Showing papers in "Psychological Medicine in 1999"

Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS).

Abstract: BACKGROUND: Scales to measure the severity of different dimensions of auditory hallucinations and delusions are few. Biochemical and psychological treatments target dimensions of symptoms and valid and reliable measures are necessary to measure these. METHOD: The inter-rater reliability and validity of the Psychotic Symptom Rating Scales (PSYRATS: auditory hallucination subscale and delusions subscale), which measure several dimensions of auditory hallucinations and delusions were examined in this study. RESULTS: The two scales were found to have excellent inter-rater reliability. Their validity as compared with the KGV scale (Krawiecka et al. 1977) was explored. CONCLUSIONS: It is concluded that the PSYRATS are useful assessment instruments and can complement existing measures.

The epidemiology of autism: a review

Abstract: Background. There is some uncertainty about the rate and correlates of autism.Method. Twenty-three epidemiological surveys of autism published in the English language between 1966 and 1998 were reviewed.Results. Over 4 million subjects were surveyed; 1533 subjects with autism were identified. The methodological characteristics of each study are summarized, including case definition, case-finding procedures, participation rates and precision achieved. Across surveys, the median prevalence estimate was 5·2/10000. Half the surveys had 95% confidence intervals consistent with population estimates of 5·4–5·5/10000. Prevalence rates significantly increased with publication year, reflecting changes in case definition and improved recognition; the median rate was 7·2/10000 for 11 surveys conducted since 1989. The average male/female ratio was 3·8[ratio ]1, varying according to the absence or presence of mental retardation. Intellectual functioning within the normal range was reported in about 20% of subjects. On average, medical conditions of potential causal significance were found in 6% of subjects with autism, with tuberous sclerosis having a consistently strong association with autism. Social class and immigrant status did not appear to be associated with autism. There was no evidence for a secular increase in the incidence of autism. In eight surveys, rates for other forms of pervasive developmental disorders were two to three times higher than the rate for autism.Conclusion. Based on recent surveys, a minimum estimate of 18·7/10000 for all forms of pervasive developmental disorders was derived, which outlines the needs in special services for a large group of children.

The unhealthy lifestyle of people with schizophrenia.

Abstract: Background. Schizophrenia has a high natural mortality of a largely environmental aetiology. There is, however, little research about possible risk factors. This study measured the diet, cigarette and alcohol use, exercise and obesity of a cohort of people with schizophrenia and compared results to general population rates.Methods. Semi-structured interview using validated research instruments on 102 middle-aged subjects with a diagnosis of schizophrenia, living in the community. Results were compared to general population norms using standard statistical tests.Results. The subjects ate a diet higher in fat and lower in fibre than the general population. They took little exercise but were not significantly more obese. They smoked heavily but drank less alcohol. Most differences remained significant after controlling for social class.Conclusions. People with schizophrenia have an unhealthy lifestyle, which probably contributes to the excess mortality of the disease. They are therefore an appropriate target group for health promotion interventions.

Psychometric properties of the Liebowitz Social Anxiety Scale.

Abstract: Background. The present study provides data on the reliability, validity and treatment sensitivity of the Liebowitz Social Anxiety Scale (LSAS), one of the most commonly used clinician-administered scales for the assessment of social phobia.Method. Three hundred and eighty-two patients from several studies of the treatment of social phobia were evaluated. An independent assessor administered the LSAS to each patient prior to the initiation of treatment. Patients also completed other measures of social anxiety and avoidance, although the specific measures varied across samples.Results. The LSAS and its subscales were normally distributed and demonstrated excellent internal consistency. The convergent validity of the LSAS was demonstrated via significant correlations with other commonly-used measures of social anxiety and avoidance. These correlations also tended to be larger than correlations with measures of depression, especially after treatment. However, the pattern of correlations of LSAS subscales with one another and with the other measures suggest that the fear subscales and the avoidance subscales may not be sufficiently distinct in clinical samples. The LSAS was also demonstrated to be sensitive to the effects of pharmacological treatments of social phobia over time and in comparison to double-blind pill placebo.Conclusion. The LSAS appears to be a reliable, valid and treatment sensitive measure of social phobia. Further study of the LSAS, both in samples with severe social phobia and in community samples, is needed.

Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity.

