Showing papers in "Psychological Medicine in 2000"

Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood.

Abstract: BACKGROUND: This study examined associations between childhood circumstances, adolescent mental health and life events, and the development of suicidal behaviour in young people aged between 15 and 21 years. METHOD: Data were gathered over the course of a 21-year longitudinal study of a birth cohort of 1265 children born in New Zealand. The measures collected included: (1) patterns of suicidal behaviour (ideation, attempt) (15-21 years); (2) social background, family functioning, parental and individual adjustment during childhood (0-16 years); and (3) time dynamics of mental health and stressful life events during adolescence and early adulthood (15-21 years). RESULTS: By the age of 21 years, 28.8% of the sample reported having thought about killing themselves and 7.5% reported having made a suicide attempt. The childhood profile of those at greatest risk of suicidal behaviour was that of a young person reared in a family environment characterized by socio-economic adversity, marital disruption, poor parent-child attachment and exposure to sexual abuse, and who as a young adolescent showed high rates of neuroticism and novelty seeking. With the exception of the socio-economic and personality measures, the effects of childhood factors were largely mediated by mental health problems and exposure to stressful life events during adolescence and early adulthood. Mental health problems including depression, anxiety disorders, substance use disorder, and to some extent conduct disorder, in addition to exposure to adverse life events, were significantly associated with the onset of suicidal behaviours. CONCLUSIONS: Findings support a life course model of the aetiology of suicidal behaviour in which risk of developing suicidal behaviour depends on accumulative exposure to a series of social, family, personality and mental health factors. Language: en

The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults

Abstract: Background. The aims of this study were to use longitudinal report data on physical and sexual abuse to examine the stability and consistency of abuse reports.Methods. The study was based on the birth cohort of young people studied in the Christchurch Health and Development Study. At ages 18 and 21 years, these young people were questioned about their childhood exposure to physical punishment and sexual abuse. Concurrent with these assessments, sample members were also assessed on measures of psychiatric disorder and suicidal behaviour.Results. Reports of childhood sexual abuse and physical punishment were relatively unstable and the values of kappa for test–retests of abuse reporting were in the region of 0·45. Inconsistencies in reporting were unrelated to the subject's psychiatric state. Latent class analyses suggested that: (a) those not abused did not falsely report being abused; and (b) those who were abused provided unreliable reports in which the probability of a false negative response was in the region of 50%. Different approaches to classifying subjects as abused led to wide variations in the estimated prevalence of abuse but estimates of the relative risk of psychiatric adjustment problems conditional on abuse exposure remained relatively stable.Conclusions. There was substantial unreliability in the reporting of child abuse. This unreliability arose because those who were subject to abuse often provided false negative reports. The consequences of errors in reports appear to be: (a) that estimates of abuse prevalence based on a single report are likely to seriously underestimate the true prevalence of abuse; while (b) estimates of the relative risk of psychiatric adjustment problems conditional on abuse appear to be robust to the effects of reporting errors.

Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the adult life span.

Abstract: Background. There is considerable disagreement about what happens to the risk of anxiety and depression disorders and symptoms as people get older.Methods. A search was made for studies that examine the occurrence of anxiety, depression or general distress across the adult life span. To be included, a study had to involve a general population sample ranging in age from at least the 30s to 65 and over and use the same assessment method at each age.Results. There was no consistent pattern across studies for age differences in the occurrence of anxiety, depression or distress. The most common trend found was for an initial rise across age groups, followed by a drop. Two major factors producing this variability in results were age biases in assessment of anxiety and depression and the masking effect of other risk factors that vary with age. When other risk factors were statistically controlled, a more consistent pattern emerged, with most studies finding a decrease in anxiety, depression and distress across age groups. This decrease cannot be accounted for by exclusion of elderly people in institutional care from epidemiological surveys or by selective mortality of people with anxiety or depression.Conclusion. There is some evidence that ageing is associated with an intrinsic reduction in susceptibility to anxiety and depression. However, longitudinal studies covering the adult life span are needed to distinguish ageing from cohort effects. More attention needs to be given to understanding the mechanism behind any ageing-related reduction in risk for anxiety and depression with age. Possible factors are decreased emotional responsiveness with age, increased emotional control and psychological immunization to stressful experiences.

