Background. The median age at first childbirth has increased dramatically in many high-income countries during the past decades. The psychiatric consequences of this demographic change are insufficiently described on a population level. This study aimed to investigate whether parental age at childbearing is related to psychiatric morbidity among Swedish youths.

Method. This was a cohort study based on Swedish national registers. A national cohort of 292129 children born to primiparas women during 1973–1979 was followed prospectively from 1987 to 2002 in registers. Multivariate Cox analyses of proportional hazards were used to estimate the relative risk of hospital admission for schizophrenia, alcohol and illicit drug abuse, suicide attempts and deaths.

Results. Youths born of teenage mothers had a high risk for suicide death [relative risk (RR) 1·9, 95% confidence interval (CI) 1·3–2·7] and hospital admissions because of suicide attempt (RR 2·0, 95% CI 1·7–2·3) and substance abuse (alcohol: RR 1·6, 95% CI 1·4–1·8; illicit drug: RR 2·2, 95% CI 1·9–2·5) after adjustments for major sociodemographic confounders, compared with children of mothers aged 25–29 years. Offspring of older parents (>34 years) had the highest risk for schizophrenia (RR 1·8, 95% CI 1·0–3·0).

Conclusions. Parental age is related to psychiatric morbidity.

Background. Pregnancy has often been associated with cognitive deficits, but results are equivocal and little is known about how these deficits progress with time.

Method. In the present study, the cognitive performance of 57 pregnant women was compared with that of 50 non-pregnant women matched for age and education, using a well-validated neurocognitive test battery at weeks 14, 17, 29, and 36 of pregnancy, and 32 weeks postpartum in the pregnant group and at comparable times in the non-pregnant group.

Results. Memory encoding and retrieval, as assessed with a word learning task, were significantly lower in the pregnant group than in the control group. This difference was still present at 32 weeks after delivery. The two groups did not differ in complex speed of information processing at any of the test moments; however, general speed of information processing was significantly compromised during early motherhood (week 32 postpartum).

Conclusion. Thus, memory performance is poorer during pregnancy and early motherhood, and general speed of information processing is slower during early motherhood.

Background. Impulsiveness, hostility and aggressiveness are traits associated with suicidal behavior, but also with borderline personality disorder (BPD). The presence of large numbers of BPD subjects in past attempter samples may distort the relative importance of each of these traits to predicting suicidal behavior, and lead to prospective, biological and genetic models that systematically misclassify certain subpopulations of suicidal individuals.

Method. Two hundred and seventy-five subjects with major depressive disorder (MDD), including 87 with co-morbid BPD (69 past suicide attempters, 18 non-attempters) and 188 without BPD (76 attempters, 112 non-attempters) completed standard impulsiveness, hostility and aggressiveness ratings. Differences between past suicide attempters and non-attempters were examined with the sample stratified by BPD status.

Results. As expected, BPD subjects scored significantly higher than non-BPD subjects on all three trait measures. Stratifying by BPD status, however, eliminated attempter/non-attempter differences in impulsiveness and hostility in both patient subgroups. Past suicide attempters in each of the two subgroups of patients were only distinguished by higher levels of aggressiveness.

Conclusions. Once BPD is accounted for, a history of aggressive behavior appears to be the distinguishing trait characteristic of suicide attempters with major depression, rather than global personality dimensions such as impulsiveness or hostility. Aggressiveness, and not these related traits, may be the ideal target for behavioral, genetic and biological research on suicidal behavior, as well as for the clinical assessment of suicide risk.

Background. Although included in the current edition of the DSM, there does not seem to be consensus among mental health professionals regarding the diagnostic status and scientific validity of dissociative identity disorder (DID). This study was aimed at the detection of simulation of inter-identity amnesia in DID.

Method. A sample of 22 DID patients was included, together with a matched control sample of subjects instructed to simulate inter-identity amnesia, a guessor group that had no knowledge of the stimulus material and a normal control group. A multiple-choice recognition test was included. The rate of incorrect answers was determined. Moreover, the specific simulation strategy used was examined by providing subjects with a range of choices that varied in extent of disagreement with the correct answer and determining whether plausible or implausible answer alternatives were selected.

Results. On the recognition test DID patients selected incorrect answers above chance like simulators. Patients thus seem to use their knowledge of the correct answer in determining their given answer. They were not characterized by a well-thought-out simulating behaviour style, as indicated by the differences in selection of specific answer alternatives found between patients and simulators.

Conclusions. DID patients were found not to be characterized by an actual memory retrieval inability, in contrast to their subjective reports. Instead, it is suggested that DID may more accurately be considered a disorder characterized by meta-memory problems, holding incorrect beliefs about their own memory functioning.

Background. Previous studies suggest that worry content and prevalence may vary as a function of age, but evidence is limited.