Abstract: Background. The paper describes prevalence, impairments, patterns of co-morbidity and other correlates of DSM-IV social phobia in adolescents and young adults, separating generalized and non-generalized social phobics. Methods. Data are derived from the baseline investigation of the Early Developmental Stages of Psychopathology Study (EDSP), a prospective longitudinal community study of 3021 subjects, aged 14‐24. Diagnoses were based on the DSM-IV algorithms of an expanded version of the Composite International Diagnostic Interview. Results. Lifetime prevalence of DSM-IV}CIDI social phobia was 9‐5% in females and 4‐9% in males, with about one-third being classified as generalized social phobics. Twelve-month prevalence was only slightly lower, indicating considerable persistence. Respondents with generalized social phobia reported an earlier age of onset, higher symptom persistence, more co-morbidity, more severe impairments, higher treatment rates and indicated more frequently a parental history of mental disorders than respondents with non-generalized social phobia. Conclusions. History of DSM-IV social phobia was found to be quite prevalent in 14‐24 year-olds. The generalized subtype of social phobia was found to have dierent correlates and to be considerably more persistent, impairing and co-morbid than non-generalized social phobia. Although generalized social phobics are more likely than non-generalized social phobics to receive mental health treatments, the treatment rate in this sample was low despite the fact that mental health services are free in Germany.

Emotional bias and inhibitory control processes in mania and depression.

Abstract: Background. Despite markedly different clinical presentations, few studies have reported differences in neuropsychological functioning between mania and depression. The disinhibited behaviour characteristic of mania and evidence that subgenual prefrontal cortex is differentially activated in mania and depression both suggest that dissociable deficits will emerge on tasks that require inhibitory control and are subserved by ventromedial prefrontal cortex.Methods. Manic patients and controls undertook computerized neuropsychological tests of memory and planning ability. In addition, manic and depressed patients were directly compared with controls on a novel affective shifting task that requires inhibitory control over different components of cognitive and emotional processing.Results. Manic patients were impaired on tests of memory and planning. Importantly, affective shifting performance of manic patients differed from that of depressed patients. Manic patients were impaired in their ability to inhibit behavioural responses and focus attention, but depressed patients were impaired in their ability to shift the focus of attention. Depressed patients exhibited an affective bias for negative stimuli, and we believe this to be the first demonstration of an affective bias for positive stimuli in manic patients.Conclusions. Observed impairments on tests of memory and planning suggest a global pathology for mania consistent with previous profiles for this disorder and similar to established profiles for depression. The results on the affective shifting task demonstrate the presence of mood-congruent bias and dissociable components of inhibitory control in mania and depression. Against a background of memory and planning impairments in the two groups, these findings are consistent with a role for the ventromedial prefrontal cortex in mediating mood–cognition relationships.

Prevalence of suicide ideation and suicide attempts in nine countries.

Abstract: BACKGROUND: There are few cross-national comparisons of the rates of suicide ideation and attempts across diverse countries. Nine independently conducted epidemiological surveys using similar diagnostic assessment and criteria provided an opportunity to obtain that data. METHODS: Suicide ideation and attempts were assessed on the Diagnostic Interview Schedule in over 40000 subjects drawn from the United States, Canada, Puerto Rico, France, West Germany, Lebanon, Taiwan, Korea and New Zealand. RESULTS: The lifetime prevalence rates/100 for suicide ideation ranged from 2.09 (Beirut) to 18.51 (Christchurch, New Zealand). Lifetime prevalence rates/100 for suicide attempts ranged from 0.72 (Beirut) to 5.93 (Puerto Rico). Females as compared to males had only marginally higher rates of suicidal ideation in most countries, reaching a two-fold increase in Taiwan. Females as compared to males had more consistently higher rates for suicide attempts, reaching a two- to three-fold increase in most countries. Suicide ideation and attempts in most countries were associated with being currently divorced/separated as compared to currently married. CONCLUSIONS: While the rates of suicide ideation varied widely by country, the rates of suicide attempts were more consistent across most countries. The variations were only partly explained by variation in rates of psychiatric disorders, divorce or separation among countries and are probably due to cultural features that we do not, as yet, understand. Language: en

Pubertal changes in hormone levels and depression in girls.

