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Showing papers in "British Journal of Psychiatry in 1998"


Journal ArticleDOI
TL;DR: All mental disorders have an increased risk of premature death, and risk of death from unnatural causes is especially high for the functional disorders, particularly schizophrenia and major depression.
Abstract: BACKGROUND We describe the increased risk of premature death from natural and from unnatural causes for the common mental disorders. METHOD With a Medline search (1966-1995) we found 152 English language reports on the mortality of mental disorder which met our inclusion criteria. From these reports, covering 27 mental disorder categories and eight treatment categories, we calculated standardised mortality ratios (SMRs) and 95% confidence intervals (CIs) for all causes of death, all natural causes and all unnatural causes; and for most, SMRs for suicide, other violent causes and specific natural causes. RESULTS Highest risks of premature death, from both natural and unnatural causes, are for substance abuse and eating disorders. Risk of death from unnatural causes is especially high for the functional disorders, particularly schizophrenia and major depression. Deaths from natural causes are markedly increased for organic mental disorders, mental retardation and epilepsy. CONCLUSION All mental disorders have an increased risk of premature death.

1,854 citations


Journal ArticleDOI
TL;DR: The resulting 12-item HoNOS instrument is simple to use, covers clinical problems and social functioning with reasonable adequacy, has been generally acceptable to clinicians who have used it, is sensitive to change or the lack of it, and showed good reliability in independent trials.
Abstract: BACKGROUND An instrument was required to quantify and thus potentially measure progress towards a Health of the Nation target, set by the Department of Health, "to improve significantly the health and social functioning of mentally ill people". METHOD A first draft was created in consultation with experts and on the basis of literature review. This version was improved during four stages of testing: two preliminary stages, a large field trial involving 2706 patients (rated by 492 clinicians) and tests of the final Health of the Nation Outcome Scales (HoNOS), which included an independent study (n = 197) of reliability and relationship to other instruments. RESULTS The resulting 12-item instrument is simple to use, covers clinical problems and social functioning with reasonable adequacy, has been generally acceptable to clinicians who have used it, is sensitive to change or the lack of it, showed good reliability in independent trials and compared reasonably well with equivalent items in the Brief Psychiatric Rating Scales and Role Functioning Scales. CONCLUSIONS The key test for HoNOS is that clinicians should want to use it for their own purposes. In general, it has passed that test. A further possibility, that HoNOS data collected routinely as part of a minimum data set, for example for the Care Programme Approach, could also be useful in anonymized and aggregated form for public health purposes, is therefore testable but has not yet been tested.

1,057 citations


Journal ArticleDOI
TL;DR: Several brain structures in schizophrenia are affected to a greater extent than expected from overall reductions in brain volume, and substantial reductions were also evident in the amygdala and hippocampus.
Abstract: BACKGROUND Numerous in vivo brain imaging studies suggest that cerebral structure is abnormal in schizophrenia, but implicate different regions to varying extents. METHOD We identified published MRI studies in schizophrenia with searches of the computerised literature and key journals. Reports giving the volumes of cortical structures in people with schizophrenia and controls were included. The percentage differences in volumes were calculated and the median taken as a summary measure for each brain region. RESULTS Forty relevant studies were identified. The median percentage volume differences revealed overall reductions in the whole brain (3%), temporal lobe (6% left, 9.5% right), and the amygdala/ hippocampal complex (6.5%, 5.5%); and increases in the lateral ventricles (44%, 36%), that were greatest in the body and occipital horns. Segmentation studies suggest that grey matter is reduced but that white matter volumes may actually be increased. In men, substantial reductions were also evident in the amygdala and hippocampus, as well as the largest reductions of all in the parahippocampus (14%, 9%). Few studies gave figures for women alone. CONCLUSIONS Several brain structures in schizophrenia are affected to a greater extent than expected from overall reductions in brain volume. Further studies are required in affected women, and to try to identify clinical and aetiological associations of these findings.