Method. Cross-sectional national survey of 8580 householders in Great Britain aged between 16 and 74 years. This analysis examined the relationship between age, worry content (relationships/family, financial/housing, work, health, miscellaneous), common mental disorders, and functional limitation, adjusting for other sociodemographic factors.

Results. Overall, the prevalence of worries declined with age. However, with the exception of worry about relationships, the strength of associations between worry types and mental disorder either remained constant or increased in the older age groups. Compared to the 16–24 years reference group, worries about relationships/family, finances/housing and work were lower in the 55–74 years age groups. Financial/housing worries were increased in the 25–44 years group, and health worries were increased in the 25–64 years groups. There were independent associations between all worry items and the categories of mental disorder. All worry types apart from miscellaneous worries were independently associated, positively or negatively, with functional limitation.

Conclusions. Worry content in the general population varies as a function of age, gender, marital status, and educational attainment. All categories of worry are more prevalent in individuals with common mental disorders. The lower prevalence of worries and their stronger association with mental disorder in old age emphasize the clinical significance of these symptoms in this age group.

Background. Psychotherapy's equivalence paradox is that treatments have equivalently positive outcomes despite non-equivalent theories and techniques. We compared the outcomes of contrasting approaches practised in routine care.

Method. Patients (n=1309) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) and psychodynamic therapy (PDT) at one of 58 National Health Service (NHS) primary and secondary care sites in the UK during a 3-year period completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. Therapists indicated which treatment approaches were used on an End of Therapy form. We compared outcomes of six groups: three treated with CBT, PCT or PDT only, and three treated with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1, PCT+1 or PDT+1 respectively.

Results. All six groups averaged marked improvement (pre–post effect size=1·36). Treatment approach and degree of purity (‘only’ vs. ‘+1’) each accounted for statistically significant but comparatively tiny proportions of the variance in CORE-OM scores (respectively 1% and 0·5% as much as pre–post change). Distributions of change scores were largely overlapping.

Conclusions. Results for these three treatment approaches as practised routinely across a range of NHS settings were generally consistent with previous findings that theoretically different approaches tend to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, lack of a control group, missing data and other issues.

Background. This study examined the relationships between self-reported childhood sexual abuse (CSA) and drug-related outcomes in an Australian twin panel.

Method. A semi-structured psychiatric interview was conducted in 1996–2000 by telephone with young adult Australian twins (mean age 29·9 years). Data reported here are from 6050 twins who responded to both CSA and drug-related items.

Results. A history of CSA was associated with significant risk for subsequently occurring regular smoking and use of each illicit drug class. Further CSA-associated risk was found among regular users, for nicotine and alcohol dependence, and among illicit drug users, for abuse/dependence of most drug classes. In same-sex discordant pairs, significant risk for regular smoking and illicit drug use was found in twins with a history of CSA compared to their non-abused co-twins. Similar analyses for abuse/dependence found significant risk for opioids, any illicit drug, and any non-cannabis illicit drug. CSA was associated with significantly earlier drug use. Despite the association of CSA with risk for early-onset cannabis use and regular smoking, risks for illicit drug outcomes associated with CSA and with either form of early-onset use combine in near-additive fashion.

Conclusions. CSA is associated with risk for subsequently occurring regular smoking and illicit drug use and abuse/dependence. Risks for drug use are mildly attenuated with control for familial contributions; similar risks for abuse/dependence remain significant for opioids and for illicit drugs combined across classes. Although we found evidence of earlier onset drug use with CSA, risks associated with CSA and with early-onset use combine in a largely additive manner.

Background. Routine use of standardized outcome measures within adult mental health services is compulsory in many countries, but not common in clinical practice. As well as political and professional factors, one reason may be that there is little empirical evidence of benefit for patients. It is therefore important to identify predictors of response. Pre-morbid intellectual functioning has predicted response to other interventions. This paper tests the hypothesis that pre-morbid IQ impacts on the effectiveness of routine assessment and feedback of outcome measures.

Method. The Feedback of Outcomes to Users and Staff (FOCUS) single-blind randomized controlled trial (RCT) investigated routine completion and feedback of outcome measures for 160 (101 intervention, 59 control) adult mental health service patients in Croydon, South London (International Standard RCT Number 16971059).

Results. Patients in the top quarter (pre-morbid IQ>110) differentially improved in patient-rated unmet need (adjusted difference 3·4, 95% CI 0·8 to 5·9, p=0·012) and in the top half (pre-morbid IQ>99) in quality of life (adjusted difference −0·6, 95% CI −1·1 to −0·1, p=0·02). The top quarter result remained when controlling for the influence of baseline (p=0·004) and baseline plus follow-up variables (p=0·047).

Conclusions. Feedback of routine outcome measures may improve outcome for patients with higher pre-morbid IQ. There is a need to understand more how routine outcome information is used by staff and patients to inform care. If the goal of routine use of outcome measures is to benefit patients directly, then targeted policies are required.