Abstract: Background. Throughout their reproductive years, women suffer from a higher prevalence of depression than men. Before puberty, however, this is not the case. In an earlier study, we found that reaching Tanner Stage III of puberty was associated with increased levels of depression in girls. This paper examines whether the morphological changes associated with puberty (as measured by Tanner stage) or the hormonal changes underlying them are more strongly associated with increased rates of depression in adolescent girls.Methods. Data from three annual waves of interviews with 9 to 15-year-olds from the Great Smoky Mountains study were analysed.Results. Models including the effects of testosterone and oestradiol eliminated the apparent effect of Tanner stage. The effect of testosterone was non-linear. FSH and LH had no effects on the probability of being depressed.Conclusions. These findings argue against theories that explain the emergence of the female excess of depression in adulthood in terms of changes in body morphology and their resultant psychosocial effects on social interactions and self-perception. They suggest that causal explanations of the increase in depression in females need to focus on factors associated with changes in androgen and oestrogen levels rather than the morphological changes of puberty.

A population-based twin study in women of smoking initiation and nicotine dependence.

Abstract: Background The development of drug dependence requires prior initiation. What is the relationship between the risk factors for initiation and dependence? Methods Using smoking as a model addiction, we assessed smoking initiation (SI) and nicotine dependence (ND) by personal interview in 1898 female twins from the population-based Virginia Twin Registry. We developed a twin structural equation model that estimates the correlation between the liability to SI and the liability to ND, given SI. Results The liabilities to SI and ND were substantially correlated but not identical. Heritable factors played an important aetiological role in SI and in ND. While the majority of genetic risk factors for ND were shared with SI, a distinct set of familial factors, which were probably partly genetic, solely influenced the risk for ND. SI was associated with low levels of education and religiosity, high levels of neuroticism and extroversion and a history of a wide range of psychiatric disorders. ND was associated with low levels of education, extroversion, mastery, and self-esteem, high levels of neuroticism and dependency and a history of mood and alcohol use disorders. Conclusions The aetiological factors that influence SI and ND, while overlapping, are not perfectly correlated. One set of genetic factors plays a significant aetiological role in both SI and ND, while another set of familial factors, probably in part genetic, solely influences ND. Some risk factors for SI and ND impact similarly on both stages, some act at only one stage and others impact differently and even in opposite directions at the two stages. The pathway to substance dependence is complex and involves multiple genetic and environmental risk factors.

Vulnerability to assaultive violence: further specification of the sex difference in post-traumatic stress disorder.

Abstract: Background. We examine potential sources of the sex differences in post-traumatic stress disorder (PTSD) in the community.Methods. Data were obtained from a representative sample of 2181 persons aged 18–45 years in the Detroit primary metropolitan statistical area, which is a six-county area containing more than four million residents. A random digit dialling method was used to select the sample and a computer-assisted telephone interview was used to obtain the data. DSM-IV PTSD was assessed with respect to a randomly selected trauma from the list of qualifying traumas reported by each respondent.Results. The lifetime prevalence of exposure and the mean number of traumas were lower in females than males. The overall conditional risk of PTSD (i.e. the probability of PTSD among those exposed to a trauma) was approximately twofold higher in females than males, adjusting for the sex difference in the distribution of trauma types. The sex difference was due primarily to females' greater risk following assaultive violence. The sex difference in the avoidance and numbing symptom group following assaultive violence exceeded the sex differences in other symptom groups.Conclusions. Future research should focus on sex differences in the response to assaultive violence, including potential explanations for females' greater probability to experience avoidance and numbing.

Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey

Abstract: Background. General population data were used to study co-morbidities between lifetime social phobia and mood disorders. Methods. Data come from the US National Comorbidity Survey (NCS). Results. Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2‐9), dysthymia (2‐7) and bipolar disorder (5‐9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10‐15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. Conclusions. Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children.

Abstract: Background. Executive function deficits have been reported repeatedly in children with Attention Deficit Hyperactivity Disorder (ADHD). Stimulant medication has been shown to be effective in improving cognitive performance on most executive function tasks, but neuropsychological tests of executive function in this population have yielded inconsistent results. Methodological limitations may explain these inconsistencies. This study aimed to measure executive function in medicated and non-medicated children with ADHD by using a computerized battery, the Cambridge Neuropsychological Test Automated Battery (CANTAB), which is sensitive to executive function deficits in older patients with frontostriatal neurological impairments.Methods. Executive function was assessed in 30 children with ADHD: 15 were stimulant medication naive and 15 were treated with stimulant medication. These two groups were compared to 15 age, sex and IQ matched controls.Results. The unmedicated children with ADHD displayed specific cognitive impairments on executive function tasks of spatial short-term memory, spatial working memory, set-shifting ability and planning ability. Impairments were also seen on spatial recognition memory and delayed matching to sample, while pattern recognition memory remained intact. The medicated children with ADHD were not impaired on any of the above executive function tasks except for deficits in spatial recognition memory.Conclusions. ADHD is associated with deficits in executive function. Stimulant medication is associated with better executive function performance. Prospective follow-up studies are required to examine these effects.

