This article critically reviews the design and methodology of studies aimed at evaluating relapse and recurrence prevention in major depression. A literature search in MEDLINE was performed with the medical subject headings ‘depression’, ‘recurrence’, ‘relapse’, ‘prevention’ and ‘study’. This search covered the period from January 1990 to July 1999. Only long-term placebo-controlled studies that included patients with non-chronic major depression were selected. Two types of design could be distinguished: randomised withdrawal studies in responders/remitters (N = 11) and extension studies in responders without re-randomisation (N = 3).

Randomised withdrawal studies are suitable for demonstrating long-term efficacy for the duration of the study period. However, this design does not permit a clear differentiation between relapse or recurrence and, therefore, is not suitable to demonstrate unequivocally relapse prevention or recurrence prevention. Extension studies in short-term responders without randomisation are not even suitable to demonstrate long-term efficacy.

A novel design is proposed that overcomes the weaknesses of designs employed thus far. In essence, this design calls for a long-term randomised placebo-controlled study in patients who are free of medication for a substantial period of time and who fulfil the criteria of major depression (recurrent) in sustained remission (e.g., HDRS < 7) as a possible option.

A review was made of the literature on Huntington’s disease, including the clinical neurology, recent advances in pathophysiology and genetic mechanisms and psychopathology. It can be concluded that research on the latter is scarce, although the subject is relevant because of the co-occurrence of psychiatric, neurological and genetic phenomena, which may lead to novel concepts in the understanding of brain function. So far, attempts to provide a comprehensive and pragmatic description of the psychopathology of Huntington’s disease have been disappointing, probably due to the limitations of the DSM classification system in this disorder. Future research should focus not only on this classification system, but also on neuropsychological functioning, because of the degenerative nature of the disease. Systematic and controlled studies should be performed on the treatment of psychiatric abnormalities in Huntington’s disease before any conclusions can be drawn.

Foulds’ model proposing a four-class hierarchical structure of mental illness represents an interesting dimension of psychiatric research and discussion and probably has a significant potential on diagnosis, taxonomy, therapeutics and theory. Psychiatric symptoms were investigated in a group of 244 schizophrenic patients with the purpose of analyzing Foulds and Bedford’s notion that psychiatric symptoms are arranged hierarchically. To achieve this the R (recent) version of the Delusions, Symptoms, States, Inventory (DSSI) was administered in the form of a constructed interview to these patients. The hierarchical arrangement of psychiatric symptoms was verified since a great majority of the cases (80.8%) produced symptom patterns conforming to the hierarchy model. However, patients with duration of illness longer than 10 years reported conforming patterns in a lower percentage (77%), whereas 84.6% of those with a duration of illness less than 2 years reported conforming patterns. The non-conforming patterns were those in which integrated delusions were absent in the presence of delusions of disintegration, neurotic symptoms were absent in the presence of integrated delusions, and dysthymic states were absent in the presence of neurotic symptoms.

Psychiatric services providing care for patients and their families confronted with a first psychotic episode need to be sensitive towards patients’ and families’ preferences. Ten patients, ten family members and ten professional caregivers composed a list of 42 preferences in the treatment for a first psychotic episode. In total 99 patients, 100 family members and 263 professional caregivers evaluated these preferences, thus producing an order of priorities. There appears to be considerable agreement among the groups of respondents regarding their top ten priorities, especially concerning information on diagnosis and medication. However, we found important differences between groups of respondents. The results suggest that in psychiatric services great attention should be given to psycho-education and early outpatient intervention.

Borna disease virus (BDV), a noncytolytic neurotropic nonsegmented negative-stranded RNA virus with a wide geographic distribution, infects several vertebrate animal species and causes an immune-mediated central nervous system (CNS) disease with various manifestations, depending on both host and viral factors. In animal infections, BDV can persist in the CNS and induce alterations in brain cell functions, neurodevelopmental abnormalities and behavioral disturbances. An association between BDV and psychiatric disorders (essentially schizophrenia and affective disorders) has been suggested by some serologic and molecular studies but further investigations are required to substantiate the possible contribution of this virus to the pathogenesis of these disorders.