The perception of self-produced sensory stimuli in patients with auditory hallucinations and passivity experiences: evidence for a breakdown in self-monitoring

Abstract: Background. To test the hypothesis that certain psychotic symptomatology is due to a defect in selfmonitoring, we investigated the ability of groups of psychiatric patients to dierentiate perceptually between self-produced and externally produced tactile stimuli. Methods. Responses to tactile stimulation were assessed in three groups of subjects: schizophrenic patients; patients with bipolar aective disorder or depression; and normal control subjects. Within the psychiatric groups subjects were divided on the basis of the presence or absence of auditory hallucinations and}or passivity experiences. The subjects were asked to rate the perception of a tactile sensation on the palm of their left hand. The tactile stimulation was either self-produced by movement of the subject’s right hand or externally produced by the experimenter. Results. Normal control subjects and those psychiatric patients with neither auditory hallucinations nor passivity phenomena experienced self-produced stimuli as less intense, tickly and pleasant than identical, externally produced tactile stimuli. In contrast, psychiatric patients with these symptoms did not show a decrease in their perceptual ratings for tactile stimuli produced by themselves as compared with those produced by the experimenter. This failure to show a dierence in perception between self-produced and externally produced stimuli appears to relate to the presence of auditory hallucinations and}or passivity experiences rather than to the diagnosis of schizophrenia. Conclusions. We propose that auditory hallucinations and passivity experiences are associated with an abnormality in the self-monitoring mechanism that normally allows us to distinguish selfproduced from externally produced sensations.

The power and omnipotence of voices: subordination and entrapment by voices and significant others.

Abstract: Background. Cognitive therapy for psychotic symptoms often embraces self-evaluative beliefs (e.g. self-worth) but whether and how such beliefs are related to delusions remains uncertain. In previous research we demonstrated that distress arising from voices was linked to beliefs about voices and not voice content alone. In this study we examine whether the relationship with the voice is a paradigm of social relationships in general, using a new framework of social cognition, ‘ranking’ theory.Method. In a sample of 59 voice hearers, measures of power and social rank difference between voice and voice hearer are taken in addition to parallel measures of power and rank in wider social relationships.Results. As predicted, subordination to voices was closely linked to subordination and marginalization in other social relationships. This was not the result of a mood-linked appraisal. Distress arising from voices was linked not to voice characteristics but social and interpersonal cognition.Conclusion. This study suggests that the power imbalance between the individual and his persecutor(s) may have origins in an appraisal by the individual of his social rank and sense of group identification and belonging. The results also raise the possibility that the appraisal of voice frequency and volume are the result of the appraisal of voices' rank and power. Theoretical and novel treatment implications are discussed.

Quantitative MRI of the hippocampus and amygdala in severe depression.

Abstract: Background There is little evidence to support possible structural changes in the amygdala and hippocampus of patients with severe depressionMethods Quantitative MRI of the amygdala and hippocampus, as well as proton spectroscopy (MRS) of mesial temporal structures were studied in 34 drug-resistant in-patients with major depression and compared with 17 age-matched controls Volumetric MRI data were normalized for brain sizeResults The volume of the left hippocampus was significantly smaller in the patients compared with the controls Both groups exhibited similar significant hippocampal asymmetry (left smaller than right) The patients, but not the controls, had significant asymmetry of the amygdalar volumes (right smaller than left) No differences were observed between the patients and controls in the T2 relaxation times for the hippocampus and amygdala Mesial temporal lobe MRS revealed a significantly elevated choline/creatine ratio in the patients compared with the controlsConclusions This quantitative MRI study provides support for a possible association between structural and biochemical substrates and severe drug-resistant major depression

The stability of the factor structure of the General Health Questionnaire.

Abstract: Background. Different versions of the General Health Questionnaire (GHQ), including the GHQ-12 and GHQ-28 have been subjected to factor analysis in a variety of countries. The World Health Organization study of psychological disorders in general health care offered the opportunity to investigate the factor structure of both GHQ versions in 15 different centres.Methods. The factor structures of the GHQ-12 and GHQ-28 extracted by principal component analysis were compared in participating centres. The GHQ-12 was completed by 26120 patients and 5273 patients completed the GHQ-28. The factor structure of the GHQ-28 found in Manchester in this study was compared with that found in the earlier study in 1979.Results. For the GHQ-12, substantial factor variation between centres was found. After rotation, two factors expressing depression and social dysfunction could be identified. For the GHQ-28, factor variance was less. In general, the original C (social dysfunction) and D (depression) scales of the GHQ-28 were more stable than the A (somatic symptoms) and B (anxiety) scales. Multiple cross-loadings occurred in both versions of the GHQ suggesting correlation of the extracted factors. In Manchester, the factor structure of the GHQ had changed since its development. Validity as a case detector was not affected by factor variance.Conclusions. These findings confirm that despite factor variation for the GHQ-12, two domains, depression and social dysfunction, appear across the 15 centres. In the scaled GHQ-28, two of the scales were remarkably robust between the centres. The cross-correlation between the other two subscales, probably reflects the strength of the relationship between anxiety and somatic symptoms existing in different locations.