Responses to depression in unipolar depressed patients : an investigation of Nolen-Hoeksema's response styles theory

Abstract: Background. The response styles theory suggests that rumination in response to depressed mood exacerbates and prolongs depression, while distraction ameliorates and shortens it. Gender differences in response styles are said to contribute to the observed gender differences in the prevalence of unipolar depression. While empirical support for the theory has been found from a variety of non-clinical studies, its generalizability to clinically depressed patient populations remains unclear. Methods. A cohort of 52 unipolar depressed in-patients was assessed with the Response Styles Questionnaire during in-patient stay (T1) and 4 weeks after discharge (T2). The patients were followed up 4 months after discharge (T3). Clinical assessment included the SCAN-PSE-10. Results. Moderate and statistically significant retest-stabilities for rumination and distraction were found, comparable for patients with stable and changing depression status from T1 to T2. A cross-sectional diagnosis of a major depressive episode was associated with rumination, while gender was not. Post-discharge baseline rumination (T2), adjusted for concurrent depression, predicted follow-up levels of depression (T3), and, in patients who were non-remitted at post-discharge baseline, it predicted presence of a major depressive episode at follow-up (T3). Results on distraction were more ambiguous. Conclusions. Our results suggest that rumination is likely to have a deteriorating impact on the course of clinical episodes of depression in unipolar depressed patients. Larger longitudinal patient studies are needed to validate these findings.

Consequences of anxiety in older persons: its effect on disability, well-being and use of health services.

Abstract: Background. Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources. Methods. Data of a large community-based random probability sample (N = 659) of older subjects (55-85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables. Results. Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low. Conclusions. Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.

Cognitive function in depression: a distinct pattern of frontal impairment in melancholia?

Abstract: Background Although depressed patients demonstrate impaired performance on a range of neuropsychological tests, there is little research that examines either frontal cognitive deficits or possible differences in test performance between melancholic and non-melancholic subtypes. Methods Depressed subjects were administered a broad neuropsychological battery. In an overall analysis, 77 depressed subjects were compared with 28 controls. In a second set of analyses, the depressed sample was divided into melancholic and non-melancholic subsets according to DSM-III-R, the CORE system and the Newcastle scale. These depressed subsets were contrasted to controls and with each other using ANCOVA controlling for age, IQ, simple reaction time and Hamilton Depression scores where appropriate. Results The total depressed sample was impaired on most mnemonic tasks, simple reaction time and Trails B. Similar findings applied to DSM-III-R melancholic and non-melancholic subjects. When defined by the CORE and Newcastle (narrower definitions of melancholia), melancholic patients were additionally impaired on WCST (perseverative response) and (for Newcastle) digit symbol substitution. In contrast, the cognitive performance of the CORE and Newcastle-defined non-melancholic patients was largely unimpaired. Conclusions Using narrower definitions of melancholia, i.e. CORE and (in particular) Newcastle, melancholic patients were impaired on mnemonic tasks and tasks of selective attention, and set-shifting while non-melancholic subjects were largely unimpaired in their cognitive performance. These differences may be due to impairment of specific neuroanatomical regions in narrowly defined melancholic patients, in particular the anterior cingulate.

Subclinical symptoms in mood disorders: pathophysiological and therapeutic implications.

Abstract: Background The aim of this review was to survey the available literature on prodromal and residual symptoms of unipolar major depression and bipolar disorder. Methods Both a computerized (Medline) and a manual search of the literature were performed. Results In a substantial proportion of patients with affective disorders a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). Conclusions Appraisal of subclinical symptomatology in mood disorders has important implications for pathophysiological models of disease and relapse prevention. In depression, specific treatment of residual symptoms may improve long-term outcome, by acting on those residual symptoms that progress to become prodromes of relapse. In bipolar disorder, decrease of subclinical fluctuations and improvement of level of functioning by specific therapeutic strategies may add to the benefits provided by lithium prophylaxis.

Recovery rates in generalized anxiety disorder following psychological therapy: an analysis of clinically significant change in the STAI-T across outcome studies since 1990.

