A review of the efficacy of antidepressant drug treatment in patients with obsessive–compulsive disorder (OCD), using a meta-analytic approach.

Randomised double-blind clinical trials of antidepressant drugs, carried out among patients with OCD and published in peer-reviewed journals between 1975 and May 1994, were selected together with three studies currently in press. Forty-seven trials were located by searching the Medline and Excerpta Medica – Psychiatry data bases, scanning psychiatric and psychopharmacological journals, consulting recent published reviews and bibliographies, contacting pharmaceutical companies and through cross-references. Hedges' g was computed in pooled data at the conclusion of treatment under double-blind conditions or at the latest reported point of time during this treatment period. For each trial, effect sizes were computed for all available outcome measures of the following dependent variables: obsessive–compulsive symptoms considered together; obsessions; compulsions; depression; anxiety; global clinical improvement; psychosocial adjustment; and physical symptoms.

Clomipramine was superior to placebo in reducing both obsessive–compulsive symptoms considered together (g = 1.31; 95% CI = 1.15 to 1.47) as well as obsessions (g = 0.89, 95% CI = 0.36 to 1.42) and compulsions (g = 0.79; 95% CI = 0.34 to 1.24) taken separately. Also, selective serotonin re-uptake inhibitors (SSRIs) as a class were superior to placebo, weighted mean g being respectively 0.47 (95% CI = 0.33 to 0.61), 0.54 (95% CI = 0.34 to 0.74) and 0.52 (95% CI = 0.34 to 0.70) for obsessive–compulsive symptoms considered together, and obsessions and compulsions taken separately. Although on Y–BOCS the increase in improvement rate over placebo was 61.3%, 28.5%, 28.2% and 21.6% for clomipramine, fluoxetine, fluvoxamine, and sertraline respectively, the trials testing clomipramine against fluoxetine and fluvoxamine showed similar therapeutic efficacy between these drugs. Finally, both clomipramine and fluvoxamine proved superior to antidepressant drugs with no selective serotonergic properties.

Antidepressant drugs are effective in the short-term treatment of patients suffering from OCD; although the increase in improvement rate over placebo was greater for clomipramine than for SSRIs, direct comparison between these drugs showed that they had similar therapeutic efficacy on obsessive–compulsive symptoms; clomipramine and fluvoxamine had greater therapeutic efficacy than antidepressant drugs with no selective serotonergic properties; concomitant high levels of depression at the outset did not seem necessary for clomipramine and for SSRIs to improve obsessive–compulsive symptoms.

People with obsessive–compulsive disorders (OCD) are widely treated with a combination of medication and behavioural techniques. The success rate is 50–85%, but both relapse and drop-out rates appear high. The use of cognitive therapy (CT) for the treatment of OCD has been suggested. The empirical evidence supporting the use of CT for OCD is examined.

A manual and computer (Medline) literature search was performed.

Fifteen empirical studies were found: ten non-controlled, and five controlled.

There are few controlled CT studies, and these show little evidence of improvement when CT is added to existing therapeutic techniques.

The White Paper The Health of the Nation targets a reduction in suicide rates. Preventive strategies must be guided by an understanding of the demography and antecedents of suicide. These issues are examined in relation to suicide by old people in Manchester.

One hundred consecutive coroners' inquisitions on people aged over 65 occurring between 1980 and 1991 in which the verdict was suicide were scrutinised and related to Health Service notes.

Suicides were rare, numbers ranging from 0 to seven per annum per Health District. Rates did not vary between district but did within smaller sub-populations. Most individuals died at home; 65% were physically ill, of whom 23% had been hospitalised within the previous year. At least 60% were clinically depressed, with 25% being prescribed antidepressants. A total of 43% had seen their general practitioner in the previous month but only 14% were in contact with psychiatric services.

Many elderly people who commit suicide are not in close contact with primary care services; those who are may not be prescribed appropriate treatment, and few are referred for specialist care. Specialist services will fail to reduce suicide rates unless they embark upon programmes to increase public awareness of therapeutic possibilities and work more closely with primary care agencies to realise these possibilities.

This study explored some of the problems associated with current procedures for the ascertainment of suicide.

A sample of 242 deaths which were known to have been self-inflicted was followed up through the coroners' courts where causes of death were legally established.

Verdicts other than suicide were returned on half of the men, and on one-quarter of the women.

For suicide statistics to become valid indicators of suicide rates it might be more appropriate to apply the civil, rather than the criminal, standard of proof during inquest proceedings.

This paper examines the evidence that rates of anorexia nervosa have increased over time.

Epidemiological studies that have provided time trends in incidence rates in specific countries or psychiatric registers and prevalence surveys were reviewed to assess whether or not prevalence estimates are higher in the most recent studies.

Estimated trends in incidence rates showed an increase but no study ruled out plausible alternative explanations. Studies showing no upward trend were as numerous and were generally based on larger samples. Analysis of 29 cross-sectional surveys conducted over the last 25 years indicated that the median prevalence rate was 1.3 per 1000 females. There was no indication that more recent surveys yielded higher prevalence rates.