858 citations


Journal ArticleDOI
TL;DR: Routine use of MANOVA for the analysis of longitudinal data, particularly when there is a substantial proportion of drop-outs, is ill advised and psychiatric researchers dealing with such data should be aware of the advantages of the newer methods.
Abstract: BACKGROUND Longitudinal data arise frequently in psychiatric investigations, and are most often analysed by multivariate analysis of variance (MANOVA) procedures However, as routinely applied, the method is not satisfactory, particularly when the data are affected by subjects dropping-out of the study More suitable methods are now available METHOD Problems with the MANOVA approach are discussed and the advantages of alternative procedures stressed RESULTS Using MANOVA on complete cases to analyse unbalanced longitudinal data can be seriously misleading More recently developed methods are far more suitable, but only if the missing values are non-informative CONCLUSIONS Routine use of MANOVA for the analysis of longitudinal data, particularly when there is a substantial proportion of drop-outs, is ill advised Statisticians have considerably enriched the available methodologies during the past decade, and psychiatric researchers dealing with such data should be aware of the advantages of the newer methods

841 citations


Journal ArticleDOI
TL;DR: It is demonstrated that it is possible to identify individuals with a high likelihood of onset of psychosis within a brief follow-up period, which lays the foundation for early treatment in an attempt to prevent, delay or minimise the severity of first onset of schizophrenia.
Abstract: Background The identification of people at high risk of becoming psychotic within the near future creates opportunities for early intervention prior to the onset of psychosis to prevent or minimise later ill-health. The present study combines current knowledge about risk factors for schizophrenia with our knowledge of psychotic prodromes in an attempt to identify a group particularly vulnerable to impending psychosis. We wanted to identify people with high likelihood of transition to psychosis within a follow-up period of 12 months, and to determine the rate of transition to psychosis in this group. Method Various state and trait risk factors for psychosis were used alone and in combination to operationally define a putatively high-risk group. Operationalised criteria for onset of psychosis were established. The individuals were assessed monthly on measures of psychopathology for six months. Results Eight out of 20 people made the transition to frank psychosis within a six-month follow-up period. Follow-up of this group is still in progress, and the 12 month transition rate might prove to be higher still. Conclusions We have demonstrated that it is possible to identify individuals with a high likelihood of onset of psychosis within a brief follow-up period. This lays the foundation for early treatment in an attempt to prevent, delay or minimise the severity of first onset of schizophrenia.

769 citations


Journal ArticleDOI
TL;DR: The lifetime suicide risk figures often quoted in the literature appear to be too high, based on data from 1921–1975 and calculations performed before computerised modelling techniques became available.
Abstract: BACKGROUND The lifetime risks of suicide are generally quoted as 15% for affective disorder and alcoholism and 10% for schizophrenia, based on data from 1921-1975 and on calculations performed before computerised modelling techniques became available. This study recalculates the risk using contemporary data and modern techniques. METHOD Twenty-seven mortality studies provided data for affective disorder, 27 for alcohol dependence and 29 for schizophrenia. The proportion of the cohort who had died was plotted against the proportion of deaths from suicide. Modelling techniques fitted curves through the data points extrapolating them to cohort extinction, thus estimating the lifetime risk of suicide for each disorder. RESULTS The lifetime risk was estimated at 6% for affective disorder. 7% for alcohol dependence and 4% for schizophrenia. CONCLUSIONS The lifetime suicide risk figures often quoted in the literature appear to be too high.

576 citations


Journal ArticleDOI
TL;DR: The results support the effectiveness of compliance therapy in improving functioning and community tenure after an acute psychotic episode and survival in the community prior to readmission was significantly longer in the compliance therapy group.
Abstract: BACKGROUND: A randomised controlled trial was conducted in an acute treatment setting to examine the effectiveness of compliance therapy, a brief pragmatic intervention targeting treatment adherence in psychotic disorders, based on motivational interviewing and recent cognitive approaches to psychosis. METHOD: Seventy-four patients with psychotic disorders according to DSM-III-R criteria recruited from consecutive admissions to an acute in-patient unit, received 4-6 sessions of either compliance therapy or non-specific counselling, and were followed-up over 18 months. The principal outcome measures were observer-rated compliance, attitudes to treatment, insight and social functioning. RESULTS: Significant advantages were found for the compliance therapy group post-treatment on measures of insight, attitudes to treatment and observer-rated compliance which were retained over the follow-up period. Global social functioning improved relatively more over time in the compliance therapy group compared with the control group. Survival in the community prior to readmission was significantly longer in the compliance therapy group. CONCLUSIONS: The results support the effectiveness of compliance therapy in improving functioning and community tenure after an acute psychotic episode.

