The purpose of this overview is to appraise the studies on the efficacy and effectiveness of family interventions in decreasing relapse in schizophrenic patients. The studies were identified by means of a computerized MEDLINE search, and the scanning of review articles and the reference lists of the primary articles identified. More than 300 citations were reviewed, and the potentially relevant articles revealed six randomized controlled trials that were included in this meta-analysis. The criteria for selecting potential studies as well as for the meta-analysis were tested by means of an inter-rater reliability check that showed a good agreement between two independent raters (K = 0·83, and K = 0·82, respectively). There were independent assessments of the quality of the studies selected, and data extraction comprised a descriptive information of the study population, the types of interventions, and the relevant outcome measurements. The total number of patients included in the six trials was 350 (181 in the control group and 169 in the experimental group). Regarding the decrease of relapse in the experimental group, the pooled odds ratios and their 95% confidence intervals were: 0·30 (0·06, 0·71) for six months; 0·22 (0·09, 0·37) for nine months; and 0·17 (0·10, 0·35) for the 2-year follow-up. Two to five patients needed to be treated to avert one episode of relapse in a nine-month follow-up. The changes in Expressed Emotion status between experimental and control group combining nine months and one year follow-ups were shown to be marginally significant (P < 0·06), in favour of the experimental group. Emotional over-involvement was also marginally significant (P < 0·07), and there was no statistical difference in the distribution of criticism and hostility. In addition, the experimental group showed a significant increase with drug compliance and a reduction in hospitalization over time. These findings are discussed in light of the potential ingredients in the efficacy of family interventions by focusing on the limitations of using relapse as primary outcome in the assessment of efficacy trials with schizophrenic patients.

A study of the validity of the 30- and 12-item versions of the Chinese Health Questionnaire (CHQ) was carried out with a consecutive sample of 386 patients admitted during one year to a medical centre in Taiwan for a 3-day comprehensive general health screening. The Chinese version of the Clinical Interview Schedule was used to derive a criterion measure of minor psychiatric morbidity.

The areas under the Relative Operating Charcteristic curves of both short versions of the CHQ were equivalent (area = 0·85, S.D. = 0·02). The sensitivities of the CHQ-30 and CHQ-12 were found to be 76 and 78% respectively, while the specificity of both was 77%. The estimated prevalence of minor psychiatric morbidity in the sample was 37% (95% confidence intervals 32–41%). In contrast, physicians diagnosed 11% of these patients as having psychiatric disorders, and their sensitivity was 29%.

Taken altogether, the above findings suggest that the CHQ-12 is as effective as and is more efficient than the CHQ-30 in this context, and could be used by physicians in similar settings to improve their identification of minor psychiatric disorders in Chinese patients.

The great shortage, and inequitable distribution, of psychiatrists in low- and middle-income countries is one of the key reasons for the large treatment gap for people with mental disorders. Psychiatrists need to play a public mental health leadership role in increasing the coverage of mental health care through task shifting of effective interventions to non-specialist health workers. Psychiatrists' new roles should include designing and managing such programmes, building clinical capacity, supervision and quality assurance, providing referral pathways and research.

Background. This paper summarizes work with the Interview for Recent Life Events (IRLE), an instrument that has been used extensively but not previously reported in detail.

Methods. Rationale, development, organization, content, reliability, validity and applications are reviewed in full.

Results. The instrument covers a comprehensive range of recent life events, their timing and other important qualities. It has been found reliable and valid, and has been translated into a number of languages. It has been used by many research groups in different countries, in studies of psychiatric patients, medical patients and subjects in the general population.

Conclusions. The instrument is useful, has been widely applied and has the necessary qualities for ascertainment of life events in research studies.

One hundred and forty-one women, aged 40–60 years, recruited from the community were assessed with an initial interview, plus four interviews at intervals of 1 week and blood samples. The objective was to investigate the determinants of sexuality and well-being in this sample. Measures included interview ratings of sexual function, Frenken Sexual Experience Scales and the Multiple Affect Adjective Check List. Determinants evaluated, using multiple regression analysis, included age, menopausal status, BMI, smoking, ovarian steroids and adrenal androgens. None of the hormonal parameters significantly predicted measures of sexuality; the most important predictors were other aspects of the sexual relationship, sexual attitudes and measures of well-being. The best predictor of both well-being and depression was tiredness. The only hormone positively related to well-being was dehydroepiandrosterone (DHEA).

