Showing papers in "Psychological Medicine in 1998"

Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment

Abstract: Background. The paper reports on the development of the WHOQOL-BREF, an abbreviated version of the WHOQOL-100 quality of life assessment. Method. The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health. Results. Domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test-retest reliability. Conclusion. These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy. [References: 9]

Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group.

Abstract: Background. The paper reports on the development of the WHOQOL-BREF, an abbreviated version of the WHOQOL-100 quality of life assessment. Method. The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health. Results. Domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test-retest reliability. Conclusion. These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy. [References: 9]

Puberty and depression: the roles of age, pubertal status and pubertal timing.

Abstract: Background. Previous work has indicated that the 2[ratio ]1 female[ratio ]male sex ratio in unipolar depressive disorders does not emerge until some time between ages 10 and 15.Methods. Data from four annual waves of data collection from the Great Smoky Mountains Study (GSMS) involving children aged nine to 16 were employed.Results. Pubertal status better predicted the emergence of the expected sex ratio than did age. Only after the transition to mid-puberty (Tanner Stage III and above) were girls more likely than boys to be depressed. The timing of this transition had no effect on depression rates. Before Tanner Stage III, boys had higher rates of depression than girls, and the prevalence of depression appeared to fall in boys at an earlier pubertal stage than that at which it began to rise in girls. In addition, recent transition to Tanner Stage III or higher had a transient effect in reducing the prevalence of depression in boys.Conclusions. The period of emergence of increased risk for depression in adolescent girls appears to be a relatively sharply demarcated developmental transition occurring in mid-puberty. Previously reported effects of the timing of puberty (which have tended to be transient) appeared less important in increase of risk for depression than pubertal status.

Prevalence of mental disorders and psychosocial impairments in adolescents and young adults.

Abstract: Background. As part of a longitudinal study, prevalence findings of DSM-IV disorders are presented for a random sample of 3021 respondents aged 14 to 24, with response rate 71%.Method. Assessment included various subtypes of disorders, subthreshold conditions and disorders that have only rarely been studied in other epidemiological surveys. The computer-assisted Munich-Composite International Diagnostic Interview (M-CIDI) was used to derive DSM-IV diagnoses.Results. Substance disorders were the most frequent (lifetime 17·7%; 12-month 11·4%), with abuse being considerably more frequent than dependence. Other mental disorders had a lifetime prevalence of 27·5% (12-month, 17·5%) with depressive disorders (16·8%) being more frequent than anxiety disorders (14·4%). Eating disorders (3·0%) and threshold somatoform disorders (1·2%) were rare disorders. Subthreshold anxiety and somatoform disorders, however, were more frequent than threshold disorders. Prevalence of disorders was equally high for males and females, although specific disorder prevalence varied significantly by gender. The co-occurrence of disorders (co-morbidity) was substantial and was significantly related to greater reductions in work productivity and increased rates of professional helpseeking behaviour.Conclusions. Findings underline that mental disorders in young adults are frequent and impairing, limiting work and education ability and social interaction. Given the fact that adolescents and young adults are in a key phase of socialization in terms of professional career and interpersonal relationships, our findings indicate a considerable risk potential for an accumulation of complicating factors and future chronicity. This paper is the first report of this ongoing longitudinal study about early developmental conditions of mental disorders.

The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view

Abstract: Background. The social rank theory of psychopathology suggests that with the evolution of social hierarchies various psychobiological mechanisms became attuned to the success or failure in conflict situations. Specifically, subordinates and those who have lost status are at greater risk of pathology than winners and those of higher status. In this theory concepts of defeat and entrapment are seen to be of special relevance to the study of depression. We outline the role of defeat and entrapment within the social rank theory of depression. Methods. New self-report measures of entrapment and defeat were developed and used to test predictions of the social rank theory of depression. Both a sample of students and depressed patients were assessed with these new scales and other social rank measures (e.g. social comparison and submissive behaviour). Results. The entrapment and defeat measures were found to have good psychometric properties and significantly correlated with depression. They were also strongly associated with other rank variables. Defeat maintained a strong association with depression even after controlling for hopelessness ( r =0·62), whereas the relationship between hopelessness and depression was substantially reduced when controlling for defeat. Entrapment and defeat added substantially to the explained variance of depression after controlling for the other social rank variables. Conclusions. Defeat and entrapment appear to be promising variables for the study of depression. These variables may also help to develop linkages between human and animal models of psychopathology.