524 citations


Journal ArticleDOI
TL;DR: Maternal stress during pregnancy may contribute to the development of vulnerability to schizophrenia and the apparent longer window of exposure in male foetuses may be related to the slower pace of male early cerebral development.
Abstract: BACKGROUND It has been suggested that prenatal exposure to maternal stress increases the risk of subsequently developing schizophrenia. METHOD The five-day invasion and defeat of The Netherlands by the German army in May 1940 constituted a severe, well-circumscribed national stressful event. Individuals exposed and non-exposed to this stressor in the first, second and third trimester of pregnancy were followed up for lifetime schizophrenia outcome through the National Psychiatric Case Register. REGISTER: Cumulative incidence of schizophrenia was higher in the exposed cohort (risk ratio (RR): 1.15, 95% CI 1.03-1.28), especially in those exposed in the first trimester (RR: 1.28, 95% CI 1.07-1.53). Significant interaction with gender was apparent in second trimester exposed cohorts (RR men: 1.35, 95% CI: 1.05-1.74; RR women: 0.83, 95% CI: 0.61-1.12). CONCLUSION Maternal stress during pregnancy may contribute to the development of vulnerability to schizophrenia. The apparent longer window of exposure in male foetuses may be related to the slower pace of male early cerebral development.

476 citations


Journal ArticleDOI
TL;DR: Social factors in exile, particularly the level of ‘affective’ social support, proved important in determining the severity of both post-traumatic stress disorder and depressive reactions, particularly when combined with a severe level of trauma/torture.
Abstract: BACKGROUND Refugees who have suffered traumatic events present complex therapeutic challenges to health professionals. There is little research into post-exile factors that may be amenable to change, and therefore reduce morbidity. We examined the importance of social factors in exile and of trauma factors in producing the different elements of psychological sequelae of severe trauma. METHOD Eighty-four male Iraqi refugees were interviewed. Adverse events and level of social support were measured. Various measures of psychological morbidity were applied, all of which have been used in previous trauma research. RESULTS Social factors in exile, particularly the level of "affective" social support, proved important in determining the severity of both post-traumatic stress disorder and depressive reactions, particularly when combined with a severe level of trauma/torture. Poor social support is a stronger predictor of depressive morbidity than trauma factors. CONCLUSIONS Some of the most important factors in producing psychological morbidity in refugees may be alleviated by planned, integrated rehabilitation programmes and attention to social support and family reunion.

472 citations


Journal ArticleDOI
TL;DR: The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse, but the risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them to either increased institutional containment or greater coercion.
Abstract: BACKGROUND A relationship exists between mental disorder and offending behaviours but the nature and extent of the association remains in doubt. METHOD Those convicted in the higher courts of Victoria between 1993 and 1995 had their psychiatric history explored by case linkage to a register listing virtually all contacts with the public psychiatric services. RESULTS Prior psychiatric contact was found in 25% of offenders, but the personality disorder and substance misuse accounted for much of this relationship. Schizophrenia and affective disorders were also over-represented, particularly those with coexisting substance misuse. CONCLUSIONS The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse. The risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion.