The early literature on Alzheimer Dementia (AD) describes the clinical features aphasia, apraxia and agraphia as characteristic. We investigated the hypothesis that these features would specifically identify the familial form of AD (FAD). Since pedigree studies had suggested that FAD is an autosomal dominant genetic disorder, we hypothesized that the first-degree relatives of language-disordered or apractic AD probands would show at least 50% lifetime risks of dementia. Using standardized methods, we screened 3500 nursing home beds for stringently defined AD cases and controls, tested for agraphia, and obtained probands' clinical and family histories from multiple informants. Language disorder and apraxia were found in 78% of AD cases. They strongly predicted familial aggregation of dementia, with a 90-year lifetime incidence among relatives exceeding 50%, or 7 times the control values. The results suggest that language disorder and apraxia specifically identify a distinct clinical entity, Familial Alzheimer Dementia, that is among the commonest forms of senile dementia.

Background. The paper describes a randomized controlled trial of targeting cognitive behavioural therapy (CBT) during prodromal or early signs of relapse in schizophrenia. We hypothesized that CBT would result in reduced admission and relapse, reduced positive and negative symptoms, and improved social functioning.

Method. A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU) (N=72) or CBT+TAU (N=72). Participants were prospectively followed up between entry and 12 months.

Results. At 12 months, 11 (15·3%) participants in the CBT group were admitted to hospital compared to 19 (26·4%) of the TAU group (hazard ratio=0·53, P=0·10, 95% CI 0·25, 1·10). A total of 13 (18·1%) participants in CBT relapsed compared to 25 (34·7%) in TAU (hazard ratio=0·47, P<0·05, 95% CI 0·24, 0·92). In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and prosocial activities.

Conclusions. The study provides evidence for the feasibility and effectiveness for targeting CBT on the appearance of early signs of relapse in schizophrenia. The results are discussed in context of the study's methodological limitations.

Background. The demand for time-consuming psychotherapy of phobia/panic exceeds the supply of trained therapists. Delegating routine therapy aspects to a computer might ease this problem.

Method. Ninety-three out-patients with phobia or panic disorder were randomized in a 2[ratio ]2[ratio ]1 ratio to have self-exposure therapy guided either mainly by a stand-alone computer system (FearFighter) or entirely face-to-face by a clinician, or to have mainly computer-guided self-relaxation as a placebo. Both computer groups (FearFighter and relaxation) had brief back-up advice from a clinician. Primary outcome measures were self- and blind-assessor ratings of Main Problem and Goals, and Global Phobia.

Results. Drop-outs occurred significantly more often in the two self-exposure groups (43% if mainly computer-guided, 24% if entirely clinician-guided) than with self-relaxation (6%); the difference between the two self-exposure groups was not significant. Even with all drop-outs included, the mainly computer-guided exposure group and the relaxation group had 73% less clinician time per patient than did the entirely clinician-guided exposure group. The two self-exposure groups had comparable improvement and satisfaction at post-treatment and at 1-month follow-up, while relaxation was ineffective. Mean improvement on the primary outcome measures (self- and assessor-rated) was 46% computer, 49% clinician, 9% relaxation at post-treatment (week 10) and 58% computer, 53% clinician and −4% relaxation at 1-month follow-up (week 14). Mean effect sizes on the primary outcome measures were 2·9 computer, 3·5 clinician and 0·5 relaxation at post-treatment; and 3·7 computer, 3·5 clinician and 0·5 relaxation at 1-month follow-up. The assessor did not rate patients at follow-up.

Conclusions. Despite its (non-significantly) higher dropout rate, self-exposure therapy for panic/phobia cut clinician time per patient by 73% without losing efficacy when guided mainly by a computer rather than entirely by a clinician. The finding needs confirmation at a follow-up that is longer and includes a blind assessor. Self-relaxation had the highest rate of completers but was ineffective.

Background. A number of recent epidemiological studies have shown that the prevalence and incidence of dementia are increased in population strata with low compared to high levels of education. This has been explained as a consequence of a greater ‘brain reserve capacity’ in people with a high level of education. Theoretically, however, brain reserve capacity is better reflected by intelligence than by level of education. Thus, the emergence of dementia will be better predicted by low pre-morbid intelligence than by low education.

Methods. This prediction was tested in a population based sample of elderly subjects (N=2063; age range 65–84; Amsterdam Study of the Elderly) who were followed over 4 years. Dementia was diagnosed using the Geriatric Mental State examination (GMS). Pre-morbid intelligence was measured using the Dutch Adult Reading Test (DART), a short reading test which gives a good estimate of verbal intelligence, and is relatively insensitive to brain dysfunction. The effects of age, gender, occupational level, number of diseases affecting the central nervous system and family history of dementia or extreme forgetfulness were also examined.