Anorexia nervosa remains a rare disorder and there is no evidence of a secular increase in its incidence.

It is important to determine the optimal manner of categorising eating disorder patients so as to aid in the understanding of their specific psychopathological state.

We compared subgroups of eating disorder patients divided according to different sets of factors, using a structured interview which elicits the specific psychopathological features of these illnesses. The patients, comprising 116 consecutive women admitted to two university-affiliated eating disorder clinics, were grouped according to DSM–III–R criteria, clinical presentation (purging, binge eating), nutritional status, and age.

The clearest separation of groups was afforded by the clinical dimension of purging as opposed to not purging. This was superior to DSM–III–R criteria. Other systems, such as presence of binge eating, and various levels of nutritional status and of age, were clearly inferior.

The presence or absence of purging behaviour appears to offer the most heuristic means of categorising eating disorder patients with respect to their specific psychopathological state.

This is a sociobiological approach to depression using hierarchy and its hypothesised relevance to self-esteem in the marsupial sugar glider (Petaurus breviceps).

Differential access to resources between the dominant and submissive animal is measured by observation in four stable colonies. The dominant animals from two of these colonies are then introduced into the other two, resulting in the transferred former dominants becoming subordinate. Behavioural and biochemical measures relevant to depression and involving access to resources are then repeated. These measures include eating, drinking, social and sexual access, motility, grooming and biochemical estimates of cortisol and testosterone.

Subordinate animals have significantly less access to resources, both in the stable colony and when the formerly dominant animals become subordinate.

A sociobiological approach using a hierarchy model equating resource-holding potential with self-esteem, exemplified by this study, may provide new concepts and insights into the phenomenology and pathophysiology of depression. It allows comparisons to be made between animal behaviour and cognition: the lack of such has been a major difficulty in animal studies hitherto. The findings are possibly more relevant to dysthymia than to affective disorder and imply a relationship between low resource-holding potential in sub-human animals as a phylogenetic antecedent of some of the cognitive and affective aspects of depression in man.

The effectiveness of different assessment procedures for determining prevalence rates of psychiatric disorder in young adults was investigated.

In a two-stage multi-method procedure, the Young Adult Self-Report, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the Structured Interview for Personality Disorders (Revised), and the Global Assessment of Functioning (GAF) Scale were used to assess prevalence rates in 706 19–24-year-olds from the general population. Furthermore, individuals' subjective perception of distress and referral to mental health services were assessed.

The prevalence of any SCAN/DSM–III–R disorder was 19.3% (95% confidence interval: 11.2–27.4%). Most subjects who received a SCAN/DSM–III–R diagnosis were only mildly impaired. The highest prevalence rates of dysfunctioning (GAF score below 61) without referral to mental health services were for dissociative disorder (2.3%), sleep disorder (2.1 %), alcohol dependence (1.3%) and affective disorder (1.8%).

Instruments that assess functional impairment in addition to DSM–III–R diagnoses are indispensable in prevalence studies.

The study tests the hypothesis that juvenile-onset schizophrenia is associated with premorbid developmental impairments. It was predicted that the pattern of developmental impairments would vary with age of onset and with gender.

A case-control design was used to examine developmental impairments in 61 consecutive juvenile-onset (age 7–17) referrals with ICD-9 schizophrenia; 61 non-psychotic psychiatric controls were matched on age and gender. Cases and controls were divided into childhood-onset (age 7–13) and adolescent-onset (age 14–17).

The schizophrenic cases had a significantly higher risk of premorbid social (χ2 = 9.1, P<0.005), motor (χ2 = 9.1, P<0.005) and language impairments (χ2 = 10.1, P<0.005). Specific impairments of language production and comprehension were associated with childhood-onset schizophrenia and were independent of gender.

Juvenile-onset schizophrenia is associated with a range of developmental antecedents. There may be a specific link between cases with a very early onset and an impairment in the processes underlying the development of language.

We highlight the profile of brain computerised tomography (CT) measures among Nigerian psychiatric patients for comparison with findings from developed countries, and study of the relationship between CT values and clinical variables.

Seven brain ventricle measures of 50 schizophrenic patients, 14 manic patients, and 41 healthy control subjects were compared.

Patients had a significantly higher mean Sylvian fissure area. The third ventricle of schizophrenic patients was significantly larger than those of control subjects. CT measures were not significantly correlated with duration of illness.

The so-called functional psychotic states are most probably associated with nonspecific brain abnormality.

A possible association between disordered water homeostasis and cerebral ventricular size in patients with schizophrenia was investigated.

In a cross-sectional study of hospitalised patients, cerebral ventricular size was measured in 16 schizophrenic patients with disordered water homeostasis and 16 matched schizophrenic controls by magnetic resonance imaging.