442 citations


Journal ArticleDOI
TL;DR: The Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) had satisfactory psychometric properties and a cut-off score of 9/10 is recommended for screening depressive illness in a general postnatal population.
Abstract: BACKGROUND We evaluated the utility of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) and measured the prevalence of major depression six weeks after confinement among Chinese women in Hong Kong. METHOD A prospective cohort of 145 women completed the EPDS, the 12-item General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) six weeks after giving birth. They were then assessed with the Structured Clinical Interview for DSM-III-R, non-patient version (SCID-NP) to establish psychiatric diagnosis. The criterion validity of EPDS was tested against this clinical diagnosis, and the concurrent validity against the GHQ and BDI scores was also evaluated. The internal consistency of the scales was measured by Cronbach's alpha coefficient. RESULTS The Chinese EPDS had satisfactory psychometric properties and a cut-off score of 9/10 is recommended for screening depressive illness in a general postnatal population. At six weeks postpartum, 5.5% of the study population suffered from major depression. CONCLUSIONS The Chinese EPDS will be useful for screening for postnatal depression.

Journal ArticleDOI
TL;DR: Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.
Abstract: Background The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity. Method Cross-sectional and prospective data on 20 291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period. Results Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder. Conclusions Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.

Journal ArticleDOI
TL;DR: C cumulative trauma continued to affect psychiatric symptom levels a decade after the original trauma events, and the diagnostic validity of PTSD criteria, with the notable exception of avoidance, was supported.
Abstract: BACKGROUND The dose-effect relationships of cumulative trauma to the psychiatric symptoms of major depression and post-traumatic stress disorder (PTSD) in a community study of Cambodian survivors of mass violence were evaluated. METHOD In 1990, a survey of 1000 households was conducted in a Thai refugee camp (Site 2) using a multi-stage random sampling design. Trauma history and psychiatric symptoms were assessed for two time periods. Analysis used linear dose-response regression modelling. RESULTS 993 Cambodian adults reported a mean of 14 Pol Pot era trauma events and 1.3 trauma events during the past year. Symptom categories of depression, PTSD, dissociative and culturally dependent symptoms exhibited strong dose-effect responses with the exception of avoidance. All symptom categories, except avoidant symptoms, were highly correlated. CONCLUSIONS Cumulative trauma continued to affect psychiatric symptom levels a decade after the original trauma events. The diagnostic validity of PTSD criteria, with the notable exception of avoidance, was supported. Inclusion of dissociative and culturally dependent symptoms increased the cultural sensitivity of PTSD.

Journal ArticleDOI
TL;DR: The results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity.
Abstract: BACKGROUND The aetiology of treatment-resistant major depression is little understood; its apparent intractability may reflect brain abnormality. METHOD Magnetic resonance images of the brains of 20 subjects with major depression lasting for two years or more were compared with 20 healthy control subjects and 20 other subjects who had completely recovered from depression. Subjects were individually matched for age, gender, years of education and premorbid IQ. Grey matter was segmented from the images, and compared between groups on a voxel-by-voxel basis. RESULTS Subjects with chronic depression showed reduced grey matter density in the left temporal cortex including the hippocampus. There was also a trend for reduction in the right hippocampus. Left hippocampal grey matter density was correlated with measures of verbal memory, supporting the functional significance of the observed magnetic resonance imaging changes. CONCLUSIONS Our results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity. Confirmatory longitudinal and prospective studies are required to determine whether these differences pre-date the onset of depression or are the result of the chronic illness process or its treatment.

Journal ArticleDOI
TL;DR: Positive attitude change was achieved during the Defeat Depression Campaign, although there is still room for improvement in some aspects.
Abstract: BACKGROUND Aims of the Defeat Depression Campaign between 1991 and 1996 included the reduction of stigma associated with depression, education of the public about the disorder and its treatment and encouragement of earlier treatment-seeking. Newspaper and magazine articles, radio and television programmes and other media activities were employed. METHOD Surveys of public attitudes were conducted by MORI in late 1991, early 1995 and mid-1997. Each covered approximately 2000 subjects, sampled to be representative of the population of Great Britain. Structured interviews covered views on depression, treatment and general practitioners (GPs). RESULTS There were significant positive changes regarding attitudes to depression, reported experience of it, attitudes to antidepressants, and less consistently, to treatment from GPs. Changes were of the order of 5-10%. Throughout, attitudes to depression and to treatment by counselling were very favourable, whereas antidepressants were regarded as addictive and less effective. CONCLUSIONS Positive attitude change was achieved during the Campaign, although there is still room for improvement in some aspects.