Suicidal behaviour: an epidemiological and genetic study

Abstract: Background. Psychiatric history, familial history of suicide attempts, and certain traumatic life events are important predictors of suicidal thoughts and behaviour. We examined the epidemiology and genetics of suicidality (i.e. reporting persistent suicidal thoughts or a plan or suicide attempt) in a large community-based sample of MZ and DZ twin pairs. Method. Diagnostic telephone interviews were conducted in 1992-3 with twins from an Australian twin panel first surveyed in 1980-82 (N = 5995 respondents). Data were analysed using logistic regression models, taking into account twin pair zygosity and the history of suicidality in the respondent's co-twin. Results. Lifetime prevalence of suicidal thoughts and attempts was remarkably constant across birth cohorts 1930-1964, and across gender. Major psychiatric correlates were history of major depression, panic disorder, social phobia in women, alcohol dependence and childhood conduct problems. Traumatic events involving assault (childhood sexual abuse, rape or physical assault) or status-loss Gob loss, loss of property or home, divorce), and the personality trait neuroticism, were also significantly associated with suicide measures. Prevalence of serious suicide attempts varied as a function of religious affiliation. After controlling for these variables, however, history of suicide attempts or persistent thoughts in the respondent's co-twin remained a powerful predictor in MZ pairs (odds ratio = 3'9), but was not consistently predictive in DZ pairs. Overall, genetic factors accounted for approximately 45 % of the variance in suicidal thoughts and behaviour (95 % confidence interval 33-51 %).

Why GHQ threshold varies from one place to another

Abstract: Background. No convincing explanation has been forthcoming for the variation in best threshold to adopt for the GHQ in different settings. Methods. Data dealing with the GHQ and the CIDI in 15 cities from a recent WHO study was subjected to further analysis. Results. The mean number of CIDI symptoms for those with single diagnoses, or those with multiple diagnoses, does not vary between cities. However, the best threshold is found to be related to the prevalence both of single and of multiple diagnoses in a centre. Variations in the diagnoses to be included in the 'gold standard' did not account for the variation observed. There was a strong relationship between area under the ROC curve (as a measure of the discriminatory power of the GHQ) and the best threshold, with higher thresholds being associated with superior performance of the GHQ. The items on the GHQ-12 that provided most discrimination between cases and non-cases varied from one centre to another. Conclusions. The GHQ threshold is partly determined by the prevalence of multiple diagnoses, with higher thresholds being associated by higher rates of both single and multiple diagnosis. The mean GHQ score for the whole population of respondents provides a rough guide to the best threshold. In those centres where the discriminatory power of the GHQ is lowest, it is necessary to use a low threshold as a way of ensuring that sensitivity is protected, but the positive predictive Value of the GHQ is then lower. Some of the variation between centres is due to variation in the discriminatory power of different items.

Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders.

Abstract: Background. There is increasing awareness of the prognostic value of residual symptomatology in affective disorders and of the need for specific therapeutic strategies in this phase of illness. The aims of the study were to apply a novel, short-term psychotherapeutic approach for increasing well-being, based on Ryff's conceptual model, to remitted patients with affective disorders and to compare the results with those obtained with symptom-oriented cognitive behavioural strategies.Methods. Twenty patients with affective disorders (major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder, obsessive–compulsive disorder) who had been successfully treated by behavioural or pharmacological methods were randomly assigned to a well-being enhancing therapeutic strategy (well-being therapy) or cognitive–behavioural treatment of residual symptoms.Results. Both well-being and cognitive–behavioural therapies were associated with a significant reduction of residual symptoms. However, a significant advantage of well-being therapy over cognitive–behavioural strategies was observed with observer-rated methods.Discussion. These preliminary results suggest the feasibility of well-being therapy in the residual stage of affective disorders. Further research should determine its value as a relapse-preventive strategy in specific mood and anxiety disorders.

The influence of age and sex on the prevalence of depressive conditions : report from the National Survey of Psychiatric Morbidity

Abstract: Background Women are consistently reported to have a greater prevalence of depressive disorders than men. The reason for this is unclear, and is as likely to be social as biological. There is some evidence that the excess of depression is greater during women's reproductive lives. Data from the National Survey of Psychiatric Morbidity were used to test the hypothesis that the excess disappeared in the post-menopausal years and that obvious social explanations for this were inadequate. Method Subjects (N = 9792) from a random sample of the British population provided data for the analysis. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects with ICD-10 depressive episode or mixed anxiety/depression were compared with the remainder. Social variables that were likely to contribute to a post-menopausal decline in depressive disorders were controlled in logistic regression analyses. Results There was a clear reversal of the sex difference in prevalence of depression in those over age 55. This could not be explained in terms of differential effects of marital status, child care, or employment status. Conclusions This large and representative survey adds considerably to the increasingly held view that the sex difference in prevalence of depression is less apparent in later middle age. This may be linked to the menopause, and our attempts to explain it in terms of obvious conditions among social variables were not successful. More specific studies are required to clarify the finding.