Early sexual abuse and lifetime psychopathology: a co-twin-control study.

Abstract: Background. This study was designed to determine lifetime prevalence of psychiatric disorders among twins who reported childhood sexual abuse (CSA), and to compare these rates with those among non-abused co-twins. The contribution of familial and individual-specific factors to reported sexual abuse was also examined. Method. Information about lifetime psychopathology and substance use was obtained by structured telephone interviews with 5995 Australian twins. Twins who reported a history of childhood sexual abuse (CSA) were contrasted on lifetime psychopathology with subjects without such a history; in addition, comparisons were made between same-sex twin pairs discordant for CSA. Results. A history of CSA was reported by 5‐9% of the women and 2‐5% of the men. In the sample as a whole, those reporting CSA were more likely to receive lifetime diagnoses of major depression, conduct disorder, panic disorder and alcoholism, and were more likely to report suicidal ideation and a history of suicide attempt. Abused women, but not men, were also more likely to report social phobia. When comparisons were restricted to non-abused co-twins, no dierences in psychopathology were seen. However, rates of major depression, conduct disorder and suicidal ideation were higher if both co-twins were abused than if the respondent alone reported CSA. Model-fitting indicated that shared environmental factors influenced risk for reported CSA in women, but not in men. Conclusion. The association between CSA and psychopathology arises at least in part through the influence of shared familial factors on both risk of victimization and risk of psychopathology.

Cognitive impairment in remission in bipolar affective disorder.

Abstract: Background Although the traditional view of bipolar affective disorder is that the majority of patients have full remission between episodes, recent evidence suggests that residual cognitive deficits are present. The aim of this study was to determine whether memory and executive deficits were present in a well-defined clinically remitted group of patients. Methods This was a case-control study of bipolar patients in remission (N = 18). Subjects had to fulfil stringent clinical criteria for inclusion into the study and had to have been in remission for at least 4 months. Subjects also had no history of substance dependence. The cognitive battery examined memory and executive function. Results Patients in excellent clinical remission and who reported good social adaptation showed imipairment on tests of visuospatial recognition memory. Accuracy on four tests of executive function was not impaired in patients in remission compared with controls, although response latency on these executive tests was still impaired. Conclusions As our group and others have shown, patients with mania and unipolar depression show generalized impairment on tests of memory and executive function. In comparison, this study has demonstrated that patients in remission show a relatively specific impairment in memory with recovery of accuracy measures on executive function task. The increased response latency on the executive tasks suggests a possible small residual impairment. These findings suggest that in netIroanatomical terms, more posterior cortical function (temporal lobe) has not improved but there is at least some recovery of frontal lobe function in remission.

Current and residual functional disability associated with psychopathology: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS).

Abstract: Background Few population studies have investigated the functional disabilities that accompany specific psychiatric diagnoses. This study assesses the nature and strength of current and residual impairments in various functional domains of life. Methods Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective study in the Dutch general population aged 18 to 64 (N = 7147). Psychiatric diagnoses were based on the Composite International Diagnostic Interview; functional disability was assessed on the basis of the Short-Form-36 and the number of disability days. Results Psychopathology was associated with increased disability in social, emotional and physical domains of life. Disability levels varied by psychiatric diagnosis, with mood disorders showing the poorest levels of functioning, especially for vitality and social functioning; alcohol-related disorders were associated with few disabilities. Co-morbidity strongly aggravated the disability. The effect of contextual factors on disability was limited, although somatic ill health, unemployment and adverse youth history increased the likelihood of functional disability. The findings indicate that psychopathology can also have residual debilitating effects. Conclusions Mental health care providers should be aware that the extent and the type of disability may vary with the different types of disorders and among different groups within the population. Since recovery from functional limitations may not be complete or may take more time than the remission of the psychiatric symptomatology, non-psychiatric follow-up care is needed. The high number of lost work days is relevant from an economic perspective. There is a need for illness-specific disability assessment instruments.

Decreased working memory and processing speed mediate cognitive impairment in geriatric depression.