Journal ArticleDOI
TL;DR: The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified, and the socio-demographic, clinical and ethnic characteristics of the patients are presented.
Abstract: BACKGROUND This paper sets out the rationale for the PRiSM Psychosis Study, and the research design used. Nine accompanying papers present the main results. The questions addressed by the PRiSM Psychosis Study are: can the gains of experimental studies which have demonstrated benefits arising from treatment by community mental health teams be translated to routine settings? If so, are the benefits diluted in ordinary clinical practice? What are the costs? METHOD A prospective nonrandomised controlled trial of two types of community mental health service, in two phases: case identification followed by patient interviews. For the case identification the research team conducted the complete ascertainment of all prevalent cases of psychosis in the two study catchment areas in the index year (1991-1992). From all 514 patients with psychotic disorders thus identified, 302 were randomly allocated for interview, along with a key informant clinician and a carer. Interviews were under taken at two time points, two years apart. RESULTS This paper presents the socio-demographic, clinical and ethnic characteristics of the patients. CONCLUSIONS The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified.

Journal ArticleDOI
TL;DR: Caseness at follow-up was associated with disability and economic deprivation, and targeting risk groups for poor outcome for interventions and policy interventions to reduce the impact of economic deprivation may provide a way of tackling CMD in primary care in low income countries.
Abstract: BACKGROUND Little is known about the outcome of common mental disorders (CMD) in primary care attenders in low income countries. METHOD Two and 12 month (T1 and T2) follow-up of a cohort of cases of CMD (n = 199) recruited from primary health, traditional medical practitioner, and general practitioner clinics in Harare, Zimbabwe. The Shona Symptom Questionnaire (SSQ) was the measure of caseness. RESULTS The persistence of case level morbidity was recorded in 41% of subjects at 12 months. Of the 134 subjects interviewed at both follow-up points, 49% had recovered by T1 and remained well at T2 while 28% were persistent cases at both T1 and T2. Higher SSQ scores, a psychological illness model, bereavement and disability predicted a poor outcome at both times. Poorer outcome at T1 only was associated with a causal model of witch-craft and an unhappy childhood. Caseness at follow-up was associated with disability and economic deprivation. CONCLUSIONS A quarter of cases of CMD were likely to be ill throughout the 12 month follow-up period. Targeting risk groups for poor outcome for interventions and policy interventions to reduce the impact of economic deprivation may provide a way of tackling CMD in primary care in low income countries.

Journal ArticleDOI
TL;DR: Most male and a substantial proportion of female suicides die in their first suicide attempt, a fact that necessitates early recognition of suicide risk, particularly among males.
Abstract: BACKGROUND This study investigated three questions with major implications for suicide prevention: the sensitivity of the history of previous suicide attempt(s) as an indicator of suicide risk, the time interval from a preceding suicide attempt to the fatal one, and switching of suicide methods by those eventually completing suicide. METHOD The lifetime history of suicide attempts and the methods the victims (n = 1397) used were examined in a nationwide psychological autopsy study comprising all suicides in Finland within a 12-month research period in 1987-1988. RESULTS Overall, 56% of suicide victims were found to have died at their first suicide attempt, more males (62%) than females (38%). In 19% of males and 39% of females the victim had made a non-fatal attempt during the final year. Of the victims with previous attempts, 82% had used at least two different methods in their suicide attempts (the fatal included). CONCLUSIONS Most male and a substantial proportion of female suicides die in their first suicide attempt, a fact that necessitates early recognition of suicide risk, particularly among males. Recognition of periods of high suicide risk on the grounds of recent non-fatal suicide attempts is likely to be important for suicide prevention among females. Subjects completing suicide commonly switch from one suicide method to another, a finding that weakens but does not negate the credibility of restrictions on the availability of lethal methods as a preventive measure.