Abstract: Background. There have been six randomized controlled trials of psychological therapy with generalized anxiety disorder (GAD) using DSM-III-R and DSM-IV. All have used the Trait version of the Spielberger State–Trait Anxiety Inventory (STAI-T) as one of several outcome measures. Each study, however, employed different methods of calculating the clinical significance of outcomes making it difficult to reach a balanced appraisal of the efficacy of psychological treatment.Methods. Raw data on STAI-T scores at pre-, post- and follow-up were obtained for each of the six studies (total N=404). Jacobson methodology for defining clinically significant change (criterion c, reliable change index = 8, cut-off point = 46) was used to allocate each patient to one of four outcomes: worse, unchanged, improved and recovered. The proportion of patients in each category was calculated for treatment conditions in each study and also for aggregate data across types of treatment.Results. A recovery rate of 40% was found for the sample as a whole with 12 of the 20 treatment conditions obtaining very modest recovery rates of 30% or less. Two treatment approaches – individual cognitive behavioural therapy and applied relaxation – do relatively well with overall recovery rates at 6-month follow-up of 50–60%.Conclusions. Jacobson methodology, in distinguishing between improvement and recovery on a standardized measure of general vulnerability to anxiety, provides a stringent but clinically more meaningful evaluation of the efficacy of psychological therapies with GAD than has been available hitherto. Systematic focus on either excessive worry or physiological arousal gives worthwhile results.

A comparison of the utility of dimensional and categorical representations of psychosis.

Abstract: Background. The usefulness of any diagnostic scheme is directly related to its ability to provide clinically useful information on need for care. In this study, the clinical usefulness of dimensional and categorical representations of psychotic psychopathology were compared. Method. A total of 706 patients aged 16-65 years with chronic psychosis were recruited. Psychopathology was measured with the Comprehensive Psychopathological Rating Scale (CPRS). Lifetime RDC, DSM-III-R, and ICD-10 diagnoses and ratings of lifetime psychopathology were made using OPCRIT. Other clinical measures included: (i) need for care; (ii) quality of life; (iii) social disability; (iv) satisfaction with services; (v) abnormal movements; (vi) brief neuropsychological screen; and (vii) over the last 2 years - illness course, symptom severity, employment, medication use, self-harm, time in hospital and living independently. Results. Principal component factor analysis of the 65 CPRS items on cross-sectional psychopathology yielded four dimensions of positive, negative, depressive and manic symptoms. Regression models comparing the relative contributions of dimensional and categorical representations of psychopathology with clinical measures consistently indicated strong and significant effects of psychopathological dimensions over and above any effect of their categorical counterparts, whereas the reverse did not hold. The effect of psychopathological dimensions was mostly cumulative: high ratings on more than one dimension increased the contribution to the clinical measures in a dose-response fashion. Similar results were obtained with psychopathological dimensions derived from lifetime psychopathology ratings using the OCCPI. Conclusions. A dimensional approach towards classification of psychotic illness offers important clinical advantages.

Genetic differences in alcohol sensitivity and the inheritance of alcoholism risk.

Abstract: Background. Substantial evidence exists for an important genetic contribution to alcohol dependence risk in women and men. It has been suggested that genetically determined differences in alcohol sensitivity may represent one pathway by which an increase in alcohol dependence risk occurs. Methods. Telephone interview follow-up data were obtained on twins from male, female and unlike­ sex twin pairs who had participated in an alcohol challenge study in 1979-81, as well as other pairs from the same Australian twin panel surveyed by mail in 1980-82. Results. At follow-up, alcohol challenge men did not differ from other male twins from the same age cohort on measures of lifetime psychopathology or drinking habits; but alcohol challenge women were on average heavier drinkers than other women. A composite alcohol sensitivity measure, combining subjective intoxication and increase in body-sway after alcohol challenge in 1979-81, exhibited high heritability (60 %). Parental alcoholism history was weakly associated with decreased alcohol sensitivity in women, but not after adjustment for baseline drinking history, or in men. High alcohol sensitivity in men was associated with substantially reduced alcohol dependence risk (OR = 0'05, 95 % CI 0'01-0'39). Furthermore, significantly decreased (i.e. low) alcohol sensitivity was observed in non-alcoholic males whose MZ co-twin had a history of alcohol dependence, compared to other non-alcoholics. These associations remained significant in conservative analyses that controlled for respondents' alcohol consumption levels and alcohol problems in 1979-81. Conclusions. Men (but not women) at increased genetic risk of alcohol dependence (assessed by MZ co-twin's history of alcohol dependence) exhibited reduced alcohol sensitivity. Associations with parental alcoholism were inconsistent.

Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm.

Abstract: Background. The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy. Methods. Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N =18) or treatment as usual (TAU N =16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined. Results. Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0·17/month MACT; 0·37/month TAU; P =0·11) and self-rated depressive symptoms also improved ( P =0·03). The treatment involved a mean of 2·7 sessions and the observed average cost of care was 46% less with MACT ( P =0·22). Conclusions. Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.

Gender differences in the effects of bereavement-related psychological distress in health outcomes.

Abstract: Background This study examined whether traumatic grief, depressive and anxiety symptoms formed three distinct factors for widows and widowers. In addition, we examined whether high symptom levels of traumatic grief, depression and anxiety predicted different mental and physical health outcomes for widows and widowers. Method Ninety-two future widows and 58 future widowers were interviewed at the time of their spouse's hospital admission and then at 6 weeks, 6, 13 and 25 month follow-ups. Principal axis factor analyses tested the distinctiveness of traumatic grief, depressive and anxiety symptoms, by gender. Repeated measures ANOVA tested for gender differences and changes over time in mean symptom levels of traumatic grief, depression and anxiety. Linear and logistic regression models estimated the effects of high symptom levels of traumatic grief, depression and anxiety at 6 months on health outcomes at 13 and 25 months post-intake by gender. Results Three distinct symptom clusters (i.e. traumatic grief, depressive and anxiety symptoms) were found to emerge for both widows and widowers. Widows had higher mean levels of traumatic grief, depressive and anxiety symptoms. High symptom levels of traumatic grief measured at 6 months predicted a physical health event (e.g. cancer, heart attack) at 25 months post-intake for widows. High symptom levels of anxiety measured at 6 months predicted suicidal ideation at 25 months for widowers. Conclusions The results suggest that there are gender differences in the levels of psychological symptoms resulting from bereavement and in their effects on subsequent mental and physical health for widows and widowers.

Age differences in depression and anxiety symptoms: a structural equation modelling analysis of data from a general population sample.

Abstract: Background. There is debate as to whether the elderly are really at lower risk for depressive disorders, or whether endorsement of symptoms is artefactually low. The present paper assesses the effects of age on anxiety and depression, and examines whether age has direct effects on self-report of individual symptoms independent of its effect on the underlying dimensions of anxiety and depression.Methods. Structural equation modelling was used to assess the structure of the items and their associations with age and a number of demographic variables. The sample of 2622 participants aged between 18 and 79 years from Canberra (Australia) was drawn from the Electoral Roll. Two instruments were used: the anxiety and depression scales of Goldberg et al. (1988) and the Personal Disturbance Scale from the DSSI of Bedford et al. (1976).Results. Both scales were found to fit satisfactorily to a two factor model. Age correlated negatively with depression. After controlling for the effects of gender, marital status, education and financial difficulty, direct effects of age were found on items from both instruments, indicating that certain depression items were associated with a differential probability of endorsement in older people, even when the level of depression was equal to that of younger people. Items with direct age effects reflected physical (feeling slowed down; waking early) and psychological (hopeless about the future) components of depression. Direct effects of age on items from both anxiety scales were also found.Conclusions. The nature of the depression and anxiety experienced by younger and older people may differ qualitatively. Depression may be associated with an increase in somatic symptoms linked to physical changes and to an increase in endorsement of items which reflect the narrowing of opportunities in the long-term.

Apathy and depressed mood in acquired brain damage: relationship to lesion localization and psychophysiological reactivity

Abstract: Background. Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation.Methods. Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Asberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity.Results. Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity.Conclusion. Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

How do people with schizophrenia explain the behaviour of others? A study of theory of mind and its relationship to thought and speech disorganization in schizophrenia

Abstract: Background. This paper examines the attribution of mental states to others in schizophrenia and its links with thought and speech disorganization.Methods. Two groups of schizophrenic subjects (15 with and 10 without thought and speech disorganization) were compared with 10 manic subjects and 15 normal controls on their pattern of answers to 14 theory of mind comic strips.Results. Schizophrenic subjects with disorganization and a more severe general psychopathology exhibited more unadaptated interpretations of others' mental states than those without disorganization or the manic or normal controls. Their explanation of other people's behaviour tended to be influenced by the frequency of their actions rather than their mental states.Conclusions. The disorganization pattern in schizophrenia may be associated with a specific deficit of the cognitive ability referred to as theory of mind, and this deficit could be a state rather than a trait variable. Patients with thought and speech disorders may be more likely to understanding other people's mental states in unambiguous and common situations.

