie the absence of attempts to group symptoms “vertically” according to their diagnostic weight. The issues are in need of urgent scientific attention, lest biological depression research will stagnate and ultimately whither. We have indicated ways to approach the issues.

The history of the description by Jean-Pierre Falret of circular insanity, the origin of our present day bipolar disorder, is presented as well as the claims of priority raised by his colleague Jules Baillarger. A detailed account is given of the long-lasting controversy which has often given rise to biased judgments about the respective roles of the two psychiatrists. It is shown that the clinical concept was an expression of Falret's views about the nature of mental disorders and that, through the influence these views had on future nosological systems, the apparently purely picturesque episode corresponds to a landmark in the history of psychiatry.

Case management has been an integral part of psychiatric practice in the United States for over a decade and has generated a large body of literature. The application of case management principles to the care of people suffering from psychiatric disorders is becoming increasingly popular in the United Kingdom and Europe and literature is now beginning to be published. However, no definitive statements about the efficacy of case management have been made due to a range of conceptual and methodological problems. The present paper is a critical review of the case management outcome literature. Reported outcomes are reviewed in the context of study design and service characteristics. The authors conclude that case management practice can have at least some impact on patients' use of services (including marked decrease in in-patient bed days); satisfaction with services; engagement with services; and social networks and relationships when it is delivered as a direct, clinical service with high staff: patient ratios. A set of recommendations are suggested for the future practice and presentation of research into case management.

The World Health Organization (WHO) Somatoform Disorders Schedule (SDS) is a highly standardized instrument for the assessment of somatoform disorders according to the tenth revision of the International Classification of Diseases (ICD-10) and the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). The SDS was produced in the framework of the WHO International Study of Somatoform Disorders and tested for its reliability in Brazil, India, Italy, the USA and Zimbabwe. A sample of 180 patients from general psychiatry, primary care and general medical settings were interviewed with the SDS within a three-day interval by nonclinician and clinician interviewers. The agreement between the two interviews was tested using the intraclass correlation coefficients (ICC) and kappa statistic. The test-retest reliability of the SDS was found to be very good (the ICC for all the centres was 0.76; overall kappa value for SDS questions was 0.58; one-third of SDS questions had a kappa value of 0.60 or higher). The field test results of the SDS indicated that the instrument may be administered in larger studies by non-clinician interviewers without compromising the ability to document the prevalence of somatoform disorders in different cultures.

The conceptualisation and investigation of panic disorder have developed on two different axes, medical and psychological, for more than 100 years. In medicine, reports of acute anxiety attacks with cardiac, circulatory, and respiratory symptoms date back to the French Revolution, and terms such as “soldier's heart”, “neurocirculatory neurasthenia”, or “hyperventilation syndrome” have been used to describe them. In psychological medicine, anxiety attacks were first reported by Domrich in 1849. These attacks, which were thought to be caused by strong emotions, were classified mainly within neurasthenia, until Freud created the concept of anxiety neurosis in 1895.

Attempting an update of the epidemiology of schizophrenia, it is pointed out that schizophrenia seems to occur with the same core symptoms and almost at the same frequency in all countries and cultures studied. Methodologically sound studies have failed to produce evidence for a secular trend of the morbid risk. The genotype of schizophrenia is expressed as psychosis, personality disorders and non-specific disorders or it goes without manifest psychopathology. Minor brain anomalies are present in most cases. The British Child Development Study showed that behavioural, cognitive, emotional and neuromotor antecedents occur in 50% of cases, thus pointing to disordered brain development, very likely not specific to schizophrenia, since found in many other mental disorders as well. A look into the hidden early course of schizophrenia revealed a significant sex difference in age of onset and a prodromal phase of some 3 to 4 years throughout the cases. A case-control study showed that it is mainly during this early course before first admission that social disadvantage in schizophrenia arises. In the prephase a disease-related lack of social ascent plays a greater role than steps of social decline. The early social course differs between the sexes mainly due to an earlier onset of the disorder in males. The actual disease variables, that is, core symptoms and type of course, do not show any essential differences between males and females. These results indicate that schizophrenia is one of the rare uniform patterns of response of the brain, capable of being triggered by a large number of causes or favoured by non-specific risk factors. In this context the protective effect of estrogens will be discussed.

