The study reports a comparison of 10 definitions of schizophrenia (Feighner's, Taylor's, Schneider's, Langfeldt's, Spitzer's, Carpenter's, Astrachan's, 2 from Forrest & Hay and Catego) in respect of their reliability, concordance and prediction of outcome. Some (including Feighner's) proved too strict, and others (including Schneider's) were weak predictors of clinical and social state. Four definitions (Spitzer's, Langfeldt's, Carpenter's and Catego) emerged as relatively effective and these also had a somewhat more satisfactory mutual concordance.

A random sample of 237 women in a south-east London area were seen by non-medical interviewers, trained to use a standard technique (the Present State Examination) to elicit and record psychiatric symptoms. Ninety-five were interviewed a second time by psychiatrists, who also rated audiotape recordings. The reproducibility of the techniques is adequate though not as high, in some respects, as that obtained from out-patient or in-patient samples. This is true at the level of symptom, syndrome, total score, and index of definition of psychiatric disorder. It is concluded that nonmedical interviewers can obtain as high reproducibility as psychiatrists on most of the non-psychotic sections of the PSE if they have appropriate training. Repeatability is lower than reproducibility, partly due to fluctuations in clinical condition, partly to environmental changes between interviews, and partly to differential responses to medical and non-medical interviewers. Over a short period of time, such as a week, repeatability is satisfactory.

Background. No instrument has been developed specifically for assessing the clinician–patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction.

Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction, test–retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden.

Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test–retest reliability was r=0·76 for STAR-P and r=0·68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit.

Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care.

Seventy-seven 10–18-year-old psychiatric in-patients and out-patients took part in a test-retest study of the Child and Adolescent Psychiatric Assessment (CAPA). They were interviewed on two occasions several days apart. Overall reliability of diagnosis ranged from K = 0·55 (conduct disorder) to 1·0 (substance abuse or dependence). In general, reliability for scale scores of psychopathology was somewhat lower in out-patients than in-patients, though the opposite was the case for anxiety disorders and psychosocial incapacity and the reliability of the diagnosis of conduct disorder – the only individual diagnosis sufficiently common to permit this comparison. Unreliability of reports of behavioural problems was found to be related to admitting to being a liar in the first interview. The implications of these results for the use of the CAPA are discussed.

Background. Partial PTSD, employed initially in relation to Vietnam veterans, has been recently extended to civilian victims of trauma. We examined the extent to which partial PTSD is distinguishable from full DSM-PTSD with respect to level of impairment.

Method. A representative sample of 2181 persons was interviewed by telephone to record lifetime traumatic events and to assess DSM-IV PTSD criteria. Partial PTSD was defined as [ges ]1 symptom in each of three symptom groups (criteria B, C and D) and duration of [ges ]1 month. Impairment in persons with PTSD and partial PTSD was measured by number of work-related and personal disability days during the 30-day period when the respondent was most upset by the trauma.

Results. Compared to exposed persons with neither PTSD nor partial PTSD, increment in work-loss days associated with PTSD was 11·4 (S.E.=0·6) days and with partial PTSD, 3·3 (S.E.=0·4) days (adjusted for sex, education and employment). Similar disparities were found across other impairment indicators. Persons who fell short of PTSD criteria by one symptom of avoidance and numbing reported an increment of 5·0 (S.E.=0·7) work-loss days, 6·0 fewer than full PTSD. PTSD was associated with excess impairment, controlling for number of symptoms. A significantly lower proportion of persons with partial PTSD than full PTSD experienced symptoms for more than 2 years. A lower proportion of persons with partial PTSD than full PTSD had an etiologic event of high magnitude.

Conclusions. PTSD identifies the most severe trauma victims, who are markedly distinguishable from victims with subthreshold PTSD.

The study is a prospective investigation of the factors associated with treatment compliance in 61 patients discharged from hospital with a ward diagnosis of schizophrenia. All cases were classified using reliable diagnostic criteria and all were followed up for two years. Compliance was assessed by inspection of records and by analysis of urine. Sociodemographic factors and illness variables were unrelated to compliance. Some aspects of a patient's insight and attitude, namely, a belief that medication had helped during the admission, a stated willingness to take treatment after discharge and a generally optimistic outlook, were associated with improved compliance. Other variables which showed such an association were the absence of the drug side-effect akinesia, good previous compliance and voluntary, as opposed to compulsory, admission to hospital.

The Lundby cohort consists of all inhabitants in a delimited area in Sweden studied in 1947 by Essen-Möller, then by Hagnell in 1957, and by Hagnell & Öjesjöin 1975. It has been claimed that depressive disorders have increased during the sixties and seventies. In order to examine this hypothesis on a normal population (the Lundby Study), comparisons were made of the incidence figures for depression during the periods 1947–57 and 1957–72, and during the five 5-year intervals within the period.

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.