Journal ArticleDOI
TL;DR: The results appear to be most consistent with a multi-factorial aetiology for schizophrenia and offer tentative support for a psychological disturbance mediating genetic and environmental effects on the causal pathway to the illness.
Abstract: BACKGROUND Schizoid personality and poor social adjustment have been thought of as common antecedents of schizophrenia but the existing literature is inconclusive. We have carried out a large cohort study with improved methodology. METHOD The premorbid personality and adjustment of 50,054 Swedish men were assessed on entry into the army at the age of 18. Individuals who developed schizophrenia or another psychosis after 15-year follow-up were identified. Odds ratios for variables independently associated with the later development of schizophrenia were calculated, adjusting for potential confounders. RESULTS Four variables reflecting early problems with interpersonal relationships were strongly associated with later schizophrenia and, to a lesser extent, non-schizophrenic psychoses, but also occurred commonly in the cohort as a whole. These associations with schizophrenia persisted after early-onset cases were excluded, though their predictive value was low (3.0%, 95% CI 1.5-4.5). CONCLUSIONS Some aspects of premorbid personality and adjustment may act as risk factors for schizophrenia. The results appear to be most consistent with a multi-factorial aetiology for schizophrenia and offer tentative support for a psychological disturbance mediating genetic and environmental effects on the causal pathway to the illness.

Journal ArticleDOI
TL;DR: The findings indicate a persistent effect of postnatal depression on child adjustment and highlight the need for resources devoted to supporting mothers of young children and particularly routine screening and treatment for postnatal mood disorder.
Abstract: BACKGROUND Little is known of the behavioural adjustment of children of postnatally depressed mothers. Previous studies have relied on maternal reports, and have produced inconsistent findings. METHOD In a prospective, longitudinal study of the five-year-old children of a community sample of postnatally depressed and well women, evidence was collected concerning the children's adjustment in the context of school, teachers being asked to complete questionnaires after the children had finished their first term. RESULTS Family social class and the child's gender had the most pervasive influences on adjustment. However, both postnatal and recent maternal depression were associated with significantly raised levels of child disturbance, particularly among boys and those from lower social class families. CONCLUSIONS The findings indicate a persistent effect of postnatal depression on child adjustment. They highlight the need for resources devoted to supporting mothers of young children and particularly routine screening and treatment for postnatal mood disorder.

Journal ArticleDOI
TL;DR: Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotics, and over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.
Abstract: BACKGROUND Although increased mortality is one of the most consistent and accepted epidemiological findings in schizophrenia, a high rate of suicide appears unable to account fully for this burden which remains poorly understood. METHOD A cohort of 88 in-patients was followed prospectively over a 10-year period and predictors of survival sought among demographic, clinical and treatment variables. RESULTS Over the decade, 39 of the 88 patients (44%) died, with no instances of suicide. Reduced survival was predicted by increasing age, male gender, edentulousness and time since pre-terminal withdrawal of antipsychotics; additionally, two indices of polypharmacy predicted reduced survival: maximum number of antipsychotics given concurrently (relative risk 2.46, 95% CI 1.10-5.47; P = 0.03) and absence of co-treatment with an anticholinergic (relative risk 3.33, 95% CI 0.99-11.11; P = 0.05). CONCLUSIONS Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotic polypharmacy. Conversely, over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.

Journal ArticleDOI
TL;DR: This paper reviews the history of Asperger syndrome and high-functioning autism, current diagnostic concepts and criteria, some controversial diagnostic issues, epidemiology, background factors, outcome, and intervention guidelines.
Abstract: This paper reviews the history of Asperger syndrome (AS) and high-functioning autism (HFA), current diagnostic concepts and criteria, some controversial diagnostic issues, epidemiology, background factors, outcome, and intervention guidelines.