The purpose was to assess personality traits in subjects with a DSM-IV diagnosis of social phobia. Thirty-two subjects were administered the Structured Clinical Interview for DSM-IV for Axes I and II disorders (SCID I and II). Personality traits were assessed by means of the Karolinska Scales of Personality (KSP). Current and lifetime axis I co-morbidity was diagnosed in 28% and 53% of the subjects, respectively. In total, 59% had at least one personality disorder and 47% were diagnosed with an avoidant personality disorder.

The social phobics scored significantly higher than a Swedish normative sample on the KSP measuring anxiety proneness, irritability, detachment, and indirect aggression but lower on the scales for socialisation and social desirability. The presence as compared to absence of avoidant personality disorder in the social phobics was associated with significantly higher psychic anxiety and inhibition of aggression. In addition, symptom severity was higher in social phobics with an avoidant personality disorder. Generally, the results support the view that social phobia and avoidant personality disorder reflect different aspects of a social anxiety spectrum.

Psychological autopsy is one of the most valuable tools of research on completed suicide. The method involves collecting all available information on the deceased via structured interviews of family members, relatives or friends as well as attending health care personnel. In addition, information is collected from available health care and psychiatric records, other documents, and forensic examination. Thus a psychological autopsy synthesizes the information from multiple informants and records. The early generation of psychological autopsies established that more than 90% of completed suicides have suffered from usually co-morbid mental disorders, most of them mood disorders and/or substance use disorders. Furthermore, they revealed the remarkable undertreatment of these mental disorders, often despite contact with psychiatric or other health care services. More recent psychological autopsy studies have mostly used case-control designs, thus having been better able to estimate the role of various risk factors for suicide. The future psychological autopsy studies may be more focused on interactions between risk factors or risk factor domains, focused on some specific suicide populations of major interest for suicide prevention, or combined psychological autopsy methodology with biological measurements.

The overall high relapse rates observed in schizophrenia are attributed to several causes. One important factor influencing satisfactory prevention of relapse is the lack of consistent treatment strategies among medical doctors, especially neurologists-psychiatrists. Nearly one-third of the members of the Hellenic Society of Neurology and Psychiatry were asked to fill in anonymously a structured questionnaire on their treatment attitudes and prescribing tactics regarding schizophrenic patients both after the first schizophrenic episode and after multiple episodes. The majority of Greek neurologists-psychiatrists seem to adopt prescribing habits that approximate the current international standards for prevention of schizophrenic relapse. Their attitudes regarding the treatment and prevention of relapse for the first schizophrenic episode and first relapse are determined from multiple factors. These are: the expected relapse rates after the first episode, the expected prevalence of extrapyramidal side effects following a long-term neuroleptic treatment, the patient’s expected treatment compliance after the first episode, the doctor’s experience with treating schizophrenics, and lastly the knowledge of current literature on the topic. These results point to the need for continuing education, especially of the younger mental health professionals and those working in the private sector, addressing the issue of the actual risk of developing side effects from the treatment. In due course, benefits could result for everyday psychiatric practice and the patients’ compliance with treatment.

Studies examining OC phenomena in schizophrenic and schizoaffective disorders have shown a prevalence of such phenomena in 1 to 60% of schizophrenic or schizoaffective patients. In this prospective study, about 10% of 150 male patients suffering from acute psychotic disorders (fulfilling DSM-IV criteria for Schizophrenia or Schizoaffective Disorder) were found to have OC symptoms. These symptoms showed no correlation to the type and severity of psychosis. As only 19% of the patients with obsessions and compulsions during acute psychosis showed an obsessive-compulsive personality disorder prior to their psychotic episodes, it may be concluded that there is no clear linkage between intrapsychotic OC phenomena and premorbid anancastic personality traits.

Presence of a family history of alcoholism may predict clinical characteristics in affected subjects, such as an earlier age at onset. More frequent and severe social maladjustment and somatic complications are also regularly cited for familial alcoholism, although subject to many other confusing factors. We analysed the clinical specificities of 79 alcohol-dependent inpatients according to the absence versus presence of family history of alcoholism.