Abstract: Background. While neuropsychological dysfunction is common in geriatric depression, not all aspects of cognition are equally affected. It has been suggested that depressed patients are impaired only in tasks that make heavy demands on processing resources and that a resource decrement therefore underlies the neuropsychological decrements seen in geriatric depression. The present study examined whether processing resources in the form of working memory and information processing speed are decreased in depression and whether a decrease in these resources actually mediates neuropsychological impairment.Methods. Measures of processing resources were administered to elderly depressed patients prior to treatment and to age-matched controls. Patients whose depression remitted were retested as were the controls. Subjects also received neuropsychological tests of episodic memory and visuospatial performance.Results. Depressed patients performed significantly worse on measures of both processing speed and working memory. While performance on these measures improved in patients whose depression remitted, the amount of improvement was no greater than that seen in the controls with repeat testing. Hierarchical regression analyses showed that depression explained a significant amount of variance on the neuropsychological tasks. However, if the variance associated with processing resources was removed first, depression no longer accounted for a significant amount of neuropsychological variance.Conclusions. Processing resources are decreased in elderly depressed patients and this decrease in resources appears to mediate impairments in several areas of neuropsychological functioning including episodic memory and visuospatial performance. The resource decrement persists after remission of the depression and thus may be a trait marker of geriatric depression.

Cognitive vulnerability in patients with bipolar disorder.

Abstract: Background. No study has simultaneously explored key components of Beck's model of cognitive vulnerability to depression in people with bipolar disorders.Methods. We compared 41 euthymic bipolar patients with 20 healthy control subjects. All subjects were assessed on the Hamilton Rating Scale for Depression, the Autobiographical Memory Test and the Mean Ends Problem-Solving procedure and also completed the Beck Depression Inventory, the Dysfunctional Attitude Scale, the Sociotropy Autonomy Scale and the Rosenberg Self-Esteem Questionnaire.Results. In comparison to control subjects, patients with bipolar disorder demonstrated significantly higher levels of dysfunctional attitudes (particularly perfectionism and need for approval) and sociotropy, significantly greater over-general recall on an autobiographical memory test and significantly less ability to generate solutions to social problem-solving tasks. These between group differences remained significant when age, intelligence, latency to respond to autobiographical memory test cue words, and subjective mood ratings were included as co-variates in the statistical analysis. Within the patient group, cognitive dysfunction was significantly correlated with level of morbidity (as measured by number of previous illness episodes).Conclusions. This study suggests that cognitive vulnerability in patients with bipolar disorder is similar to that described in unipolar disorders. It is not clear whether this dysfunction is a cause or an effect of repeated episodes of bipolar disorder. However, the findings may have implications for clinical treatment as well as suggesting a number of important new avenues of research into psychological models of affective disorder.

Unequal access and unmet need: neurotic disorders and the use of primary care services.

Abstract: Background. In this paper we use data from the National Survey of Psychiatric Morbidity to examine how many people with neurotic disorders receive professional evaluation, and how this is affected by clinical and sociodemographic differences, We hypothesized that psychiatric symptoms and attendant dysfunctions would both have an effect on contacting, and that key demographic variables would not.Method. The household component of the British National Surveys of Psychiatric Morbidity was based on a random sample of > 10000 subjects. Psychiatric symptoms and ICD-10 diagnosis were established by lay interviewers using the CIS-R. Social dysfunction was tapped by asking about difficulties in performing seven types of everyday activity. We examined symptom score, ADL deficit score and demographic variables in relation to contact with primary care physicians for psychiatric symptoms.Results. The major determinant of contacting a primary care physician was severity, mainly due to the level of psychiatric symptoms, but with an independent contribution from social dysfunction. There were also significant contributions from sex, marital status, age, employment status and whether the subject had a physical condition as well.Conclusions. The major influence on whether people seek the help of their family doctors for mental health problems is the severity of disorder. Although there are some social inequalities in access to family doctors, these are less important, The most salient finding from our study is that even people suffering from high levels of psychiatric symptoms very often do not have contact with professionals who might help them.

Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study

Abstract: Background. Hip fracture is common in the elderly. Previous studies suggest that psychiatric illness is common and predicts poor outcome, but have methodological weaknesses. Further studies are required to address this important issue. Methods. We prospectively recruited 731 elderly participants with hip fracture in two Leeds hospitals. Psychiatric diagnosis was made within 5 days of surgery using the Geriatric Mental State schedule and other standardized instruments, and data on confounding factors was collected. Main study outcomes were length of hospital stay, and mortality over 6 months after fracture. Results. Fifty-five per cent of participants had cognitive impairment (dementia in 40% and delirium in 15%), 13% had a depressive disorder, 2% had alcohol misuse and 2% had other psychiatric diagnoses. Participants were likely to remain in hospital longer if they suffered from dementia, delirium or depression. The relative risks of mortality over 6 months after hip fracture were increased in dementia and delirium, but not in depression. Conclusions. Psychiatric illness is common after hip fracture, and has significant effects on important outcomes. This suggests a need for randomized, controlled trials of psychiatric interventions in the elderly hip fracture population.