Background. There are no published criteria for improving the quality of effectiveness of randomized controlled trials (RCTs) in psychiatry.

Method. The authors review and systematize the relevant literature on effectiveness trials, with particular reference to psychiatry.

Results. In planning effectiveness RCTs in psychiatry, seven sets of issues need to be carefully considered: (i) study question (i.e. is the study question expressed in an answerable way?); (ii) reference population (i.e. what is the reference group or subgroup to which the trial results should be generalized?); (iii) patient sample (i.e. how far does the sample reflect the target population?); (iv) study settings (i.e. how representative are the study settings of routine clinical sites?); (v) study interventions (i.e. is the study intervention manualized, acceptable to patients and suitable for widespread use?); (vi) control condition (i.e. are the key characteristics of the control condition well described, and do they vary within and between sites?); and (vii) bias (e.g. attrition, blinding, concealment, consent and contamination).

Conclusions. More effectiveness trials are needed which have sufficient statistical power to provide precise answers to assist clinicians in making treatment decisions. The development of effectiveness trials in psychiatry, both for studies of individual treatments and for service evaluations, may be enhanced by carefully considering and justifying decisions in relation to each of the seven key headings proposed here.

Background. The majority of people providing informal care for people with amyotrophic lateral sclerosis (ALS) are spouses. This prospective study set out to examine changes in and predictors of psychological distress in spouse carers of people with ALS.

Method. Fifty spouse carers of people with ALS underwent an initial interview and at least 21 underwent two further interviews, at median intervals of approximately 5–6 months. They rated the functional impact of their partner's ALS on everyday activities and everyday cognitive, emotional and behavioural changes that might have occurred in the person with ALS. They also rated their own social support and marital relationship, and completed measures of mood, burden and strain. The ALS Severity Scale was also completed for their partner with ALS.

Results. Over time, carers' psychological distress (a global measure combining mood, burden and strain) increased significantly. Initially carers' psychological distress was best predicted by the psychosocial impact of their spouse/partners' ALS, the extent to which their partner demonstrated emotional lability and how many other people were considered as dependents of the carer. Subsequently, carer distress was best predicted by an initial measure of negative social support and by their initial satisfaction with their social relationships.

Conclusions. Despite the significant physical impairment associated with ALS, psychosocial factors appear important in determining short- and longer-term psychological well-being in carers of people with ALS and may help clinicians to predict which carers are likely to experience psychological difficulties as part of their caring role.

Background. Depression and cognitive functioning have a negative impact on functional recovery after hip fracture surgery in older people, and the same has been suggested for pain and fear of falling. These variables, however, have never been studied together, nor has the timing of psychiatric assessment been taken into account.

Method. Two parallel, randomized controlled trials were undertaken aiming to prevent and treat depression after hip fracture surgery in older people. Multiple logistic regression analyses corrected for age and pre-morbid level of functioning were performed to evaluate the effect of depressive symptoms (15-item Geriatric Depression Scale, GDS), pain (Wong–Baker pain scale), cognitive functioning (Mini-mental State Examination, MMSE) and fear of falling (Modified Falls Efficacy Scale, MFES) within 2 weeks after surgery and 6 weeks later on functional recovery at 6 months. Main outcome measures were performance-based measures (up-and-go test, gait test, functional reach) and the self-report Sickness Impact Profile (SIP) questionnaire to assess the impact of the hip fracture on activities of daily living (ADL).

Results. Two hundred and ninety-one patients participated and outcome measures for 187 (64%) patients were available at 6 months. All mental health variables interfered with functional recovery. However, in the final multivariate model, cognitive functioning and fear of falling assessed 6 weeks after surgery consistently predicted functional recovery, whereas pain and depressive symptoms were no longer significant.

Conclusion. Fear of falling and cognitive functioning may be more important than pain and depression to predict functional recovery after hip fracture surgery. Rehabilitation strategies should take this into account.

Background. Psychiatric in-patients are at particularly high risk of suicide but few studies have investigated trends in in-patient suicide over time.

Method. We conducted a prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997–2003). The study was carried out as part of the National Confidential Inquiry into Suicide. The main outcome measure was death by suicide. Suicide rates were determined using Hospital Episode Statistics (HES) as the denominator.

Results. Between the first 2 years of the study (1997 and 1998) and the last 2 years of the study (2002 and 2003) the annual number of in-patient deaths from suicide fell from 187 to 156 (a 17% reduction). The rate of in-patient suicide fell by between 9% and 28% depending on which denominator was used. This fall was observed for both males and females, and was most marked for those aged 15–44 years. Reductions were also observed for the three most common methods of death (hanging, jumping, poisoning), but the trend for hanging did not reach statistical significance. Although the number of post-discharge suicides fell, the risk of post-discharge suicide (using admissions as a denominator) may have increased by as much as 10% during the study period.