Ventricle to brain ratio, third ventricular index, bicaudate index and bifrontal index tended to be greater in those with schizophrenia with disordered water homeostasis, although differences were significant only for the bifrontal index (P<0.05). Strong negative correlations were found between ventricular size and performance on neuropsychological testing in the disordered water homeostasis group.

These results provide evidence for an association between structural brain abnormality and disordered water homeostasis in a subset of schizophrenic patients.

This brief report presents initial findings from a prospective descriptive study of adults after the homicide of a family member. Within the first year of bereavement, the responses and risk factors associated with unrecovered grief and post-traumatic stress disorder in subjects who requested or refused supportive psychotherapy were compared.

Fifty-two adult members of 237 families contacted within three months of a homicide attended a specialised out-patient clinic (32 requested, and 20 refused, supportive therapy) after a structured interview and completion of measures of grief (TRIG), trauma (RIES and DES), and death imagery.

Only two risk factors (childhood history of sexual abuse and lack of religious faith) were associated with treatment seeking. Treatment-seeking subjects also scored significantly higher (P<0.001) on all measures of grief, trauma, and intrusive re-enactment imagery of the dying.

Adults who seek therapy after the homicide of a family member are highly reactive to all measures of trauma, grief, and death imagery.

Pharmacological approaches to opiate addiction have for the most part been limited to a role in detoxification. A high percentage of patients who complete detoxification programmes relapse.

In the present study, we used a simple laboratory method to investigate suggestions from preclinical studies that 5-(hydroxytryptamine) HT3 receptor antagonists have a role in the treatment of addiction.

We showed that addicts stably maintained on methadone experienced significant craving, dysphoria, and withdrawal-like symptoms when exposed to a video containing drug-related cues. The craving was not lessened by treatment with the 5-HT3 receptor antagonist, ondansetron (4 mg orally).

Our current findings do not support a role for 5-HT3 receptor agonists in the reduction of craving in opiate addicts.

This exploratory study investigates the performance of the Health Measurement Questionnaire (HMQ), as compared with the Psychiatric Assessment Schedule (PAS) and the Nottingham Health Profile (NHP), and compares self- and observer-completed measures.

A total of 138 medical patients scoring over the screening threshold for probable psychiatric illness completed the HMQ, NHP and PAS, and were rated by a psychiatrist on Rosser disability and distress.

HMQ disability correlated well with NHP and PAS physical health items, while HMQ distress correlated well with the NHP emotional reactions and PAS Index of Definition. There was significant correlation between self-report and psychiatrist ratings, the latter being more sensitive to distress.

The HMQ is a useful measure of generic health status in liaison psychiatry settings.

This study measures psychiatric morbidity, quality of life, and cognitive function after liver transplantation.

We undertook a cross-sectional study, with a longitudinal subgroup. The setting was a tertiary referral centre for liver transplantation. The subjects were 30 post-liver-transplantation patients, including 11 also interviewed before the operation. The main outcome measures were the Clinical Interview Schedule (CIS), the General Health Questionnaire (GHQ), the Nottingham Health Profile (NHP), and the Mini-Mental State Examination (MMSE).

Of the patients, 8/30 were CIS cases, and 7/30 were GHQ cases. NHP scores were higher than a previous postal study indicated, with less impairment after than before transplant. MMSE scores were 24–30. Median GHQ was 7.0 before operation and 1.0 after operation (P = 0.03), with no significant change in CIS score.

Liver transplantation improves quality of life, but not to the level of the general population; post-transplantation patients have a prevalence of psychiatric morbidity comparable with that of general medical patients.

There has been discussion about the possible occurrence of post-traumatic stress disorder (PTSD) in mothers after difficult childbirth.

Four cases with a symptom profile suggestive of PTSD commencing within 48 hours of childbirth are presented.

The PTSD was in each case associated with the delivery. In each case, there was an associated depressive illness. All four had persistent disorders, and two had difficulties with mother/infant attachment.

As confirmed by other reports, the prevalence of PTSD associated with childbirth is a matter of concern.

New cases of erotomania in men, plus cases from the literature, were analysed to explore any association between erotomania and dangerousness, and to identify possible predictors.

Files at two in-patient facilities were examined to determine the presence of DSM–III–R delusional disorder, erotomanic type. The sample (13 cases) was divided into dangerous and benign groups on the basis of serious antisocial behaviour directly related to erotomanic delusions. These cases were combined with all reports of erotomania in men (16 cases), found in the English language psychiatric literature, to allow for statistical analysis.

Two factors, multiple delusional objects (P < 0.0005) and serious antisocial behaviour unrelated to the delusions (P < 0.05), were found to be significantly associated with dangerousness. Using a combination of these two variables it was possible to predict dangerousness with an accuracy of 88.9% (weighted prediction accuracy or ‘hit rate’). We identified no false negatives but three false positives.

The presence of multiple objects, and a history of serious antisocial behaviour unrelated to the erotomanic delusions, are useful predictors of dangerous behaviour in men with erotomania.