Background. Negative associations between religion and suicide, in individuals and countries, may be mediated by the degree to which suicide is tolerated.

Methods. Linear regression was used to examine ecological associations between suicide tolerance, religion and suicide rates in 19 Western countries in 1989/90. Logistic regression was used to study associations between suicide tolerance and strength of religious belief in 28085 individuals in these countries. The concept of effect modifying function was used to examine whether the strength of the association between suicide tolerance and religious belief in individuals depended on the extent of religious belief in their country.

Results. Higher female suicide rates were associated with lower aggregate levels of religious belief and, less strongly, religious attendance. These associations were mostly attributable to the association between higher tolerance of suicide and higher suicide rates. In the 28085 subjects suicide tolerance and the strength of religious belief were negatively associated even after adjustment for other religious and sociodemographic variables and general tolerance levels (odds ratios: men 0·74 (95% CI 0·58–0·94), women 0·72 (95% CI 0·60–0·86)). This negative individual-level association was more pronounced in more highly religious countries but this modifying effect of the religious context was apparent for men only.

Conclusions. Ecological associations between religious variables and suicide rates are stronger for women than men, stronger for measures of belief than observance and mediated by tolerance of suicide. In individuals, stronger religious beliefs are associated with lower tolerance of suicide. Personal religious beliefs and, for men, exposure to a religious environment, may protect against suicide by reducing its acceptability.

The question of whether psychopathology constructs are discrete kinds or continuous dimensions represents an important issue in clinical psychology and psychiatry. The present paper reviews psychometric modelling approaches that can be used to investigate this question through the application of statistical models. The relation between constructs and indicator variables in models with categorical and continuous latent variables is discussed, as are techniques specifically designed to address the distinction between latent categories as opposed to continua (taxometrics). In addition, we examine latent variable models that allow latent structures to have both continuous and categorical characteristics, such as factor mixture models and grade-of-membership models. Finally, we discuss recent alternative approaches based on network analysis and dynamical systems theory, which entail that the structure of constructs may be continuous for some individuals but categorical for others. Our evaluation of the psychometric literature shows that the kinds–continua distinction is considerably more subtle than is often presupposed in research; in particular, the hypotheses of kinds and continua are not mutually exclusive or exhaustive. We discuss opportunities to go beyond current research on the issue by using dynamical systems models, intra-individual time series and experimental manipulations.

The failure to comply with referral for out-patient after-care is a well-documented problem among attempted suicide patients. The present study aimed at the investigation of an experimental referral procedure by means of a randomized controlled study. Non-compliant patients in the experimental group were visited in their homes by a community nurse in order to assess reasons for non-compliance and to motivate patients to comply with referral. One year after their suicide attempt patients were visited in their homes in order to assess repetition of suicidal behaviour. Uni-and multi-variate analyses showed a significant beneficial effect of the experimental procedure on compliance with referral. A near-significant effect of the experimental procedure on the rate of repetition of suicidal behaviour was found.

Background. In order to improve the treatment of medication-resistant negative symptoms in schizophrenia, new interventions are needed. Neuropsychological considerations and older reports in the literature point towards a potential benefit of body-oriented psychological therapy (BPT). This is the first randomized controlled trial specifically designed to test the effectiveness of manualized BPT on negative symptoms in chronic schizophrenia.

Method. Out-patients with DSM-IV continuous schizophrenia were randomly allocated to either BPT (n=24) or supportive counseling (SC, n=21). Both therapies were administered in small groups in addition to treatment as usual (20 sessions over 10 weeks). Changes in negative symptom scores on the Positive and Negative Symptom Scale (PANSS) between baseline, post-treatment and 4-month follow-up were taken as primary outcome criteria in an intention-to-treat analysis.

Results. Patients receiving BPT attended more sessions and had significantly lower negative symptom scores after treatment (PANSS negative, blunted affect, motor retardation). The differences held true at 4-month follow-up. Other aspects of psychopathology and subjective quality of life did not change significantly in either group. Treatment satisfaction and ratings of the therapeutic relationship were similar in both groups.

Conclusions. BPT may be an effective treatment for negative symptoms in patients with chronic schizophrenia. The findings should merit further trials with larger sample sizes and detailed studies to explore the therapeutic mechanisms involved.

Background. Previous studies have shown high rates of psychosis among Afro-Caribbean immigrants to the UK and immigrants to the Netherlands. Rates of schizophrenia-like psychoses (SLP), i.e. schizophrenia or other non-affective psychosis, among the native-born and immigrant populations were assessed in Malmö, the city in Sweden with the highest proportion of immigrants.

Methods. All adult patients admitted for in-patient psychiatric treatment in Malmö during the course of a 1-year period (N = 1162) were studied with regard to ethnicity and SLP diagnosis. A smaller sample consisting only of first-onset SLP cases (regardless of in- or out-patient status) was also studied (N = 56). Risks for admission and first-onset were calculated on the basis of current background population figures for Malmö.

Results. Compared with those who were native-born, immigrants had increased risk for admission for SLP, with a similar tendency for increased risk for first-onset of SLP. Relative risk for SLP admission was most markedly increased in immigrants from East-Africa. Background factors specifically associated with migration (e.g. extreme duress) did not appear to contribute strongly to SLP in immigrants.