Autism, affective and other psychiatric disorders: patterns of familial aggregation

Abstract: Background. The liability to autism confers a risk for a range of more subtle autistic-like impairments, but it remains unclear whether it also confers a risk for other psychiatric disturbances.Methods. To investigate this, we studied the pattern of familial aggregation of psychiatric disorders in relatives of 99 autistic and 36 Down's probands, using family history and direct interview measures.Results. Family history data showed that motor tics, obsessive–compulsive (OCD) and affective disorders were significantly more common in relatives of autistic probands and that individuals with OCD were more likely to exhibit autistic-like social and communication impairments. Direct interview data confirmed the increased rate of affective disorders (especially major depressive disorder) in the first-degree relatives. There was no evidence to indicate significant co-morbidity between affective disorders and the broadly defined phenotype of autism. Moreover, the characteristics of the probands' and the relatives' that were associated with the liability to familiality of the broader phenotype of autism differed from those that predicted the liability to the familiality of affective disorders. Examination of the onset of affective disorders suggested that the increased risk was not confined to the period following the birth of the child with autism.Conclusions. Overall, the results indicated that OCD, but not affective disorders, may index an underlying liability to autism. They also indicated that the increased risk of affective disorders was not solely the consequence of the stress of raising a child with autism and that further research will be required to clarify the mechanisms involved.

A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII

Abstract: Background. Population-based studies suggest substantial co-morbidity between physical illness and depression in late-life. However, a causal relationship has not been established. If a relationship exists, it is important to establish which aspects of poor health determine risk for depression, and which factors confer vulnerability or resilience in the face of poor health. We investigate the role of disablement, measured as impairment, disability and handicap. Methods. A prospective population-based cohort study, comprising an index assessment and 1 year follow-up, of all residents aged 65 years or over, of an electoral ward in London, UK ( N =889). Results. The prevalence of SHORT-CARE pervasive depression was 17·7% at index assessment. The 1 year onset rate for pervasive depression was 12·0%, and the 1 year maintenance rate 63·2%. There was a high mortality rate among the depressed. Disablement, particularly handicap was the most important predictor of the onset of depression (population attributable fraction, 0·69). Lack of contact with friends was a direct risk factor but also modified the association between handicap and depression. Marriage was protective for men, but a risk factor for women. Maintenance of depression was predicted by low levels of social support and social participation, rather than by disablement. Conclusions. It seems likely that disablement, specifically handicap, is the chief cause of onsets of depression in late-life. Genetic predisposition, early adversity and serious life events may play a less prominent role than in earlier life. Effective prevention of late-life depression requires attention at the structural level to the sources of handicap within communities.

Executive function in first-episode schizophrenia

Abstract: Background. We tested the hypothesis that schizophrenia is primarily a frontostriatal disorder by examining executive function in first-episode patients. Previous studies have shown either equal decrements in many cognitive domains or specific deficits in memory. Such studies have grouped test results or have used few executive measures, thus, possibly losing information. We, therefore, measured a range of executive ability with tests known to be sensitive to frontal lobe function. Methods. Thirty first-episode schizophrenic patients and 30 normal volunteers, matched for age and NART IQ, were tested on computerized test of planning, spatial working memory and attentional set shifting from the Cambridge Automated Neuropsychological Test Battery. Computerized and traditional tests of memory were also administered for comparison. Results. Patients were worse on all tests but the profile was non-uniform. A componential analysis indicated that the patients were characterized by a poor ability to think ahead and organize responses but an intact ability to switch attention and inhibit prepotent responses. Patients also demonstrated poor memory, especially for free recall of a story and associate learning of unrelated word pairs. Conclusions. In contradistinction to previous studies, schizophrenic patients do have profound executive impairments at the beginning of the illness. However, these concern planning and strategy use rather than attentional set shifting, which is generally unimpaired. Previous findings in more chronic patients, of severe attentional set shifting impairment, suggest that executive cognitive deficits are progressive during the course of schizophrenia. The finding of severe mnemonic impairment at first episode suggests that cognitive deficits are not restricted to one cognitive domain.