Relatives' expressed emotion (EE) and PTSD treatment outcome.

Abstract: Background. Expressed emotion (EE) is a measure that has been used to assess the quality of the relationship between patient and their key relative. It has been shown to be strongly predictive of clinical outcome in a range of psychiatric and medical disorders. This study investigated the effect of EE on treatment outcome in chronic post-traumatic stress disorder (PTSD). Methods. A prospective design was adopted. The key relatives of 31 PTSD patients participating in a treatment trial comparing imaginal exposure with cognitive therapy were interviewed and rated on EE prior to treatment allocation. The effect of EE on post-treatment clinical outcomes was assessed. Results. Sixteen patients (52 %) had high EE and 15 (48 %) low EE relatives. Patients with high EE relatives showed lesser change scores on the main outcome variable of the trial, the total CAPS score, and on all the secondary outcome variables than those with low EE relatives. Using different multiple regression models the EE scales of criticism and hostility predicted just under 20 % of the outcome variance. These two scales were highly correlated and criticism marginally predicted the greatest variance (19.7 %). Conclusions. The results highlight the importance of the quality of the patient's social environment in influencing their response to cognitive and behavioural treatments.

Fears and phobias: reliability and heritability.

Abstract: Background. Familial factors, which are partly genetic, influence risk for phobias. Prior family and twin studies, however, were based on a single lifetime assessment, which may be only moderately reliable.Methods. We obtained, 8 years apart, two assessments of lifetime history of five unreasonable fears and phobias (agoraphobia and social, situational, animal and blood-injury phobia) from face-to-face and telephone interviews from 1708 individual female twins from a population-based registry. We also obtained, 1 month apart, test–retest reliability on 192 twins. We fitted, using the program Mx, a measurement model that estimates the role of genetic and environmental risk factors correcting for measurement error.Results. Short-term reliability of the five phobias was modest (mean κ=0·46), but higher than long-term stability (mean κ=0·30). Unreliability occurred both for subject recall of unreasonable fears and for interviewer assessment of which fears constituted phobias. Examining fears and phobias together, in a multiple threshold model, results suggested that twin resemblance was due solely to genetic factors, with estimated total heritabilities, corrected for unreliability, of: any 43%, agoraphobia 67%, animal 47%, blood/injury 59%, situational 46% and social 51%. With the exception of animal phobia, similar results were obtained analysing phobias alone.Conclusions. Lifetime histories of unreasonable fears and phobias assessed at personal interview have substantial unreliability. Correcting for unreliability, the liability to fears and their associated phobias is moderately heritable. Individual-specific environmental experiences play an important role in the development of phobias, while familial–environmental factors appear to be of little aetiological significance.

The Range of Impaired Functioning Tool (LIFE-RIFT): a brief measure of functional impairment.

Abstract: Background. The literature documents that functional impairment is associated with affective disorders. Nevertheless, the choice among thorough, yet brief, well-validated assessments of functional impairment is limited. The objective of this study was to evaluate the psychometric properties of a brief scale of functional impairment, the Range of Impaired Functioning Tool (LIFE–RIFT).Method. The study sample included subjects who presented with major depressive disorder at intake into the NIMH Collaborative Depression Study (CDS). The LIFE–RIFT is composed of items that are included in the Longitudinal Interval Follow-up Evaluation (LIFE). The reliability and validity were examined using data from LIFE–RIFT assessments conducted at four points in time: 6, 12, 18 and 24 months after intake into the CDS.Results. Cross-sectional one factor models accounted for the covariance structure among the four scale items. A longitudinal factor model, with an invariant factor structure over time, also fitted the data well and indicated that the scale items are measures of one construct, namely functional impairment. The internal consistency reliability of the scale was supported with alpha coefficients ranging from 0·81 to 0·83. The inter-rater reliability intraclass correlation coefficient (ICC) was 0·94. Mixed-effect linear regression models showed that those in episode were significantly more impaired than those in recovery. Furthermore, in analyses of predictive validity, impairment was positively associated with subsequent recurrence and negatively associated with subsequent recovery.Conclusions. This psychometric evaluation provides empirical support for the reliability and validity of the LIFE–RIFT, a brief measure of functional impairment.