Conclusion. While the current results add to the growing body of evidence showing increased risk for psychosis in immigrants, vulnerability to psychosis may have been determined by factors other than the migration process.

Background. Global characteristics and psychosocial risk factors related to delusions have been identified. The present study extends these findings to the level of everyday functioning, identifying characteristics of delusional moments (DMs) and contextual risk and protective factors for delusional exacerbations in daily life.

Methods. Data were collected using the Experience Sampling Method (ESM), a time-sampling technique. Forty-eight chronic patients diagnosed with schizophrenia rated the intensity of pathological symptoms and mood states and described their thoughts and the environmental context during consecutive moments in daily life. Delusions were defined on the basis of self-rated suspicion, preoccupation, feeling controlled, and coded thought pathology. Daily context included current activity, persons present and location. Characteristics of DMs and non-delusional moments (nDMs) were compared, and a multilevel logistic regression model was used to identify contexts that might trigger or prevent DMs.

Results. On average, patients experienced delusions less than one-third of the time. DMs were characterized by higher negative affect and lower positive affect. The presence of family or acquaintances decreased the risk of subsequently experiencing a DM, whereas withdrawal from activities increased this risk.

Conclusions. Data support the validity of ESM for investigating delusions in schizophrenia. Daily life contexts appear to alter the probability that delusions will occur. Knowledge about such contexts may therefore be useful in helping patients develop better coping strategies and in creating therapeutic interventions that can lessen emotional distress.

Background. Suicide prevention is a health priority in many countries. Improved management of suicide risk may improve suicide prevention. This study aimed to assess the feasibility of health district-wide training in the assessment and management of people at risk of suicide; and to assess the impact of training on assessment and management skills.

Methods. Staff in three health care settings, namely primary care, accident and emergency departments and mental health services (N = 359), were offered suicide risk management training in a district-wide programme, using a flexible ‘facilitator’ approach. The main outcomes were the rate of attendance at training, and changes in suicide risk assessment and management skills following training.

Results. It was possible to deliver training to 167 health professionals (47% of those eligible) during a 6 month training period. This included 95 primary care staff (39%), 21 accident and emergency staff (42%) and 51 mental health staff (78%). Of these, 103 (69%) attended all training. A volunteer sample of 28 staff who underwent training showed improvements in skills in the assessment and management of suicide risk. Satisfaction with training was high. The expected costs of district-wide training, if it were able to produce a 2·5% reduction in the suicide rate, would be £99747 per suicide prevented and £3391 per life year gained.

Conclusions. Training in the assessment and management of suicide risk can be delivered to approximately half the targeted staff in primary care, accident and emergency departments and mental health services. The current training package can improve skills and is well accepted. If it were to produce a modest fall in the suicide rate, such training would be cost-effective. However, a future training programme should develop a broader training package to reach those who will not attend.

Background. This paper describes the rationale and methodology of the first national psychiatric morbidity surveys to be carried out in Great Britain. The objectives of the surveys were to estimate the prevalence of psychiatric morbidity among adults aged 16–64 living in Great Britain; to identify the nature and extent of social disabilities associated with psychiatric morbidity; to describe the use of health and social services by people with psychiatric morbidity and to investigate the association between mental illness and potential environmental risk factors in a household sample.

Methods. Four separate surveys were carried out in order to meet the objectives; a private household sample (N=10108), a sample of institutions caring for the mentally ill (N=1191), a sample of homeless people (N=1166), and a supplementary sample of patients with psychosis living in private households (N=350). A two-stage assessment procedure was used, in which all subjects were given the Revised Clinical Interview Schedule (CIS-R) administered by lay interviewers to assess neurotic symptoms and disorders and a psychosis screen, including the Psychosis Screening Questionnaire. Those who were positive on the psychosis screen were then interviewed by psychiatrists using the SCAN (incorporating the tenth edition of the Present State Examination).

Conclusions. Large scale national surveys such as this augment the inadequate data on psychiatric morbidity that are routinely available and are, therefore, an important source of information upon which to base policy and generate aetiological hypotheses. These surveys provide a possible model for similar surveys in other countries.

The characteristics of 64 suicides with a retrospective diagnosis of depression and 128 depressives referred for psychiatric treatment were compared. The following items differentiated the suicide group: male sex, older age in females, single status, living alone, the symptoms of insomnia, impaired memory and self neglect, and a history of suicide attempts. The value of these items in assessing suicide risk in depressive illness is discussed.