Consensus was reached on the five following points: (1) “Treatment resistance” is a term which is widely used, but not adequately defined. In particular, definitions of “responders” and “non-responders” need to be more precise. (2) There is a need to extend the assessment of the results of treatment to include factors such as quality of life and the subjective evaluation by the patient and relatives. (3) Clozapine (Clozaril®/Leponex®) has become the standard for atypical antipsychotic drugs. The adjective “atypical” is not an exact descriptor. The vague nature of the term leads to confusion with other drugs that are putative atypical antipsychotic agents but have different properties. D2 dopamine receptor antagonism is the single factor common to all antipsychotic drugs. Antagonism at a specific D2-like receptor may underlie the atypical antipsychotic actions of clozapine. Drugs described as being atypical antipsychotics share a relatively low incidence of extrapyramidal side effects. (4) Clozapine is the only drug that produces antipsychotic (therapeutic) effects at doses that do not result, in significant extrapyramidal side effects. This may be due to the fact that antipsychotic efficacy is obtained with clozapine in doses that result in significantly less striatal D2 occupancy. Other factors including concomitant 5-HT2 antagonism, may contribute to the lack of motor side effects observed with clozapine treatment. (5) Clozapine is the only drug currently well proven in therapy-resistant schizophrenia, and there is a case for its earlier use in patients who can be anticipated to become therapy resistant. Other antipsychotic therapies remain unproven in this group of patients.

First admission psychiatric patients born in England and Wales between 1938 and 1963, and discharged from hospitals in England and Wales between 1976 and 1986, were examined. Using logistic regression, we tested the hypothesis that the risk of shizophrenia varies by place, and season of birth. Persons born in city areas showed a 12% greater risk of schizophrenia (odds ratio 1.12; 95% confidence interval 1.06 to 1.19) than those born in non-city areas, when compared with other psychiatric patients. The increase in risk was particularly high for individuals born in city areas in winter (21%, ie odds ratio 1.21 and confidence interval 1.08 to 1.36). These findings suggest that the factor(s) responsible for the season-of-birth effect preferentially affects city born schizophrenics.

Standardization of nomenclature and terminology used in the field of mental health has been one of the main goals of the World Health Organization's (WHO) Mental Health Programme among recent activities undertaken to achieve this goal, is the development of definition and guidelines accompanying the chapter dealing with mental disorders in the tenth revision of the International Classification of Diseases (ICD-10) and of a set of instruments for the assessment of mental disorders. To enhance common understanding and uniformity of usage of the terms embedded in the classification and instruments and to facilitate their use in different cultures and settings, a series of lexica and glossaries has also been produced by WHO. The article describes the basic characteristics of the Lexicon of psychiatric and mental health terms, 2nd edition; Lexicon of alcohol and drug terms; Lexicon of crosscultural terms in mental health; SCAN glossary; and the ICD-10 symptom glossary for mental disorders.

This paper argues for a broader definition of treatment refractoriness that would include patients with partial drug responses, a relatively recent onset, less dramatic symptoms and intolerance to conventional drugs. The drug trials that define their responsiveness should be carefully conducted over a prolonged period of time, but need not include high doses or supplemental medications. If the consensus conference can agree on a definition of responsiveness, it will provide important guidance to clinicians as well as researchers.

Cerebral deficits in schizophrenia have been associated either with left hemisphere dysfunction, or with impairment in interhemispheric transfer. To test the relative efficacy of the two hypotheses, 63 right-handed subjects (24 paranoid schizophrenics, 21 nonparanoid schizophrenics, and 18 normal controls) were given two auditory lateral tasks: identification of dichotically delivered tonal sequences and digit sets. As the data analyses showed, more correct responses were given by the normal controls than by the patients, and by males than by females. Generally, report (especially from the ear reported second) was better from the right than from the left ear. This right ear advantage (which was more consistent in males than in females) was abnormally large for the paranoid schizophrenics who showed on both tests, relative to normal subjects, a slight decrement in right ear report and a significant decrement in left ear report. The data were interpreted as indicating left hemisphere dysfunction and structural callosal damage in paranoid schizophrenics.

The authors investigated the comorbidity between obsessive-compulsive disorder (OCD) and other psychiatric disorders in a group of 154 outpatients. The influence of an associate major depressive disorder (MDD) on the outcome of treatment with clomipramine was examined in a subgroup of 52 patients. The results showed that MDD was the most frequent disorder associated with OCD (almost 20% of the patients), followed by generalized anxiety and panic disorder. The co-presence of depression delayed the effect of clomipramine.