Attentional bias for drug cues in opiate dependence.

Abstract: Background. In a number of theories of compulsive drug use conditioned responses to stimuli associated with drug taking play a pivotal role. For example, according to incentive-sensitization theory (Robinson & Berridge, 1993), drug-related stimuli selectively capture attention, and the neural mechanisms underlying this attentional bias play a key role in the development and maintenance of drug dependence, and in relapse. However, there has been little work that assesses attentional biases in addiction. Methods. We used a pictorial probe detection task to investigate whether there is an attentional bias to stimuli associated with drug use in opiate dependence. Stimuli presented included pairs of drug-related and matched neutral pictures. Methadone-maintained opiate addicts (N = 16) were compared with age-matched controls (N = 16). Results. A mixed design analysis of variance of response times to probes revealed a significant three-way interaction of group×drug picture location×probe location. Opiate addicts had relatively faster reaction times to probes that replaced drug pictures rather than neutral pictures, consistent with the predicted attentional bias to drug-related stimuli. Conclusions. These results support the idea that an attentional bias for drug-related stimuli occurs in opiate dependence. This is consistent with the concept of a central role for such salient stimuli in compulsive drug use.

Personality traits of the relatives of autistic probands.

Abstract: Background. There is substantial evidence that the genetic liability to autism confers a risk for a range of more subtle social and communication impairments, as well as stereotyped and repetitive behaviours. Recent research suggests that increased expression of particular personality traits may be a manifestation of the liability to autism.Methods. To investigate this we examined the personality traits of the adult relatives of 99 autistic and 36 Down's syndrome probands, using the informant version of the Modified Personality Assessment Schedule.Results. There was significantly increased expression of the traits anxious, impulsive, aloof, shy, over-sensitive, irritable and eccentric among the autism relatives with evidence of different profiles for male and female relatives and for parents and adult children. Factor analysis revealed three broad groups of traits, two of which (‘withdrawn’ and ‘difficult’) appeared to reflect impairments in social functioning and a third group of anxiety related traits (‘tense’). Each of these factors differed in their pattern of associations with the factor we termed ‘withdrawn’ showing a similar pattern of association to that found for other autism related conditions. The ‘tense’ factor appeared in part to be related to the burden of caring for an autistic child.Conclusions. This study confirms the finding that particular personality traits may aggregate in the family members of autistic individuals and furthermore that some of these traits may be a manifestation of the liability to autism.

Decentring and distraction reduce overgeneral autobiographical memory in depression.

Abstract: Background. Increased recall of categorical autobiographical memories is a phenomenon unique to depression and post-traumatic stress disorder, and is associated with a poor prognosis for depression. Although the elevated recall of categorical memories does not change on remission from depression, recent findings suggest that overgeneral memory may be reduced by cognitive interventions and maintained by rumination. This study tested whether cognitive manipulations could influence the recall of categorical memories in dysphoric participants. Methods. Forty-eight dysphoric and depressed participants were randomly allocated to rumination or distraction conditions. Before and after the manipulation, participants completed the Autobiographical Memory Test, a standard measure of overgeneral memory. Participants were then randomized to either a ‘decentring’ question (Socratic questions designed to facilitate viewing moods within a wider perspective) or a control question condition, before completing the Autobiographical Memory Test again. Results. Distraction produced significantly greater decreases in the proportion of memories retrieved that were categorical than rumination. Decentring questions produced significantly greater decreases in the proportion of memories retrieved that were categorical than control questions, with this eect independent of the prior manipulation. Conclusions. Elevated categorical memory in depression is more modifiable than has been previously assumed; it may reflect the dynamic maintenance of a cognitive style that can be interrupted by brief cognitive interventions.

Personality traits among currently eating disordered, recovered and never ill first-degree female relatives of bulimic and control women.

Abstract: Background. A combined family study and recovered study design was utilized to examine several hypothesized relationships between personality and bulimia nervosa (BN). Methods. We studied 47 women with a lifetime history of DSM-III-R BN (31 currently ill and 16 recovered), 44 matched control women (CW) with no history of an eating disorder (ED), and their first-degree female relatives (N fl 89 and N fl 100, respectively), some of whom had current or previous EDs. Results. BN probands’ relatives with no ED history had significantly elevated levels of perfectionism, ineectiveness, and interpersonal distrust compared to CW probands’ relatives with no ED history. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions were found among the previously eating disordered relatives of bulimic probands compared to their never ill relatives. Finally, a sense of alienation and emotional responsivity to the environment were elevated among currently ill compared to recovered bulimic probands. Conclusions. The fact that perfectionism, ineectiveness and interpersonal distrust are transmitted independently of an ED in relatives suggests that they may be of potential aetiological relevance for BN. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions are more likely consequent to, or exacerbated by, previously having experienced the illness. Finally, a sense of alienation and emotional responsivity to the environment are more likely to be associated with currently having BN.