'Theory of mind' skills during an acute episode of psychosis and following recovery.

Abstract: Background. A neuropsychological formulation of schizophrenia has suggested that problems with meta-representation underpin both positive and negative symptoms. This study tested Frith's account by asking patients experiencing an acute episode of psychosis to complete a set of tasks that involved Theory of Mind (ToM) skills. Methods. Fourteen patients who fulfilled criteria for schizophrenia, 10 deluded patients who were suffering from psychotic disorders other than schizophrenia and 12 depressed patients completed second-order false belief tasks, a test which involved substitution of a co-referential term in a linguistic description of an event, and metaphor and irony tasks. The battery of tests was completed during the acute phase and following recovery. Selection of these patient groups allowed comparisons to be made between schizophrenia patients and non-schizophrenia patients and between patients with and without persecutory delusions. Results. Schizophrenia patients, who had a multiplicity of positive and negative symptoms, performed significantly worse than non-schizophrenia patients on some of the ToM tasks during an acute episode. Patients with delusions of persecution and reference did not perform significantly worse than non-deluded patients on ToM tasks. There was no significant difference between groups in performance on any of the tasks at recovery. Conclusions. The results provide at best weak support for Frith's account and it remains unclear whether the ToM deficits demonstrated are genuine deficits or are a result of information-processing overload. However, it is clear that difficulties interpreting interpersonal contexts, as shown by some schizophrenia patients, are state rather than trait characteristics.

Co-morbidity and familial aggregation of alcoholism and anxiety disorders

Abstract: Background. This study examined the patterns of familial aggregation and co-morbidity of alcoholism and anxiety disorders in the relatives of 165 probands selected for alcoholism and/or anxiety disorders compared to those of 61 unaffected controls.Methods. Probands were either selected from treatment settings or at random from the community. DSM-III-R diagnoses were obtained for all probands and their 1053 first-degree relatives, based on direct interview or family history information.Results. The findings indicate that: (1) alcoholism was associated with anxiety disorders in the relatives, particularly among females; (2) both alcoholism and anxiety disorders were highly familial; (3) the familial aggregation of alcoholism was attributable to alcohol dependence rather than to alcohol abuse, particularly among male relatives; and (4) the pattern of co-aggregation of alcohol dependence and anxiety disorders in families differed according to the subtype of anxiety disorder; there was evidence of a partly shared diathesis underlying panic and alcoholism, whereas social phobia and alcoholism tended to aggregate independently.Conclusions. The finding that the onset of social phobia tended to precede that of alcoholism, when taken together with the independence of familial aggregation of social phobia and alcoholism support a self-medication hypothesis as the explanation for the co-occurrence of social phobia and alcoholism. In contrast, the lack of a systematic pattern in the order of onset of panic and alcoholism among subjects with both disorders as well as evidence for shared underlying familial risk factors suggests that co-morbidity between panic disorder and alcoholism is not a consequence of self-medication of panic symptoms. The results of this study emphasize the importance of examining co-morbid disorders and subtypes thereof in identifying sources of heterogeneity in the pathogenesis of alcoholism.

Cognitive impairment in the euthymic phase of affective disorder

Abstract: Background. A review of studies of cognition in the euthymic phase of unipolar and bipolar affective disorder reveals diverging results.Methods. The study was designed as a controlled cohort study, with the Danish psychiatric case register of admissions used to identify patients and the Danish civil register to identify controls. Patients who were hospitalized between 19 and 25 years ago with an affective diagnosis and who at interviews fulfilled criteria for a primary affective unipolar or bipolar disorder, according to ICD-10, were compared with age- and gender-matched controls. Interviews and assessment of the cognitive function were made in the euthymic phase of the disorder. In all, 118 unipolar patients, 28 bipolar patients and 58 controls were included. Analyses were adjusted for differences in the level of education and for subclinical depressive and anxiety symptoms.Results. Patients with recurrent episodes were significantly more impaired than patients with a single episode and more impaired than controls. Also, within patients the number of prior episodes seemed to be associated with cognitive outcome. There was no difference in the severity of the dysfunction between unipolar and bipolar patients.Conclusions. Cognitive impairment in out-patients with unipolar and bipolar disorder appears to be associated with the number of affective episodes.

Theory of mind and psychoses.