Journal ArticleDOI
TL;DR: More work is needed to determine whether these people who die by suicide show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.
Abstract: BACKGROUND Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play. METHOD A systematic review of the literature. RESULTS Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up to 9% may commit suicide within one day of discharge. The corresponding figures are 11 and 4% for community-based psychiatric care and 83 and 20% for general practitioners. CONCLUSIONS Among those who die by suicide, contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Journal ArticleDOI
TL;DR: For people with personality disorder better clinical descriptions seem essential, and treatment appears as important for public safety as for personal health for people with a pure psychosis.
Abstract: BACKGROUND From a first clinical description of a complete resident sample of special (high security) hospital patients, we examined the association between mental disorder and violence. METHOD A record survey of all 1740 patients resident at any time between 1 January and 30 June 1993, inclusive, and, for most, the official criminal record. RESULTS 1015 patients (58%) had functional psychosis, one-quarter of whom also had an independent personality disorder; 461 (26%) had personality disorders uncomplicated by psychosis, and 264 (16%) had learning disabilities. Pre-admission substance misuse, which was probably under-recorded, had been most common among those with psychosis and an independent personality disorder. Less than 10% had never been convicted of a criminal offence, although 25% had been admitted directly from other hospitals. Direct personal violence was more common among men, and fire-setting among women. Schizophrenia was most strongly associated with personal violence. More than 75% of those with a psychosis were recorded as being driven to offend by their delusions. In the absence of delusions, hallucinations had no such effect. CONCLUSIONS For people with personality disorder better clinical descriptions seem essential. For people with a pure psychosis, as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health.

Journal ArticleDOI
TL;DR: Overall, the age-related pattern of presentation and dementia diagnoses differs from that seen in the general elderly population, however, age-specific prevalence rates of Alzheimer's disease were similar but 30–40 years earlier in life.
Abstract: BACKGROUND The reported prevalence rates of dementia in people with Down's syndrome have varied considerably across studies. The aim of this study was to investigate the extent of clinical change with age using an established diagnostic instrument in an unbiased, population-based sample of older people with Down's syndrome. METHOD Changes in memory, personality, general mental functioning and daily living skills were assessed using a modified version of the informant interview of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX). RESULTS Age-specific prevalence rates of dementia varied according to the diagnostic criteria used. Using CAMDEX criteria for Alzheimer's disease, prevalence rates increased from 3.4 to 10.3 to 40% in the 30-39, 40-49 and 50-59 age group, respectively. CONCLUSIONS Overall, the age-related pattern of presentation and dementia diagnoses differs from that seen in the general elderly population. However, age-specific prevalence rates of Alzheimer's disease were similar but 30-40 years earlier in life.

Journal ArticleDOI
TL;DR: It was shown that cognitive therapy was more effective than behavioural stress management on measures of hypochondriasis, but not general mood disturbance at mid-treatment and at post-treatment.
Abstract: BACKGROUND Hypochondriasis is generally considered difficult to manage. This study aimed to assess the effectiveness of cognitive therapy and to compare it with an equally credible, alternative treatment. METHOD Forty-eight patients with hypochondriasis were initially randomly assigned to either cognitive therapy, behavioural stress management or a no treatment waiting list control group. At the end of the waiting period, patients in the control group were randomly assigned to one of the two treatments. Assessments were at pre-, mid- and post-treatment or waiting list and at three-, six- and 12-month post-treatment follow-up. RESULTS Comparisons with the waiting list group showed both treatments were effective. Comparisons between the treatments showed that cognitive therapy was more effective than behavioural stress management on measures of hypochondriasis, but not general mood disturbance at mid-treatment and at post-treatment. One year after treatment patients who had received either treatment remained significantly better than before treatment, and on almost all measures the two therapies did not differ from each other. CONCLUSIONS Cognitive therapy is a specific treatment for hypochondriasis. Behavioural stress management is also effective but its specificity remains to be demonstrated.