We report the development of a new procedure for assessing the needs for treatment and care of the long-term mentally ill. This procedure covers 21 areas of clinical and social functioning, and in each of these specifies appropriate interventions. Decision rules are described which permit problems in functioning to be primarily classified as a met need, an unmet need, or as involving no need, and which allow the identification of various secondary needs. We report preliminary data on the reliability and validity of this procedure and discuss its potential applications in the care of the long-term mentally ill.

Background. Early alcohol use is associated with abuse and dependence of licit and illicit substances later in life. The role of genetic and environmental factors in this association is not conclusive.

Method. In 1992, data on substance use, abuse/dependence and psychiatric disorders were collected from 8169 male twin members of the Vietnam Era Twin Registry. The interview obtained age of onset of regular drinking (one drink/month for 6 or more months). Regression analyses of twin pairs discordant for early alcohol use tested whether the association between early drinking (before age 17) and adult substance use and abuse/dependence remained after controlling for genetic factors, family environment and covariates. Twin models tested for common genetic and/or environmental influences on early drinking and adult alcohol dependence and ever use and abuse/dependence on marijuana and other drugs.

Results. Co-twin analyses suggested the association between early regular alcohol use and adult alcohol dependence, marijuana and other drug use, and marijuana and other drug abuse/dependence could not be entirely explained by common genetic and shared family environmental factors. Genetic contributions to early regular drinking were significantly correlated with those on use of marijuana (rA=0·59), use of other drugs (rA=0·64), alcohol dependence (rA=0·54) and abuse/dependence of marijuana and other drugs (rA=0·63 and 0·66). Small but significant unique environmental correlations (rE range 0·11–0·22) indicated that familial factors could not entirely explain the association between early alcohol use and later substance use, abuse and dependence.

Conclusions. Early regular drinking is associated with later alcohol dependence and use, abuse/dependence on drugs. The association is not entirely explained by genetic or shared family environmental factors. This suggests unique environmental factors contribute to transitions from early regular alcohol drinking to use, abuse and dependence on alcohol and other substances.

Background. Urban birth is associated with later schizophrenia. This study examined whether this finding is diagnosis-specific and which individuals are most at risk.

Methods. All live births recorded between 1942 and 1978 in any of the 646 Dutch municipalities were followed-up through the National Psychiatric Case Register for first psychiatric admission for psychosis between 1970 and 1992 (N=42115).

Results. Urban birth was linearly associated with later schizophrenia (incidence rate ratio linear trend (IRR), 1·39; 95% confidence interval (95% CI), 1·36–1·42), affective psychosis (IRR, 1·18; 95% CI, 1·15–1·21) and other psychosis (IRR, 1·27; 95% CI, 1·24–1·30). Individuals born in the highest category of the three-level urban exposure were around twice as likely to develop schizophrenia. Associations were stronger for men and for individuals with early age of onset. The effect of urban birth was also stronger in the more recent birth cohorts.

Conclusions. There are quantitative differences between diagnostic categories in the strength of the association between urban birth and later psychiatric disorder. High rates of psychosis in urban areas may be the result of environmental factors associated with urbanization, the effect of which appears to be increasing over successive generations.

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.

In a sample of 60 schizophrenic patients encompassing all grades of severity and chronicity memory impairment was found to be prevalent, often substantial, and disproportionate to the overall level of intellectual impairment. The deficits were not easily attributable to poor cooperation, attention or motivation; nor were they related to neuroleptic or anticholinergic medication. Memory impairment was significantly associated with severity and chronicity of illness and also with negative symptoms and formal thought disorder. There was evidence from the sample as a whole, and from a more detailed examination of five patients with relatively isolated deficits, that schizophrenic memory impairment conformed to the pattern seen in the classical amnesic syndrome. Additionally, there was preliminary evidence for a marked deficit in semantic memory.

The neural correlates of inner speech and of auditory verbal imagery were examined in normal volunteers, using positron emission tomography (PET). Subjects were shown single words which they used to generate short, stereotyped sentences without speaking. In an inner speech task, sentences were silently articulated, while in an auditory verbal imagery condition, subjects imagined sentences being spoken to them in an another person's voice. Inner speech was associated with increased activity in the left inferior frontal gyrus. Auditory verbal imagery was associated with increases in the same region, and in the left premotor cortex, the supplementary motor area and the left temporal cortex. The data suggest that the silent articulation of sentences involves activity in an area concerned with speech generation, while imagining speech is associated with additional activity in regions associated with speech perception.

An experiment is described in which depressed patients were asked to recall pleasant or unpleasant experiences from their past life in response to a standard series of stimulus words. The ratio between the time for recall of pleasant and unpleasant experiences was found to fall progressively with increasing severity of depression or of ‘neuroticism’ and to be significantly related to each. Among patients who scored relatively low on depression or neuroticism pleasant memories were recalled more speedily than unpleasant; among those who scored high this relationship was reversed. Possible mechanisms to account for these findings are discussed.