Social disability in schizophrenia : its development and prediction over 15 years in incidence cohorts in six European centres

Abstract: Background. This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts. Methods. Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule. Results. Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years. Conclusion. Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.

Depression and social stress in Pakistan.

Abstract: Background. The high prevalence of depression in developing countries is not well understood. This study aimed to replicate the previous finding of a high prevalence of depression in Pakistan and assess in detail the associated social difficulties.Method. A two-phase survey of a general population sample in a Pakistani village was performed. The first-phase screen used the Personal Health Questionnaire (PHQ) and the self-rating questionnaire (SRQ). A one in two sample of high scorers and a one in three sample of the low scorers were interviewed using the Psychiatric Assessment Schedule (PAS) and Life Events and Difficulties Schedule (LEDS).Results. A total of 259 people were screened (96% response rate). The second stage yielded 55 cases, of whom 54 had depressive disorder, and 48 non-cases. The adjusted prevalence of depressive disorders was 44·4% (95% CI 35·3 to 53·6): 25·5% in males and 57·5% in females. Nearly all cases had lasted longer than 1 year. Comparison of the cases and non-cases indicated that cases were less well educated, had more children and experienced more marked, independent chronic difficulties. Multivariate analysis indicated that severe financial and housing difficulties, large number of children and low educational level were particularly closely associated with depression.Conclusion. This study confirms the high prevalence of depressive disorders in Pakistan and suggests that this may be higher than other developing countries because of the high proportion of the population who experience social adversity.

A differential neural response in obsessive-compulsive disorder patients with washing compared with checking symptoms to disgust.

Abstract: Background. Patients with obsessive‐compulsive disorder (OCD) have symptoms that predominantly concern washing (washers) or checking (checkers), or both. Functional neuroimaging has been used to identify the neural correlates of the urge to ritualize but has not distinguished between washing and checking symptoms in OCD. We used functional magnetic resonance imaging to compare the neural response to emotive pictures in washers and checkers. Methods. In one of two 5-minute experiments, washers (N fl 7), checkers (N fl 7) and age-matched normal controls (N fl 14) were scanned while viewing alternating blocks of normally disgusting (rated as disgusting by all subjects) and neutral pictures. In the other experiment, all patients and a normal subgroup (N fl 8) viewed alternating blocks of washer-relevant (rated as more disgusting by washers than normal controls or checkers) and neutral pictures. Results. In all subjects, normally disgusting pictures activated visual regions implicated in perception of aversive stimuli and the insula, important in disgust perception. Only in washers were similar regions activated by washer-relevant pictures. In checkers, these pictures activated frontostriatal regions associated with the urge to ritualize in OCD. Normal controls were more similar in neural response to checkers than washers to these pictures. Both normal controls and checkers had frontal regions activated significantly more by washer-relevant than normally disgusting pictures, and had these regions activated significantly more than washers by washer-relevant pictures. Conclusions. We demonstrate a dierential neural response to washer-relevant disgust in washers and checkers: only washers demonstrate a neural response to washer-relevant disgust associated with emotion perception rather than attention to non-emotive visual detail.

Social rhythm disruption and stressful life events in the onset of bipolar and unipolar episodes.

Abstract: Background An association between social rhythm disruption (SRD) and onset of manic episodes has recently been observed. Whether other types of bipolar (depressive and cycling) or unipolar depressive episodes are similarly related to SRD is unclear, as is the association between severely threatening life events and onset of bipolar manic, depressed and cycling episodes. Methods Bipolar patients with purely manic (N= 21), purely depressed (N = 21) and cycling (N = 24) episodes, and 44 patients with recurrent unipolar depression, were interviewed with the Bedford College Life Events and Difficulties Schedule. The presence of severe and SRD events during the year prior to index episode onset was then determined. Results More manic than cycling and unipolar subjects experienced SRD events during 8- and 20-week pre-onset periods, and severe events during 20-week pre-onset periods. Controlling for age and prior number of episodes left most findings unchanged. An earlier finding of more manic subjects with SRD events in an 8-week pre-onset versus control period was also replicated. Conclusions It appears that manic onsets are influenced by stressful life events, especially those involving SRD, in a unique manner compared to onsets of other types of bipolar and unipolar episodes. Onset of bipolar cycling episodes, in contrast, seems to be relatively unaffected by SRD or severe life events. These findings refine the hypothesis that SRD may precipitate onset of affective episodes to be specific to manic onsets.