Journal ArticleDOI
TL;DR: The course of severe unipolar and bipolar disorder seems to be progressive in nature despite the effect of treatment, and the rate of recurrence after successive episodes was the same for the two disorders.
Abstract: BACKGROUND In recent years, studies of the risk of recurrence in affective disorder in relation to the number of prior episodes have given contradictory results. METHOD Survival analysis was used to calculate the rate of recurrence after successive episodes in a case register study including all hospital admissions with primary affective disorder in Denmark during 1971-1993. A total of 20,350 first-admission patients were discharged with a diagnosis of affective disorder, depressive or manic/cyclic type. RESULTS The rate of recurrence increased with the number of previous episodes in both unipolar and bipolar disorder. Initially, the two types of disorders followed markedly different courses, but later in the course of the illness the rate of recurrence was the same for the two disorders. CONCLUSIONS The course of severe unipolar and bipolar disorder seems to be progressive in nature despite the effect of treatment.

Journal ArticleDOI
TL;DR: Improvement in overall symptoms was maintained in the CBT group 18 months after baseline and nine months after intensive therapy was completed, suggesting CBT may be a specific and cost-effective intervention in medication-resistant psychosis.
Abstract: BACKGROUND A randomised controlled trial of cognitive-behavioural therapy (CBT) for people with medication-resistant psychosis showed improvements in overall symptomatology after nine months of treatment; good outcome was strongly predicted by a measure of cognitive flexibility concerning delusions. The present paper presents a follow-up evaluation 18 months after baseline. METHOD Forty-seven (78% of original n = 60) participants were available for follow-up at 18 months, and were reassessed on all the original outcome measures (see Part I). An economic evaluation was also completed. RESULTS Those in the CBT treatment group showed a significant and continuing improvement in Brief Psychiatric Rating Scale scores, whereas the control group did not change from baseline. Delusional distress and the frequency of hallucinations were also significantly reduced in the CBT group. The costs of CBT appear to have been offset by reductions in service utilisation and associated costs during follow-up. CONCLUSIONS Improvement in overall symptoms was maintained in the CBT group 18 months after baseline and nine months after intensive therapy was completed. CBT may be a specific and cost-effective intervention in medication-resistant psychosis.

Journal ArticleDOI
TL;DR: The size of burden attributed to mental disorders is of potential benefit for funding mental health services and a method for disentangling the effects of concurrent comorbidity is presented.
Abstract: BACKGROUND The Global Burden of Disease studies are important because they encompass morbidity as well as mortality. Burden due to morbidity is calculated from incidence, duration and disability. There is a dearth of epidemiological measurements of disability. METHOD Data from a quasi-community sample (n = 1364) were analysed. Diagnoses of mental and physical disorders, and reports of disability, were based on established methods. RESULTS The disabilities reported in mental and physical disorders were comparable. Disability was correlated with comorbidity. The disability in mental disorders was examined by three methods: pure disorders, main problem and regression. It appears that major depression and substance disorder weights were overestimated, and anxiety disorder weights were underestimated in the Global Burden of Disease studies. CONCLUSIONS A method for disentangling the effects of concurrent comorbidity is presented. The size of burden attributed to mental disorders is of potential benefit for funding mental health services, It is important that we get the estimates right.

Journal ArticleDOI
TL;DR: Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only, while exercise significantly improved health perception and fatigue at 28 weeks.
Abstract: BACKGROUND The Joint Working Group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners (1996) recommended graded exercise and antidepressants for patients with chronic fatigue syndrome. We assessed efficacy and acceptability of these treatments. METHOD Six-month prospective randomised placebo and therapist contact time controlled trial with allocation to one of four treatment cells: exercise and 20 mg fluoxetine, exercise and placebo drug, appointments only and 20 mg fluoxetine, appointments and placebo drug. Drug treatment was double blind and patients were blind to assignment to exercise or appointments. RESULTS Ninety-six (71%) of 136 patients completed the trial. Patients were more likely to drop out of exercise than non-exercise treatment (P = 0.05). In an intention to treat analysis, exercise resulted in fewer patients with case level fatigue than appointments only at 26 weeks (12 (18%) v. 4 (6%) respectively P = 0.025) and improvement in functional work capacity at 12 (P = 0.005) and 26 weeks (P = 0.03). Fluoxetine had a significant effect on depression at week 12 only (P = 0.04). Exercise significantly improved health perception (P = 0.012) and fatigue (P = 0.028) at 28 weeks. CONCLUSIONS Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only.