Quality of life became a paradigm in the medical setting two decades ago. Although ‘humanistic’ psychologists still maintain that what can be specified and measured is precisely what is not quality of life, time has shown that the major components of quality of life in health and disease can be measured with an acceptable internal as well as external validity. Quality of life in randomized clinical trials is now the third dimension to be measured, the other dimensions are efficacy of the drug and adverse drug reactions. Among the major areas of external validity quality of life scales (eg the PCASEE questionnaire and the Psychological General Well-Being Schedule) have discriminating validity (the discrimination between treatments), predictive-validity (the prediction of relapse of illness), and teological validity (defining goal of treatment).

The most important feature of panic disorder is the existence of a discrete crescendo of distress that peaks very quickly and disappears quickly (DSM-IV, 1994). However, a patient will frequently erroneously say that the panic lasted hours. When a person has a panic attack they feel tremendously overwhelmed and often seek help in accident and emergency units. An estimated one in three people who present at these units with chest pains has symptoms consistent with panic disorder (Fleet et al, 1994).

The aim of the present study is to evaluate the seasonal pattern of recurrences and the concordance among first episode (index episode) versus the subsequent recurrences in a sample of 210 patients affected by mood disorders, referred to the Mood Disorder Unit of San Raffaele Hospital. The most depressive recurrences are in spring for unipolar subjects and in fall for bipolars. Manic episodes are more frequent in summer. Patients presented a high concordance rate between the first and the second episode, female patients were more concordant than male subjects, and patients with low cycle of illness (one episode every six or more years) were the most concordant ones.

The course of negative and positive symptoms was studied in neuroleptic-treated patients over a 3-year period, in consideration also of the initial phase of illness (post-acute or chronic). This study was carried out in a broadly defined schizophrenic sample, in order not to give preference to one diagnostic subgroup over another. Forty-six patients were evaluated every year for 3 years, 23 in the post-acute group and 23 in the chronic group. Aggravations of the Clinical Global Impression (CGI) and of the SANS total score were observed, regardless of the group (chronic or post-acute). This global aggravation confirmed Kraepelin's concept of dementia praecox; moreover, this aggravation was not due to an increase in the number of patients relapsing, or to an aggravation of akinesia. Three types of negative and positive symptom courses were observed: i) the mean sub-scores of positive symptoms, such as hallucinations, delusions, positive formal thought disorders, and of negative symptoms such as flattening affect, avolition/apathy and attentional impairment, did not vary significantly over time in either group; ii) the mean sub-scores of bizarre behavior and alogia fluctuated over time (p < 0.05) and only poverty of speech was perfectly stable among the items constituting alogia; iii) the mean subscores of anhedonia/asociality worsened significantly over time irrespective of the groups (p < 0.05), and among the items constituting anhedonia, recreational interest-activities and intimacy-closeness abilities worsened (p < 0.05 and p < 0.01, respectively). This aggravation was neither due to an increase in neuroleptic doses nor to the duration and chronicity of illness. However, negative symptoms, except anhedonia, can be reversible in some patients. The very strong stability of anhedonia, whatever the group, emphasize the importance of taking anhedonia into account in future diagnostic classifications.

On the basis of 24 maternity hospital records, the current study investigated the validity of maternal recall and the relationship of maternal infections during pregnancy and obstetric complications (OCs) to different diagnostic subgroups of endogenous psychoses on which we reported previously in this journal. Maternal recall showed good agreement to maternity hospital records in the Lewis and Murray scale (ϑ = 0.74). With regard to infectious diseases during pregnancy maternal recall and records showed a weaker, but also good correlation (ϑ = 0.18). Psychoses with low genetic loading had more OCs than psychoses with high genetic loading. Maternal infectious diseases, especially during the fourth or fifth month of gestation, were significantly allocated to Leonhard's systematic schizophrenias. Data from maternity hospital records support our report that infectious diseases during midgestation and further perinatal complications seem to be important etiologic factors in systematic forms of schizophrenia without marked familial loading.

Primary health care is in the central position in the general sphere of mental health services. This article deals with, as a part of a joint Nordic project, the occurrence of mental disorders of patients in primary health care as based on the material (n = 1,000) collected in the health centre of Turku. The relation of the occurrence of mental disorders as diagnosed by means of a standardized psychiatric interview method (PSE) to the disorders, recognized by general practitioners (GPs) working in the health centre is also observed. It was found that one fourth of the patients had a clear mental disorder that required treatment, while studies in the general population, using the same method, reveal only 10% as having some kind of mental disorder. Three quarters of the evident mental disorders recognized by GPs were diagnosed as such also by the PSE, but the GPs were capable of recognizing only 43% of the cases identified by the PSE. On the basis of these results, the importance of the mental health issue in the basic and postgraduate training of the general practitioners must be emphasized.