Abstract: Background A cardinal feature of schizophrenia is the sufferer's difficulty in interacting appropriately within the social milieu. This deficit has recently been associated with the concept of theory of mind, more commonly constructed as a working model to understand behavioural patterns in autistic children. In this paper the complex relationships between theory of mind, IQ and psychoses are addressed. Methods Five experimental groups were used; non-psychiatric controls, affective disorder, schizophrenia with normal pre-morbid IQ, schizophrenia with pre-morbid IQ in the mildly learning disabled range, and mild learning disability with no history of psychiatric illness. All subjects were given a first order Theory of Mind Task and if successful, a second order Theory of Mind Task was then administered. All subjects were rated using the Positive and Negative Symptom Scale (PANSS). Results Subjects with schizophrenia and subjects with mild learning disability show impaired ability on a second order theory of mind task. However, when patients who are unable to answer reality questions are removed from the analysis specific impairment of theory of mind is only seen in subjects with schizophrenia. Furthermore, this impairment is relatively specific to particular psychopathological clusters in subjects with schizophrenia. Even though the same clusters of psychopathology are also seen in patients with affective disorder, their presence is not associated with poor second order theory of mind performance. Conclusions Impaired theory of mind on second order tests is specific to schizophrenia when compared to mild learning disability and affective disorder control groups. Subjects with schizophrenia and pre-morbid mild learning disability show greater impairment than subjects with schizophrenia and a pre-morbid IQ within the normal range.

Sex and depression

Abstract: Sex differences in rates of depressive disorder have not been convincingly explained, and this reflects a more general failure of research to provide a comprehensive aetiological account of depression. The difference can be used as a probe for evaluating the research base of integrative models of depressive disorder (e.g. Akiskal & McKinney, 1975). It is particularly likely to be illuminating if the causes of the sex difference do not overlap completely the causes of depression itself. While there have been many reviews in the area (Weissman & Klerman, 1977; Kessler & McRae, 1981; Wolk & Weissman, 1995; Bebbington, 1996), this point has not been adequately expressed.Several lines of investigation are necessary for assessing the relative importance of social, psychological and biological influences: the epidemiological study of macrosocial variables and of age effects; temperament, personality, and attributional and coping styles; the experience of psychosocial adversity; and the possibility of increased susceptibility to some forms of stress in women. Both the tendency to affiliation and the requirement for social support may differ by sex. The particular strains of the roles available to women may increase their risk of depression. Possible genetic explanations of the sex difference are of special relevance because of their implications for biological differences. The latter can also be studied directly: hormonal theories in particular must be evaluated.

Urbanization and psychosis: a study of 1942-1978 birth cohorts in The Netherlands.

Abstract: Background. Urban birth is associated with later schizophrenia. This study examined whether this finding is diagnosis-specific and which individuals are most at risk. Methods. All live births recorded between 1942 and 1978 in any of the 646 Dutch municipalities were followed-up through the National Psychiatric Case Register for first psychiatric admission for psychosis between 1970 and 1992 (N = 42115). Results. Urban birth was linearly associated with later schizophrenia (incidence rate ratio linear trend (IRR), 1.39; 95% confidence interval (95% CI), 1.36-1.42), affective psychosis (IRR, 1.18; 95% CI, 1.15-1.21) and other psychosis (IRR, 1.27; 95 % CI, 1.24-1.30). Individuals born in the highest category of the three-level urban exposure were around twice as likely to develop schizophrenia. Associations were stronger for men and for individuals with early age of onset. The effect of urban birth was also stronger in the more recent birth cohorts. Conclusions. There are quantitative differences between diagnostic categories in the strength of the association between urban birth and later psychiatric disorder. High rates of psychosis in urban areas may be the result of environmental factors associated with urbanization, the effect of which appears to be increasing over successive generations.

A comparative study of insight scales and their relationship to psychopathological and clinical variables.

Abstract: Background Research on the subject of insight has been hampered by difficulties in definition and reliable measurement. Methods We compared several rating scales to measure insight on a group of 33 psychotic patients as well as assessing patients' psychopathology, clinical characteristics and cognitive functioning. Results Most currently used scales showed a high degree of inter-correlation. Measures of insight related strongly to the presence of delusions; grandiosity (inversely), and depression (positively). Higher insight scores correlated with indices of treatment compliance and inversely with substance abuse. Measures of pre-morbid IQ and impaired executive functioning, including the Wisconsin Card Sorting Test were not associated with poor insight. Conclusions The study highlights aspects of psychopathology and clinical variables particularly related to insight and supports the continued use of standardized scales in further research in this area.

