Background. The purpose of the study was to examine the effect of employment status measured at baseline on the risk of suicide by years of follow-up, using a large nationally representative sample of the US population.

Methods. Cox regression models were applied to data from the National Longitudinal Mortality Study, based on the 1979–1989 follow-up. In estimating the effect of baseline employment status on suicide, adjustments were made for baseline demographic and socio-economic variables.

Results. After 3 years of follow-up, unemployed men were a little over twice as likely to commit suicide as their employed counterparts. Among men, the lower the socio-economic status, the higher the suicide risk. Among women, in each year of follow-up, the unemployed had a much higher suicide risk than the employed. After 9 years of follow-up unemployed women were over three times more likely to kill themselves than their employed counterparts.

Conclusions. Unemployment is strongly related to suicide, but this relationship is more enduring and stronger among women. For men, the unemployment effect is stronger at earlier years of follow-up. In women, unemployment increases the risk of suicide regardless of the number of follow-up years. The finding with regard to women disconfirms earlier research reports suggesting that unemployment affects suicide only in men.

The association between basal cortisol, dehydroepiandrosterone (DHEA), its sulphate (DHEAS) and major depression was investigated in 8- to 16-year-olds. Eighty-two subjects with major depression, 25 non-depressed psychiatric cases and 40 community controls were systematically assessed for current mental state and hormone levels at 08.00, 12.00 and 20.00 h, assayed from salivary samples collected over a 48 h period. The average mean of the two time points was compared between the three groups. Evening cortisol hypersecretion and morning DHEA hyposecretion were significantly, and independently, associated with major depression. High evening cortisol (> 0·594 ng/ml) and low morning DHEA (< 0·200 ng/ml) identified subgroups of depressives with different types of adrenal hormone dysregulation. The association between high evening cortisol or low morning DHEA and MDD was not affected by either age or gender.

Background. Late-life depression is associated with increased subcortical white matter hyper-intensities. There is some evidence that they are associated with a poorer response to acute treatment. Neurological signs and neuropsychological dysfunction are further evidence of abnormalities in the brain, but they have not been studied in relation to therapy resistance.

Methods. A prospective study of 24 normal controls and 75 consecutive elderly (aged 65 to 85) patients with DSM-III-R major depression entered a naturalistic study of treatment. Assessment of response to monotherapy and then lithium augmentation or ECT created three outcome groups. Investigations included magnetic resonance brain imaging, neuropsychological and neurological examination.

Results. Response to monotherapy within 12 weeks was shown by 42·7%, a further 37·3% responded to lithium augmentation or ECT within 24 weeks and 20% had responded poorly to all treatments at 24 weeks. Subcortical hyperintensities were significantly increased in the more resistant patients. These included confluent deep white matter, multiple (>5) basal ganglia lesions and pontine reticular formation lesions. Most of the neuropsychological impairment was restricted to the resistant groups and was of a subcortico-frontal type. Extrapyramidal, frontal and pyramidal neurological signs characterized the resistant groups. The combination of extrapyramidal signs, pyramidal tract signs and impairment of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant monotherapy with 89% sensitivity and 95% specificity.

Conclusion. In late-life depression a poor response to antidepressant monotherapy can be expected in those patients with a frontal lobe syndrome, extrapyramidal signs or if MRI T2-weighted lesions are present in both the basal ganglia and the pontine reticular formation.

Background. The clinical Global Impression Scale (CGI) is commonly used as a primary outcome measure in studies evaluating the efficacy of treatments for anxiety disorders. The current study evaluated the psychometric properties and predictors of clinicians' ratings on an adapted version of the CGI among individuals with social anxiety disorders.

Method. An independent assessor administered the CGI Severity of Illness and Improvement ratings to 123 patients at baseline and the subset of treated patients again mid- and post-treatment.

Results. Improvement ratings were strongly related to both concurrent Severity of Illness and changes in Severity of Illness ratings from baseline. Additionally, both CGI ratings were positively correlated with both self-report and clinician-administered measures of social anxiety, depression, impairment and quality of life. Measures of social anxiety symptoms accounted for a large portion of the variance in Severity of Illness ratings, with significant additional variance accounted for by measures of impairment and depression. Changes in social anxiety symptoms from baseline accounted for significant variance in Improvement ratings, but no significant additional variance was accounted for by changes in impairment and depressive symptoms.