Physical health and the onset and persistence of depression in older adults: an eight-wave prospective community-based study

Abstract: Background. Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. Since many aspects of physical health can be targeted for improvement in primary care, it is important to know whether physical health problems predict the onset and/or the persistence of depression. Methods. The study is based on a sample which at the outset consisted of 327 depressed and 325 non-depressed older adults (55–85) drawn from a larger random community-based sample in the Netherlands. Depression was measured using the Center for Epidemiologic Studies Depression scale (CES-D) at eight successive waves. Results. From all incident episodes, the majority (57%) was short-lived. These short episodes could generally not be predicted by physical health problems. The remaining incident episodes (43%) were not short-lived and could be predicted by poor physical health. Chronicity (34%) was also predicted by physical health problems. Conclusions. The study design with its frequent measurements recognized more incident cases than previous studies; these cases however did have a better prognosis than is often assumed. The prognosis of prevalent cases was rather poor. Physical health problems were demonstrated to be a predictor of both the onset and the persistence of depression. This may well have implications for prevention and intervention.

Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors.

Abstract: Background. Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention.Methods. We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. ‘Preparing for Parenthood’, a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview.Results. Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1·22 (95% CI 0·63–2·39), P = 0·55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders.Conclusions. Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation.

Linguistic processing in high-functioning adults with autism or Asperger's syndrome. Is global coherence impaired?

Abstract: Background Linguistic processing was explored in normally intelligent adults with either autism or Asperger's syndrome, to test if global coherence was impaired. Global coherence is the ability to establish causal connections and interrelate local chunks into higher-order chunks so that most linguistic elements are linked together thematically. Since individuals with autism are hypothesized to have weak central coherence then one would predict that the clinical groups would have difficulty integrating information globally so as to derive full meaning. Methods Two experiments were designed to test global coherence. Experiment 1 investigated whether individuals on the autism spectrum condition could arrange sentences coherently. Experiment 2 investigated whether they were less able to use context to make a global inference. Results The clinical groups were less able to arrange sentences coherently and use context to make a global inference. Conclusions The results suggest that individuals on the autism spectrum have impaired global coherence. Arranging sentences and making global inferences correlated highly, suggesting that central coherence may be a unitary force in these different tasks. Of the two clinical groups, the autism group had the greater deficit. The effect that such a deficit would have on one's daily life is discussed, along with possible explanations for the clinical groups' greater difficulty, and suggestions for future research.

Neuropsychological change in young people at high risk for schizophrenia: results from the first two neuropsychological assessments of the Edinburgh High Risk Study.

Abstract: Background. Studies of groups of individuals who have a genetically high risk of developing schizophrenia, have found neuropsychological impairments that highlight likely trait markers of the schizophrenic genotype. This paper describes the change in neuropsychological function and associations with psychiatric state of high risk participants during the first two assessments of the Edinburgh High Risk Study. Methods. Seventy-eight high risk participants and 22 normal controls, age and sex matched completed two neuropsychological assessments 18 months to 2 years apart. The areas of function assessed include intellectual function, executive function, learning and memory, and verbal ability and language. Results. The high risk participants performed significantly worse on particular tests of verbal memory and executive function over the two assessments than matched controls. Those high risk participants who experienced psychotic symptoms were found to exhibit a decline in IQ and perform worse on tests of verbal memory and executive function than those without symptoms. An increase in psychotic symptoms between the two assessments in the high risk group was found to be associated with an apparent decline in IQ and memory. Conclusions. The results suggest that the development of psychotic symptoms is preceded by a decline in IQ and memory. This may reflect a general and a more specific disease process respectively.

Non-linear relationships in associations of depression and anxiety with alcohol use

Abstract: Background Many studies have demonstrated co-morbidity of alcohol abuse/dependence with mood and anxiety disorders but relatively little is known about anxiety and depression across the full continua of alcohol consumption and problems associated with drinking. Methods Participants from a general population sample (N = 2725) aged 18-80 years completed the Alcohol Use Disorders Identification Test (AUDIT) and four measures of negative affect (two depression and two anxiety symptom scales) included in a self-completion questionnaire. Results High consumption, AUDIT total score, and AUDIT problems score were associated with high negative affect scores in participants under 60 years old (ORs in the range 1.80-2.83). Graphical and statistical analyses using continuous measures of alcohol use/problems and negative affect identified non-linear relationships where abstainers and occasional drinkers, as well as heavy and problem drinkers, were at risk of high anxiety and depression levels. This pattern, however, was not found in those aged > or = 60 years. The U-shaped relationship was not an artefact of abstainers being typical of the general population in their distribution of negative affect. Conclusions Studies of co-morbidity should acknowledge the possibility of non-linear associations and employ both continuous and discrete measures. Abstainers, as well as heavy drinkers, are at increased risk of symptoms of depression and anxiety disorders. Psychosocial factors may play a role in the U-shaped relationship between alcohol consumption and mortality.