The National Institute of Mental Health launched the Research Domain Criteria (RDoC) initiative to better understand dimensions of behavior and identify targets for treatment. Examining dimensions across psychiatric illnesses has proven challenging, as reliable behavioral paradigms that are known to engage specific neural circuits and translate across diagnostic populations are scarce. Delay discounting paradigms seem to be an exception: they are useful for understanding links between neural systems and behavior in healthy individuals, with potential for assessing how these mechanisms go awry in psychiatric illnesses. This article reviews relevant literature on delay discounting (or the rate at which the value of a reward decreases as the delay to receipt increases) in humans, including methods for examining it, its putative neural mechanisms, and its application in psychiatric research. There exist rigorous and reproducible paradigms to evaluate delay discounting, standard methods for calculating discount rate, and known neural systems probed by these paradigms. Abnormalities in discounting have been associated with psychopathology ranging from addiction (with steep discount rates indicating relative preference for immediate rewards) to anorexia nervosa (with shallow discount rates indicating preference for future rewards). The latest research suggests that delay discounting can be manipulated in the laboratory. Extensively studied in cognitive neuroscience, delay discounting assesses a dimension of behavior that is important for decision-making and is linked to neural substrates and to psychopathology. The question now is whether manipulating delay discounting can yield clinically significant changes in behavior that promote health. If so, then delay discounting could deliver on the RDoC promise.

Background. This longitudinal study investigated whether patterns of cortisol and DHEA that precede the onset of an episode of major depression influence time to recovery in a community ascertained sample of adolescents meeting DSM-IV criteria for major depression.

Method. Sixty adolescents aged 12 to 16 at high risk for psychiatric disorders were followed for 24 months. At 12 months, 30 had experienced an episode of major depression and 30 had not. The second follow-up repeated the psychiatric evaluations with all participants completing the Kiddie-SADS Schedule for Schizophrenia and Affective Disorders. Hormone characteristics and self-reports completed at entry (the Mood and Feelings questionnaire and the Ruminations scale) together with intervening undesirable life events in the 12 months prior to onset, were used to determine the best pattern of psychosocial and endocrine features to predict persistent major depression.

Results. Compared to the never depressed (N=30) and remitted adolescents (N=19), persistently depressed cases (N=11) had a raised morning cortisol/DHEA ratio at entry. Only persistent cases had higher levels of self-reported depressive symptoms and ruminations at entry compared to never depressed. There was no difference in exposure to undesirable life events before onset of disorder between remitted and persistent groups. Logistic regression techniques showed that only the cortisol/DHEA ratio predicted persistence.

Conclusions. In community adolescents at high risk for psychiatric disorder persistent major depression may be distinguished from sporadic forms by the 08.00 h salivary cortisol/DHEA ratio prior to onset.

Background. Cognitive impairment may be part of the endophenotype of bipolar disorder (BP), but little is known about patterns and severity of impairment in BP subgroups and their relation to depression. The same applies to deficits in emotion processing known to be present in BP.

Method. To explore the relationship between depression and impairment in cognition and emotion processing and the differences between BP subgroups, we assessed 36 (25 BP I and 11 BP II) patients using a cognitive battery and a facial emotion recognition task.

Results. BP patients were impaired compared to published norms on memory, naming and executive measures (Binomial Single Proportion tests, p<0·05). Cognitive performance was largely unrelated to depression ratings. Surprise recognition was the only emotion processing impairment in BP patients compared to controls (patients' recognition score 75% v. controls' 89%, p=0·024). Patients with higher depression ratings were more impaired in recognizing expressions of anger (t23=2·21, p=0·037). BP II patients were more impaired than BP I patients in IQ, memory and executive measures (Mann–Whitney tests, p<0·05). Depression severity or exposure to medication or electroconvulsive therapy (ECT) did not explain these differences.

Conclusions. We confirm cognitive impairment and an isolated facial emotion processing deficit in BP patients and suggest that these deficits are largely unrelated to depressive symptoms. Our study also provides evidence that cognitive deficits are more severe and pervasive in BP II patients, suggesting that recurrent depressive episodes, rather than mania, may have a more detrimental and lasting effect on cognition.

Over 90% of the 1202 patients investigated in the 9 centres collaborating in the International Pilot Study of Schizophrenia were traced 2 years after the initial examination and on the average over 75% of them were re-examined, using standardized instruments and methods. Results indicate that patients diagnosed as schizophrenic on the basis of standardized assessments and clearly specified diagnostic criteria demonstrated very marked variations of course and outcome over a 2-year period. Schizophrenic patients in the centres in developing countries had considerably better course and outcome than schizophrenic patients in the centres in developed countries.

The results of surveys and inquiries to identify autistic children, carried out in England and Wales, the U.S.A. and Denmark, are compared. Three studies, in each of which either a total population of children or a wide range of handicapped children was screened, using case-note inspection and interviews, all estimated the prevalence of the autistic syndrome to be between four and five children per 10,000 aged under 15 years. Inquiries that counted diagnosed cases only or that relied upon local authority records produced much lower prevalence rates for the autistic syndrome. The reasons for this are examined, and the implications for prevalence studies of handicapping conditions are discussed.

There have been relatively few reported cases of psychosis due to khat usage despite its heavy consumption in certain East African and Arabian countries. Four cases have been reported in the UK. We report here on three further cases of psychotic reactions to this substance in Somalian males, and emphasize the need to be aware of khat as a potential substance of abuse, with both medical and psychiatric complications. The features of khat psychoses are described and the relationship to amphetamine and ephedrine psychoses is discussed. The forensic aspects of two of the cases which involved homicide and combined homicide and suicide are highlighted, as is the possible role of social dislocation from the culture of origin.