A difference that matters: comparisons of structured and semi-structured psychiatric diagnostic interviews in the general population.

Abstract: Psychiatric case-identification in general populations allows us to study both individuals with functional psychiatric disorders and the populations from which they come. The individual level of analysis permits disorders to be related to factors of potential aetiological significance and the study of attributes of the disorders that need to be assessed in non-referred populations (an initially scientific endeavour). At the population level valid case identification can be used to evaluate needs for treatment and the utilization of service resources (a public health project). Thus, prevalence is of interest both to scientists and to those responsible for commissioning and planning services (Brugha et al . 1997; Regier et al . 1998). The quality of case identification techniques and of estimates of prevalence is thus of general concern (Bartlett & Coles, 1998). Structured diagnostic interviews were introduced into general population surveys in the 1970s as a method ‘to enable interviewers to obtain psychiatric diagnoses comparable to those a psychiatrist would obtain ’ (Robins et al . 1981). The need to develop reliable standardized measures was partly driven by an earlier generation of prevalence surveys showing rates ranging widely from 10·9% (Pasamanick et al . 1956) to 55% (Leighton et al . 1963) in urban and rural North American communities respectively. If the success of large scale psychiatric epidemiological enquiries using structured diagnostic interviews and standardized classifications is measured in terms of citation rates it would seem difficult to question. But the development of standardized interviews of functional psychiatric disorders has not solved this problem of variability: the current generation of large scale surveys, using structured diagnostic interviews and serving strictly defined classification rules, have generated, for example, 12-month prevalence rates of major depression in the US of 4·2% (Robins & Regier, 1991) and 10·1% (Kessler et al . 1994). This calls into question the validity of the assessments, such that we must reopen the question of what they should be measuring and how they should do it.

Source monitoring deficits in patients with schizophrenia; a multinomial modelling analysis

Abstract: Background Schizophrenia patients, particularly those with symptoms such as thought insertion, passivity experiences and hallucinations, may share an underlying cognitive deficit in monitoring the generation of their own thoughts. This deficit, which has been referred to as 'autonoetic agnosia', may result in the conclusion that self-generated thoughts come from an external source. Previous work supports this notion, yet the statistical approaches that have been used have not enabled a distinction between specific deficits suggesting autonoetic agnosia and more general cognitive dysfunction. Methods Autonoetic agnosia was assessed using source-monitoring paradigms in 28 patients with schizophrenia and 19 control subjects. Multinomial model analyses, which allow the distinction between deficits in recognizing information, remembering its source, and response biases, were applied to the data. Results Schizophrenia patients were impaired in discriminating between words that came from two external sources, from two internal sources, and one internal and one external source. In a condition requiring subjects to distinguish between words they had heard from those they had imagined hearing, when schizophrenic patients did not remember the source of the information, they showed a stronger bias than controls to report that it had come from an external source. Conclusions The application of multinomial models to source monitoring data suggests that schizophrenia patients have source monitoring deficits that are not limited to the distinction between internally-generated and externally-perceived information. However, when schizophrenia patients do not remember the source of information, they may be more likely than controls to report that it came from an external source.

Stimulation of the noradrenergic system enhances and blockade reduces memory for emotional material in man.

Abstract: Background. It is clearly established that emotional events tend to be remembered particularly vividly. The neurobiological substrates of this phenomenon are poorly understood. Recently, the noradrenergic system has been implicated in that beta blockade has been shown to reduce significantly the delayed recall of emotional material with matched neutral material being unaected. Methods. In the present study, 36 healthy young adults were randomly allocated to receive either yohimbine, which stimulates central noradrenergic activity, metoprolol which blocks noradrenergic activity, or matched placebo. The three groups were well matched. All capsules were taken orally, prior to viewing a narrated 11 slide show described a boy being involved in an accident. Results. Yohimbine significantly elevated, and metoprolol reduced mean heart rate during the slide show relative to placebo, thus confirming the ecacy of the pharmacological manipulation. One week later, in a ‘surprise’ test, memory for the slide show was tested. As predicted, yohimbinetreated subjects recalled significantly more and metoprolol subjects fewer slides relative to placebo. This result was confirmed via analysis of multiple-choice recognition memory scores. Conclusions. We conclude that stimulation of the noradrenergic system results in the enhancement and blockade in a reduction of recall and recognition of emotional material in man.