Conclusions. Our findings support the utility of the CGI as an index of global severity and symptom-specific improvement among individuals with social anxiety disorder.

Background. A neuropsychological formulation of schizophrenia has suggested that problems with meta-representation underpin both positive and negative symptoms. This study tested Frith's account by asking patients experiencing an acute episode of psychosis to complete a set of tasks that involved Theory of Mind (ToM) skills.

Methods. Fourteen patients who fulfilled criteria for schizophrenia, 10 deluded patients who were suffering from psychotic disorders other than schizophrenia and 12 depressed patients completed second-order false belief tasks, a test which involved substitution of a co-referential term in a linguistic description of an event, and metaphor and irony tasks. The battery of tests was completed during the acute phase and following recovery. Selection of these patient groups allowed comparisons to be made between schizophrenia patients and non-schizophrenia patients and between patients with and without persecutory delusions.

Results. Schizophrenia patients, who had a multiplicity of positive and negative symptoms, performed significantly worse than non-schizophrenia patients on some of the ToM tasks during an acute episode. Patients with delusions of persecution and reference did not perform significantly worse than non-deluded patients on ToM tasks. There was no significant difference between groups in performance on any of the tasks at recovery.

Conclusions. The results provide at best weak support for Frith's account and it remains unclear whether the ToM deficits demonstrated are genuine deficits or are a result of information-processing overload. However, it is clear that difficulties interpreting interpersonal contexts, as shown by some schizophrenia patients, are state rather than trait characteristics.

The steps to setting up a population register of elderly residents are described. Based upon this, 87·2% of the elderly residents of an inner-city electoral area were screened for memory disorder, depression and activity limitation using the Short CARE. Contact with medical and social agencies was also recorded; 4·7% were classed as cases by the dementia diagnostic scale, sufferers being older and not living alone. Of the residents 15·9% were classed as depressed, this state being more prevalent in those not currently married. The depresse were, in contrast to the demented residents, likely to be in recent contact with hospital and general practitioner. Thirty-two per cent of the population showed impairment in daily activity, these individuals were usually older, not married and receiving hospital care. Sleep disorder and compliant of many somatic symptoms were associated with a diagnosis of depression. In contrast, most respondents with a subjective complaint of memory disorder, which was common in this population, were neither suffering from depression nor dementia.

With this accurate sampling frame and a good response rate, the prevalence rate of clinical depression must be seen as disturbingly high. The prevalence rate of dementia approximated to that of other surveys. This study also indicated that general practitioners' lists may be inaccurate and that non-responders to first approaches for interview, although similar in demographic features to those responding, may contain among them many suffering from dementia.

Whereas in Western societies there is an inverse relationship between high social class and low body weight, the inverse is true of less developed, non-Western societies. It has also been shown that the longer immigrants have been in Western societies, the less obese they tend to be. This study examined how Kenyan Asian, British and Kenyan British females from similar backgrounds perceived female body shapes. As predicted, the Kenyans rated larger figures more favourably and smaller figures less favourably than the British. Also, as predicted, it was found that the Kenyan Asian British were more similar to the British group in their perceptions. The results support the view that social and cultural factors play dominant role in the perception of one's own and others' body shapes. In addition, the results reveal that in Britain preferences for small body shapes to the point of being anorexic are not uncommon.

Two age cohorts of young people were interviewed at times up to 2½ years after leaving school to investigate the association between unemployment and risk of minor psychiatric morbidity, as assessed by the General Health Questionnaire (GHQ), taking into account differences due to sex, ethnic group and educational qualifications. Cross-sectional data are presented on 2767 interviews. The psychometric properties of the GHQ justified the use of a total score. Although females had a higher risk of psychiatric morbidity, the strongest association was between unemployment and GHQ. The association between unemployment and GHQ scores was shown to be present after controlling for sex, ethnic group and educational qualification differences. Longitudinal analyses showed that the experience of unemployment was more likely to create increased symptoms, rather than the reverse.