Is subcortical disease associated with a poor response to antidepressants? Neurological, neuropsychological and neuroradiological findings in late-life depression.

Abstract: Background. Late-life depression is associated with increased subcortical white matter hyperintensities. There is some evidence that they are associated with a poorer response to acute treatment. Neurological signs and neuropsychological dysfunction are further evidence of abnormalities in the brain, but they have not been studied in relation to therapy resistance. Methods. A prospective study of 24 normal controls and 75 consecutive elderly (aged 65 to 85) patients with DSM-III-R major depression entered a naturalistic study of treatment. Assessment of response to monotherapy and then lithium augmentation or ECT created three outcome groups. Investigations included magnetic resonance brain imaging, neuropsychological and neurological examination. Results. Response to monotherapy within 12 weeks was shown by 42.7%, a further 37.3% responded to lithium augmentation or ECT within 24 weeks and 20 % had responded poorly to all treatments at 24 weeks. Subcortical hyperintensities were significantly increased in the more resistant patients. These included confluent deep white matter, multiple (> 5) basal ganglia lesions and pontine reticular formation lesions. Most of the neuropsychological impairment was restricted to the resistant groups and was of a subcortico-frontal type. Extrapyramidal, frontal and pyramidal neurological signs characterized the resistant groups. The combination of extrapyramidal signs, pyramidal tract signs and impairment of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant monotherapy with 89% sensitivity and 95 % specificity. Conclusion. In late-life depression a poor response to antidepressant monotherapy can be expected in those patients with a frontal lobe syndrome, extrapyramidal signs or if MRI T 2 -weighted lesions are present in both the basal ganglia and the pontine reticular formation.

The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders

Abstract: Background. Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work. Method. The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness. Results. The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings. Conclusions. The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.

Quality of life measurement in schizophrenia: reconciling the quest for subjectivity with the question of reliability

Abstract: Background The patients' ability to appraise their quality of life in schizophrenia was studied by examining the reliability and the validity of self-rated quality of life estimates. Methods Sixty-three symptomatically stable patients with schizophrenia (DSM-IV) receiving maintenance treatment were evaluated over a 4-week period. The subjects were asked to appraise their quality of life at weekly intervals on a single item global quality of life measure, as well as the self-administered sickness impact profile. The patients' quality of life was also rated by a clinician using the social performance schedule and the global assessment scale of functioning; and clinical aspects such as the severity of psychotic symptoms, neurocognitive deficits, dose of medications, and side effects were documented with standardized measures. Results The results indicated that the patients' self-reports were highly consistent over the 4 weeks, and the quality of life ratings correlated significantly with the clinician's estimates. The patients' quality of life was predictably influenced by the severity of their symptoms, side effects, cognitive deficits and the dose of their antipsychotic medication, but the reliability of their reports was not materially affected by these factors. Conclusions It is concluded that clinically compliant and stable patients with schizophrenia can evaluate and report their quality of life with a high degree of reliability and concurrent validity, implying that self-report measures are potentially useful tools in clinical trials and outcome studies.

A survey of delusional ideation in primary-care patients.

Abstract: Background. To assess the prevalence of delusional ideas in primary-care patients. Method. A survey was carried out with the Aquitaine Sentinel Network of general practitioners (GPs). Consecutive practice attenders were invited to complete the Peters et al . Delusional Inventory (PDI-21) self-report questionnaire, designed to measure delusional ideation in the normal population. GPs, blind to the questionnaire results, provided information on patients' psychiatric history. Results. Of the 1053 attenders included in the survey, 348 (35%) had a lifetime history of psychiatric disorder, of whom 20 (2%) had a history of broadly defined psychotic disorder. The self-report questionnaire was completed by 790 patients. The range of individual PDI-21 item endorsement in subjects with no psychiatric history varied between 5 and 70%, suggesting that delusional ideation is a dimensional phenomenon lying on a continuum with normality. The main discriminative items between psychotic and non-psychotic patients were those exploring persecutory (OR=15·2, 95% CI 4·3–53·7), mystic (OR=6·4, 95% CI 1·9–22·4) and guilt (OR=5·8, 95% CI 1·5–23·2) ideas. Conclusions. This survey demonstrates that questions that explore delusions and hallucinations are well-accepted by most primary-care patients. More research is needed on psychotic disorders in primary-care settings to improving early identification of these disorders.

Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: the impact on subsequent health care visits

Abstract: Background. Despite a growing literature pointing to the deleterious health effects of sexual and physical abuse history, few studies provide evidence about which medical symptoms are most affected. The aim of this paper is to determine the impact of sexual and physical abuse history on a selected set of medical symptoms, and to test how such abuse, medical symptoms and functional disability may affect subsequent health care visits.Methods. We studied 239 women from a referral-based gastroenterology clinic; follow-up data were available on 196 of these women. All women were interviewed about sexual and physical abuse history.Results. Women with abuse history, particularly those with severe abuse, were much more likely to report somatic symptoms related to panic (e.g. palpitations, numbness, shortness of breath), depression (e.g. difficulty sleeping, loss of appetite), musculoskeletal disorders (e.g. headaches, muscle aches), genito-urinary disorders (e.g. vaginal discharge, pelvic pain, painful intercourse), skin disturbance (e.g. rash) and respiratory illness (e.g. stuffy nose). Furthermore, we found that the severity of abuse history, somatic symptoms and functional disability predicted 30% of the variance in health care visits during the subsequent year, and that the effect of abuse severity on visits was explained by abused women having more somatic symptoms and functional disability.Conclusions. Patients' reports of abuse history, somatic symptoms and functional disability appear to be important factors in explaining the number of health care visits among a clinic sample of women with gastrointestinal disorders.

Assortative mating for major psychiatric diagnoses in two population-based samples

Abstract: Background. Previous studies on assortment for psychiatric disorders have reported discrepant findings. We aimed to test whether there is a significant association for psychiatric diagnoses, including alcoholism, generalized anxiety disorder, major depressive disorder, panic disorder and phobias between husbands and wives in two population-based samples. We further evaluated whether marital resemblance occurs primarily within or across psychiatric disorders and if assortment for psychopathology is primary or secondary to assortment for correlated variables. Methods. A model for mate selection addressed whether the correlation between mates for psychiatric disorders arises from direct assortment (primary homogamy) or through correlation with other variables for which assortment occurs (secondary homogamy) or through cross-variable assortment. The model accounted for within-person co-morbidity as well as across-spouse data. Results. Findings suggested that a moderate degree of assortment exists both within and across psychiatric diagnoses. Only a small amount of the observed marital resemblance for mental illness could be explained by assortment for correlated variables such as age, religious attendance and education. Similar results were obtained for the two samples separately and confirmed in their joint analysis, revealing that the co-morbidity and assortment findings, except for the marital correlation for age, religious attendance and education, replicate across samples. Conclusions. Significant but moderate primary assortment exists for psychiatric disorders. The bias in twin studies that have ignored the small amount of assortment is negligible.

Symptoms of depression among community-dwelling elderly African-American and White older adults

Abstract: Background. Few studies have explored the variance in individual symptoms by race in older adults.Methods. Data were analysed from the Duke site of the Established Populations for Epidemiologic Studies of the Elderly (EPESE), a community sample of persons 65 years-of-age and older, 54% of whom were African-Americans. Of the 3401 subjects with adequate data on depressive symptomatology, confirmatory factor analysis and LISREL were first used to confirm the presence of the factor structure previously reported for the CES-D. Next, bivariate analysis was performed to determine the prevalence of individual symptoms by race. Finally, LISREL analysis was performed to control for potential confounding variables.Results. When bivariate comparisons of specific symptoms by race were explored, African-Americans were more likely to report less hope about the future, poor appetite, difficulty concentrating, requiring more effort for usual activities, less talking, feeling people were unfriendly, feeling disliked by others and being more ‘bothered’ than usual. When LISREL analyses were applied to these data (controlling for education, income, cognitive impairment, chronic health problems and disability and other factors) racial differences in somatic complaints and life satisfaction disappeared, yet differences in interpersonal relations persisted.Conclusions. This study confirms earlier findings of minimal overall differences in symptom frequency between African-American and non-African-American community-dwelling older adults in controlled studies.

Frontal dysfunction in neurologically normal chronic alcoholic subjects: metabolic and neuropsychological findings.

Abstract: Background. Neuropsychological and imaging studies suggest that frontal dysfunction may occur in apparently normal chronic alcoholic subjects. Methods. To investigate this issue further, we performed neuropsychological and fluorodeoxyglucose-PET studies in 17 chronic alcoholics without patent neurological and psychiatric complications. Results. Metabolic abnormalities were found in the mediofrontal and in the left dorsolateral prefrontal cortex, but not in the orbitofrontal cortex. Neuropsychological testing revealed significantly reduced verbal fluency and impaired performance on the Stroop test. The mediofrontal hypometabolism correlated with the reduction in verbal fluency and the time necessary to perform the interference condition of the Stroop test. The left dorsolateral prefrontal hypometabolism correlated with the number of errors on the Stroop test. Conclusion. These data indicate that circumscribed frontal dysfunctions may occur in chronic alcoholic subjects before clinically obvious neurological complications, and may account for some of the alcohol-related neuropsychological and behavioural impairments.