Conclusion. The rate of suicide among psychiatric in-patients appears to have fallen. The fall may reflect falling general population rates, changes in in-patient case mix, service improvements, or a transfer of risk to the post-discharge period. Services need to be aware of the importance of providing high quality aftercare following discharge from hospital.

Background. Evidence for the effects of marital status and marital status change on physical health is equivocal.

Method. Structural equation models examined whether marital status predicted physical health. Six groups were examined simultaneously: married (M); widowed (W); divorced (D); never married (NM); newly widowed (NW); and newly divorced (ND). There were four annual measures (T1–T4). Both NW and ND were married at T1, but had lost their partners by T2. Four physical health variables were examined: Problems, Limitations, Service use, and Self-rated health (SRH). Age and gender were included.

Results. Previous health predicted future for all measures and for all groups. However, the specific strengths and time-courses varied between marital status groups and between health measures. The most marked patterns were associated with marital status change. Service use was influenced most strongly by NW, whilst Limitations was influenced by ND. Problems distinguished NW and ND from stable marital status groups but also from each other. SRH was influenced by W and not by recent marital status change. The effects of age and gender were modest and restricted to specific health variables and specific marital statuses.

Conclusions. The results demonstrate that marital status and marital status change, in particular, influence health longitudinally. The impact of a change to divorced or to widowed status is not the same. No two health variables responded in the same way, suggesting that marital status has a differential effect on health.

Background. Previous cross-sectional studies have found substantial genetic influences on individual variation in subjective well-being (SWB), and evidence for sex-specific genetic effects has been reported. However, the genetic and environmental influences on stability and change in SWB over time are largely unexplored.

Method. Questionnaire data on SWB from a population-based sample of Norwegian twins born 1967 to 1979, initially surveyed in 1992 (T1) and re-surveyed in 1998 (T2), were analysed using structural equation modelling to explore the relative effects of genetic and environmental influences on phenotypic stability and change.

Results. The phenotypic cross-time correlations for SWB were 0·51 and 0·49 for males and females respectively. The best-fitting longitudinal model specified only additive genetic and individual environmental effects with qualitative and quantitative sex-specific genetic influences. For both males and females, the additive genetic factors influencing SWB were largely stable, although some time-specific genetic contributions were indicated. Cross-time correlations for genetic effects were 0·85 and 0·78 for males and females respectively. The individual environmental influences were primarily time-specific. Additive genetic effects explained approximately 80% of the phenotypic cross-time correlation. For females, the magnitude of the additive genetic effects decreased significantly from T1 to T2, whereas for males, the estimates generally remained unchanged.

Conclusions. For both males and females, long-term stability of SWB was mainly attributable to stable additive genetic factors, whereas susceptibility to change was mostly related to individual environmental factors. However, both stable environmental contributions and emerging genetic influences were indicated.

Background. We measured psychopathic traits in boys with autism spectrum disorder (ASD) selected for difficult and aggressive behaviour. We asked (i) whether psychopathic tendencies can be measured in ASD independent of the severity of autistic behaviour; (ii) whether individuals with ASD with callous–unemotional (CU) traits differ in their cognitive profile from those without such traits; and (iii) how the cognitive data from this study compare with previous data of youngsters with psychopathic tendencies.

Method. Twenty-eight ASD boys were rated on psychopathic tendencies, autistic traits and a range of cognitive measures assessing mentalizing ability, executive functions, emotion recognition and ability to make moral–conventional distinction.

Results. Our results indicate that psychopathic tendencies are not related to severity of ASD. In addition, such tendencies do not seem to be related to core autistic cognitive deficits, specifically in ‘mind-reading’ or executive function. Boys with co-occurring ASD and CU tendencies share some behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone.

Conclusions. Callous/psychopathic acts in a small number of individuals with ASD probably reflect a ‘double hit’ involving an additional impairment of empathic response to distress cues, which is not part and parcel of ASD itself.

Background. Oculomotor studies have found saccadic abnormalities in obsessive–compulsive disorder (OCD), lending support for models postulating a central role for inhibition in OCD. Saccadic abnormalities in OCD may also be potential candidates for a biological marker, important for more endophenotype-oriented research. Saccadic abnormalities have not been examined in psychotropic-naive patients with OCD without co-morbidity.

Method. We compared the error rates and latencies of 14 carefully selected adult psychotropic-naive patients with OCD with no co-morbid diagnosis and 14 pairwise matched healthy controls on a fixation task, on a prosaccade task and on an antisaccade task.

Results. Patients with OCD showed normal error rates on all tasks, but latencies on the antisaccade task were significantly increased.

Conclusions. Our results indicate that patients with OCD have no gross impairment of oculomotor inhibitory capacities, but may have a disturbed capacity to deliberately initiate a saccade to an imagined target.