This paper describes the referral pathways taken by 1554 patients newly referred to the mental health services in 11 countries, and documents factors associated with delays in referral. The pathways in centres relatively well provided with psychiatric staff were dominated by general practitioners and to a lesser extent hospital doctors: the relatively less well resourced centres showed a variety of pathways with native healers often playing an important part. Delays were remarkably short in all centres regardless of psychiatric resources, but in some centres we found longer delays on pathways involving native healers. Somatic problems were a common presentation in all centres, and in some centres there was a tendency for patients presenting with somatic problems to have longer delays than those with symptoms of depression or anxiety. The implications of these findings are discussed in the context of an ongoing programme of WHO research activities aimed at improving the quality of mental illness care available in community settings.

Background. We tested the hypothesis that schizophrenia is primarily a frontostriatal disorder by examining executive function in first-episode patients. Previous studies have shown either equal decrements in many cognitive domains or specific deficits in memory. Such studies have grouped test results or have used few executive measures, thus, possibly losing information. We, therefore, measured a range of executive ability with tests known to be sensitive to frontal lobe function.

Methods. Thirty first-episode schizophrenic patients and 30 normal volunteers, matched for age and NART IQ, were tested on computerized test of planning, spatial working memory and attentional set shifting from the Cambridge Automated Neuropsychological Test Battery. Computerized and traditional tests of memory were also administered for comparison.

Results. Patients were worse on all tests but the profile was non-uniform. A componential analysis indicated that the patients were characterized by a poor ability to think ahead and organize responses but an intact ability to switch attention and inhibit prepotent responses. Patients also demonstrated poor memory, especially for free recall of a story and associate learning of unrelated word pairs.

Conclusions. In contradistinction to previous studies, schizophrenic patients do have profound executive impairments at the beginning of the illness. However, these concern planning and strategy use rather than attentional set shifting, which is generally unimpaired. Previous findings in more chronic patients, of severe attentional set shifting impairment, suggest that executive cognitive deficits are progressive during the course of schizophrenia. The finding of severe mnemonic impairment at first episode suggests that cognitive deficits are not restricted to one cognitive domain.

Background. Disturbed speech in schizophrenia may reflect pragmatic deficits of expressive language. Pragmatic comprehension deficits also occur in schizophrenia. This study investigated whether poor ‘mind-reading’ (i.e. a general difficulty with inferring and monitoring other people's thoughts) causes pragmatic language impairments of both expression and comprehension in patients with schizophrenia.

Method. Mind-reading (or theory of mind) was tested in patients with schizophrenia and in healthy controls using a false-belief picture-sequencing task. Pragmatic comprehension skills were assessed using a test of non-literal speech interpretation. Clinical ratings of formal thought disorder (FTD) indexed the expressive language deficits of patients. To control for possible contributory effects of executive dysfunction, inhibitory control was tested using capture picture-sequences and executive-planning was tested using the Tower of London task.

Results. False-belief picture-sequencing, understanding of irony and understanding of metaphors were all selectively impaired in the patients. Poor mind-reading (indexed by high error rate in sequencing false-belief stories) was associated with poor understanding of irony, but was unrelated to poor understanding of metaphors. Whereas poor appreciation of irony and poor mind-reading were associated with high ratings of positive formal thought disorder, high ratings of negative formal thought disorder were associated with poor understanding of metaphors and executive dysfunction.

Conclusions. Whereas poor mind-reading may contribute to positive aspects of formal thought disorder and impaired appreciation of irony in patients with schizophrenia; negative features of formal thought disorder and poor understanding of metaphors appear better explained by abnormal semantics. Overall, the findings of this study support the view that the functional basis of formal thought disorder in schizophrenia is not unitary.

Three studies explored the causal attributions of common somatic symptoms. The first two studies established the reliability and validity of a measure of attributional style, the Symptom Interpretation Questionnaire (SIQ). Three dimensions of causal attribution were confirmed: psychological, somatic and normalizing. The third study examined the antecedents and consequences of attributional style in a sample of family medicine patients. Medical and psychiatric history differentially influenced attributional style. Past history and attributional style independently influenced clinical presentations over the subsequent 6 months. Symptom attributional style may contribute to the somatization and psychologization of distress in primary care.