Results. Logistic regression analysis showed that low DART-IQ predicted incident dementia better than low level of education. A high occupational level (having been in charge of subordinates) had a protective effect.

Conclusions. This result supports the brain reserve theory. It also indicates that low pre-morbid intelligence is an important risk factor for cognitive decline and dementia. Use of reading ability tests is to be preferred over years of education as estimator of pre-morbid cognitive level in (epidemiological) dementia research.

Cerebrospinal fluid (CSF) cortisol levels were examined in a total group of 65 patients. Those who were not depressed (ND), and those suffering from depressive neuroses (DN) had marginally elevated values. Patients with unipolar depression (UD) and bipolar depression (BD) had levels twice as high as the ND and DN patients. Psychotic UD and BD patients had the highest values, three to four times as high as the ND and DN subjects. A significant reduction of CSF cortisol levels was observed following treatment and recovery. Manic patients had moderately elevated CSF cortisol values. The CSF results were in good agreement with plasma total cortisol levels and with urinary free cortisol excretion. Age and sex effects were not responsible for the observed differences; similar results were found in patient subgroups studied in Australia and in the United States. Preliminary equilibrium dialysis data are presented for plasma and CSF cortisol binding. CSF cortisol was 20% bound and 80% free. Plasma free cortisol levels were in good agreement with CSF free cortisol values. Depressed patients have increased tissue and central nervous system (CNS) exposure to free, physiologically active glucocorticoids. The appearance of severe depressive symptoms which manifest a diurnal rhythm may be determined in part by excessive CNS exposure to glucocorticoids.

Background. The aim of this study was to examine the linkages between suicidal ideation and attempt in adolescence and subsequent suicidal behaviours and mental health in young adulthood.

Method. Data were gathered during the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand children. The information collected included: (a) measures of suicidal thoughts and attempts in adolescence (<18 years); (b) measures of suicidal ideation, suicide attempt, major depression, anxiety disorders, and substance use disorders in young adulthood (18–25 years); and (c) measures of childhood and family background, individual characteristics, and mental disorders in adolescence.

Results. After statistical adjustment for confounding factors, suicide attempt in adolescence was associated with increased risks of subsequent suicidal ideation (OR 5·7) suicide attempt (OR 17·8) and major depression (OR 1·5). Those reporting suicidal ideation without suicide attempt showed moderate increases in risks of later suicidal ideation (OR 2·5), suicide attempt (OR 2·0) and major depression (OR 1·6). In addition, there was evidence of an interactive relationship in which suicidal behaviour in adolescence was associated with increased risks of later substance use disorders in females but not males.

Conclusions. Young people reporting suicidal ideation or making a suicide attempt are an at-risk population for subsequent suicidal behaviour and depression. Further research is needed into the reasons for suicidal adolescent females being at greater risk of later substance use disorder.

Two hundred and forty neurotic out-patients were allocated to no diagnostic category but were rated in terms of observer and self ratings of both depression and anxiety at weekly intervals during a 4-week trial of amitriptyline, diazepam, amitriptyline and diazepam, and placebo. The sample could not be divided into anxious and depressed groups on the basis of the clinical picture. The outcome tended to be good irrespective of medication but the significant drug effects found were due to amitriptyline and concerned measures of anxiety as well as depression. It is concluded that a distinction between anxiety and depression in neurotic out-patients is of no practical value with regard to drug treatment.

Background. Evidence is increasing that amygdala and hippocampus show significant structural abnormalities in affective disorders. Two previous studies found enlarged amygdala size in subjects with recent-onset major depression.

Method. Amygdala and hippocampal volumes were assessed in 17 young women with major depressive disorder and 17 healthy matched control subjects by use of three-dimensional structural magnetic resonance imaging. The severity of depressive symptoms was assessed using the Hamilton Depression Scale and the Beck Depression Inventory.

Results. Compared with control subjects, depressive subjects had significantly larger (+13%) amygdala volumes and significantly smaller (−12%) hippocampal volumes. Amygdala and hippocampal volumes were not significantly correlated with disorder-related variables.

Conclusions. Our results are consistent with previous findings of structural abnormalities of amygdala and hippocampus in subjects with recent-onset major depression. It may be suggested that the size of the amygdala is enlarged in the first years of the disorder, and may decrease with prolonged disorder duration.