Patients were evaluated for lifetime psychiatric morbidity with the Diagnostic Interview for Genetic Studies (DIGS), for somatic complications with a systematic screening list, and first-degree relatives (N  =  428) were assessed with the Family Inventory Schedule and Criteria (FISC).

Age at onset and social complications were predicting familial versus sporadic alcoholism, even when considering censored data and/or interaction between variables. But differences became non-significant when excluding patients with antisocial personality.

If age at onset effectively appears to be the most informative characteristic for predicting familial versus sporadic alcoholism, it seems that it may be necessary in future studies to systematically take into account antisocial personality diagnosis, because of a probable contamination.

The relationship between suicide attempts and different vulnerability factors was investigated in 61 male subjects during forensic psychiatric examination. Personality traits and psychopathy were determined by means of the Karolinska Scales of Personality (KSP) and the Psychopathy Checklist-Revised (PCL-R). Clinical diagnoses were determined by the use of Structured Clinical Interview for DSM-III-R (SCID). Platelet monoamine oxidase (MAO) activity was investigated in 58 subjects.

Suicide attempters had extremely low socialization and high impulsive aggression. This was independent of a history of repeatedly criminal violence or not. They had higher PCL-R scores and lower levels of platelet MAO activity than non-attempters. No relationship was found between suicide attempts and repeated violent criminality. However, among the subjects with repeated criminal violence there was a highly significant difference between suicide attempters and non-attempters, indicating different personality profiles in violent offenders with and without suicidal behavior. Suicidal behavior was significantly associated with borderline personality disorder, but not with any other single DSM-III-R disorder. The results show a far more severe personality disturbance in suicide attempters than in other violent patients in this type of population. Suicidal behavior should therefore be evaluated and treated per se.

The Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD) is a well-established instrument, designed to assess potentially remediable behavioral symptoms in Alzheimer’s disease (AD) patients as well as to evaluate treatment outcome. It consists of 25 symptoms grouped into seven categories. Each symptom is scored on the basis of severity on a four-point scale. A knowledgeable caregiver is queried and items are scored on the basis of symptoms noted in the preceding two weeks. Reliability, construct validity and criterion validity data for the BEHAVE-AD have previously been published. Because of the significance of psychopathology in dementia, it is necessary to optimally describe and define the nature, magnitude and prevalence of behavioral symptomalogy. Accordingly, a frequency component was added to each of the 25 items of the BEHAVE-AD scale. The objective of the present report is to describe this new Behavioral Pathology in Alzheimer’s Disease Frequency-Weighted Severity Scale (BEHAVE-AD-FW) and to establish its inter-rater reliability. In this investigation the BEHAVE-AD-FW scale was administered to caregivers of 28 patients with either mildly impaired cognitive function or a dementia diagnosis. Two clinicians separately and independently rated the responses. Analyses determined that the intraclass correlation coefficients (ICCs) for the frequency component varied between 0.86 and 0.97 for each of the seven BEHAVE-AD categories (ps < 0.001). ICCs for the frequency-weighted scores (item severity score x item frequency score) ranged from 0.69 to 0.98 for the seven symptom categories (ps < 0.001). For the BEHAVE-AD-FW total scores, the ICC was 0.91 (P < 0.001). These results indicate that the frequency-weighted component is a reliable addition to the BEHAVE-AD scale.

Many hypotheses have been made to explain the high rate of benzodiazepine consumption in France, including a general cultural and/or familial tendency to use certain types of psychotropic drugs. This study explored the association between lifetime medication use by parents and their children. Two hundred and twenty-one young patients (158 boys and 63 girls) consulting at a child and adolescent psychiatry department, six to 16 years of age (mean = 9.7 years), were screened for lifetime use of psychotropic drugs using a structured interview. Parents were asked about their own consumption, as well as their children’s. Lifetime consumption rates (at least once) were 22.2% in boys and 20.6% in girls, and 19.6% in children less than 11 years old. Higher rates were found in patients with emotional disorders (anxiety disorders and depression). In parents, 45.1% of mothers and 24.1% of fathers reported using medications at least once. A significant association was found between child and parental medication use: 34.1% of children had positive lifetime consumption when their mothers also used medications at least once versus only 13.6% in other children (odds ratio = 3.31 [1.68–6.50]; P = 0.001). The most significant association was found between medication use by girls and their mothers (odds ratio = 12.1 [2.38–61.5];P = 0.003). These data point to the existence of a family pattern of psychotropic drug consumption, especially in females.