Neurotic disorders and the receipt of psychiatric treatment

Abstract: Background. Access to psychiatric treatment by people with neurotic disorders in the general population is likely to be affected both by the severity of disorder and by sociodemographic differences.Method. In the household component of the National Surveys of Psychiatric Morbidity > 10000 subjects in Great Britain with psychiatric symptoms were interviewed using the CIS-R. They were also asked about difficulties experienced in performing seven types of everyday activity. All subjects classed as having an ICD-10 disorder were questioned about their experience of treatment with antidepressants, hypnotics, and counselling or psychotherapy.Results. Less than 14 % of people with current neurotic disorders were receiving treatment for them. Within the previous year, only a third had made contact with their primary care physician for their mental problem: of these < 30 % were receiving treatment. Overall, 9 % of people with disorders were given medication and 8 % counselling or psychotherapy. A diagnosis of depressive episode was that most associated with antidepressant medication. Treatment access was affected by employment status, marital status, and age, but the major determinant was symptom severity. Neither sex nor social class influenced which people received treatment.Conclusions. People with psychiatric disorders seldom receive treatment, even when they have consulted their primary care physician about them. In many cases, this must represent unmet needs with a strong claim on health resources. There are also inequalities in the receipt of treatment, although the major influence is the severity of disorder.

Validation of the prospective NIMH-Life-Chart Method (NIMH-LCM-p) for longitudinal assessment of bipolar illness.

Abstract: Background. Systematic and accurate depiction of a patient's course of illness is crucial for assessing the efficacy of maintenance treatments for bipolar disorder. This need to rate the long-term prospective course of illness led to the development of the National Institute of Mental Health prospective Life Chart Methodology (NIMH-LCMTM-p or LCM). The NIMH-LCMTM-p allows for the daily assessment of mood and episode severity based on the degree of mood associated functional impairment. We have previously presented preliminary evidence of the reliability and validity of the LCM, and its utility in clinical trials. This study is a further and more extensive validation of the clinician rated NIMH-LCMTM-p.Methods. Subjects included 270 bipolar patients from the five sites participating in the Stanley Foundation Bipolar Network. Daily prospective LCM ratings on the clinician form were initiated upon entry, in addition to at least monthly ratings with the Inventory of Depressive Symptomatology-clinician rated (IDS-C), the Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). We correlated appropriate measures and time domains of the LCM with the IDS-C, YMRS and GAF.Results. Severity of depression on the LCM and on the IDS-C were highly correlated in 270 patients (r = −0·785, P < 0·001). Similarly, a strong correlation was found between LCM mania and the YMRS (r = 0·656, P < 0·001) and between the LCM average severity of illness and the GAF (r = −0·732, P < 0·001).Conclusions. These data further demonstrate the validity and potential utility of the NIMH- LCMTM-p for the detailed daily longitudinal assessment of manic and depressive severity and course, and response to treatment.

The capacity of people with a ‘mental disability’ to make a health care decision

Abstract: Background Based on the developing clinical and legal literature, and using the framework adopted in draft legislation, capacity to make a valid decision about a clinically required blood test was investigated in three groups of people with a 'mental disability' (i.e. mental illness (chronic schizophrenia), 'learning disability' ('mental retardation', or intellectual or developmental disability), or, dementia) and a fourth, comparison group. Methods The three 'mental disability' groups (N = 20 in the 'learning disability' group, N = 21 in each of the other two groups) were recruited through the relevant local clinical services; and through a phlebotomy clinic for the 'general population' comparison group (N = 20). The decision-making task was progressively simplified by presenting the relevant information as separate elements and modifying the assessment of capacity so that responding became gradually less dependent on expressive verbal ability. Results Compared with the 'general population' group, capacity to make the particular decision was significantly more impaired in the 'learning disability' and 'dementia' groups. Importantly, however, it was not more impaired among the 'mental illness' group. All the groups benefited as the decision-making task was simplified, but at different stages. In each of the 'mental disability' groups, one participant benefited only when responding did not require any expensive verbal ability. Conclusions Consistent with current views, capacity reflected an interaction between the decision-maker and the demands of the decision-making task. The findings have implications for the way in which decisions about health care interventions are sought from people with a 'mental disability'. The methodology may be extended to assess capacity to make other legally-significant decisions.