The epidemiology of blood-injection-injury phobia.

Abstract: Background. We report the prevalence, clinical characteristics, frequency of mental health treatment, demographic correlates, frequency of co-morbid psychiatric conditions, and general health ramifications of DSM-IV blood-injection-injury phobia in the general population.Method. The Diagnostic Interview Schedule (version III-R), which included questions on blood-injection-injury phobia, was administered to 1920 subjects in the Baltimore ECA Follow-up Study.Results. The estimated unweighted lifetime prevalence of blood-injection-injury phobia was 3·5%. The median age of onset was 5·5 years; 78% had had symptoms within the last 6 months. Subjects with blood-injection-injury phobia (cases) had higher lifetime histories of fainting and seizures than those without (non-cases). None reported seeking mental health treatment specifically for phobia. Prevalences were lower in the elderly and higher in females and persons with less education. Cases had significantly higher than expected lifetime prevalences of other psychiatric conditions, including marijuana abuse/dependence, major depression, obsessive–compulsive disorder, panic disorder, agoraphobia, social phobia and other simple phobia. Cases and non-cases did not differ with regard to usual health-care settings, regular care for specific medical conditions, numbers of out-patient visits or hospitalizations, or previous general anaesthesia or live births. However, diabetics with blood-injection-injury phobia had higher than expected rates of macrovascular complications.Conclusion. Blood-injection-injury phobia is common, especially in females and those with less education, and it is associated with several co-morbid psychiatric conditions. No strong, broad general health ramifications of this phobia are apparent. However, diabetics with this phobia appear at particular risk for complications; this deserves further study.

The Leicester 500 Project. Social support and the development of postnatal depressive symptoms, a prospective cohort survey

Abstract: Background A prospective epidemiology study evaluated the role of specific social and psychological variables in the prediction of depressive symptomatology and disorders following childbirth in a community sample. Measures of social support used previously in clinically depressed populations facilitated further comparison. Methods Nulliparous pregnant women (N = 507) were interviewed during pregnancy with the Interview Measure of Social Relationships (IMSR) and a contextual assessment of pregnancy-related support and adversity and 427 were followed up at 3 months postpartum with the 30-item GHQ, including six depression items. To establish the clinical representativeness of the GHQ, high GHQ scorers and a random subsample of low scorers were interviewed using the SCAN. Regression models were developed using the GHQ Depression scale (GHQ-D), the IMSR and other risk factor data. Results GHQ-D after childbirth was predicted by lack of perceived support from members of the woman's primary group and lack of support in relation to the event becoming pregnant; this held even after controlling for antenatal depression, neuroticism, family and personal psychiatric history and adversity. Informant-rated deficits in provision of social support also predicted later depression. The size of the primary social network group previously found to be related to depression in women, did not predict depressive symptom development. Conclusion Predictors of depressive symptom development differ from predictors of recovery from clinical depression in women. Interventions should be designed to reduce specific deficits in social support observed in particular study populations.

Symptoms of depression and anxiety during adult life: evidence for a decline in prevalence with age

Abstract: Background. To test the hypothesis that the prevalence, in the general population, of symptoms of depression and anxiety declines with age.Methods. A general population sample of 2725 persons aged 18 to 79 years was administered two inventories for current symptoms of depression and anxiety, together with measures of neuroticism and of exposures that may confer increased risk of such symptoms.Results. Symptoms of depression showed a decline with age in both men and women. For anxiety, the decline was statistically significant for women but not consistently so for men. For the risk factors examined, there was a decline with age in the neuroticism score, the frequency of adverse life events, being seriously short of money and having had parents who separated or divorced. Further analysis showed that the association between age and a declining symptom score cannot be entirely attributed to these risk factors, with the single exception of neuroticism. The latter is itself likely to be contaminated by current symptoms.Conclusion. Unless these findings are due to bias in the sample of those who agreed to participate, they add to the evidence that symptoms of depression and to a lesser extent of anxiety decline in prevalence with age. Some risk factors also decline with age. It now has to be determined if these cross-sectional observations are also to be found in longitudinal data; and what process may underlie this striking change in mental health during adulthood.