We sought to establish if a brief psychoeducational intervention for relatives is effective in improving relatives’ knowledge about schizophrenia and reducing rehospitalization. We evaluated 101 relatives of 55 patients with schizophrenia before and after an 8-week psychoeducational group using a self-report method. We also conducted a matched case-control study of the effects on rehospitalisation for 28 of these patients. We calculated the number of hospital days for each index case and control in the 1 and 2 years before and after the intervention.

Relatives made significant gains in their knowledge about schizophrenia, particularly about medication. Patients whose relatives attended the group had significantly fewer days in hospital and days per admission compared to controls in the year after the programme but the effect waned in the second year after the intervention. Controls were almost four times more likely to be readmitted at 2 years than cases. Median time to readmission was significantly longer in cases compared to controls. We conclude that a psychoeducational group, which is valued by carers, is effective in increasing their knowledge about schizophrenia as well as reducing and forestalling the rehospitalization of their affected relatives. Such programmes deliver what carers frequently request in a cost-effective manner.

This review summarizes the recent literature about personality disorders among substance abusers. First, it will be shown that personality disorders are highly prevalent co-morbid conditions among addicted individuals. Second, it is argued that this co-morbidity is likely to be accounted for by multiple complex etiological relationships. Finally, the clinical relevance of routine assessment of (maladaptive) personality traits in individuals admitting for substance abuse treatment will be discussed.

In a community sample of 418 persons diagnosed with schizophrenia, subjective needs and perceived help was measured by the Camberwell Assessment of Need (CAN). The mean number of reported needs was 6.2 and the mean number of unmet needs 2.6. The prevalence of needs varied substantially between the need areas from 3.6% (‘telephone’) to 84.0% (‘psychotic symptoms’). The rate of satisfaction estimated as the percentage of persons satisfied with the help provided within an area varied between 20.0% (‘telephone’) and 80.6% (‘food’).

The need areas concerning social and interpersonal functioning demonstrated the highest proportion of unmet to total needs.

In a majority of need areas the patients received more help from services than from relatives, but in the areas of social relations the informal network provided substantial help. In general the patients reported a need for help from services clearly exceeding the actual amount of help received.

In a linear regression model symptom load (BPRS) and impaired functioning (GAF) were significant predictors of the need status, explaining 30% of the variance in total needs and 20% of the variance in unmet needs.

It is concluded that the mental health system fails to detect and alleviate needs in several areas of major importance to schizophrenic patients. Enhanced collaboration between the care system and the informal network to systematically map the need profile of the patients seems necessary to minimise the gap between perceived needs and received help.

The aim of this study was to ascertain whether the symptom profile distinguishes between schizophrenic patients born in the winter and early spring and those born in other seasons. The sample consisted of 204 patients with a DSM-III-R diagnosis of schizophrenia who had been hospitalized for acute psychotic decompensation. Symptom ratings were based on the Positive and Negative Syndrome Scale (PANSS). The use of demographic and anamnestic data as dependent variables did not detect any season-of-birth effect. In contrast, clear gender-specific differences emerged from the comparison focusing on symptom dimensions and clinical subtype. Female patients born in the winter and early spring had higher scores on the PANSS negative scale and anergia factor whereas male patients born in other seasons had higher scores on the PANSS anergia factor. In addition, we found a gender-specific association between season of birth and clinical subtype. Most paranoid female patients were born in the non-winter months whereas, among men, a slightly higher percentage of paranoid patients were born in winter months. These results suggest that gender plays a role in modulating the effect of the season of birth on symptoms of schizophrenia.

Responsiveness of quality of life (QOL) assessments in chronic schizophrenic patients was investigated by a quasi-experimental pilot study. Satisfaction ratings were assessed over five time points with an externally imposed disturbing stimulus at the second time point. Despite a markedly high stability, the disturbance provoked a temporally limited decrease in QOL.