Background. A variety of factors are related to compliance with medication in schizophrenia, but little attention has been paid to the role of families. Carers' knowledge or expressed emotion (EE) may be related to compliance. The aim of the present study was to evaluate the relevance of these two factors, as well as their relationships with other variables for the prediction of compliance.

Method. A sample of patient–carer pairs (N=79) involved in a family intervention for schizophrenia trial was recruited. Compliance, symptoms, social functioning and attitudes to their carers were assessed in patients. Carers' EE, knowledge and psychopathology were also evaluated.

Results. A number of factors were related to compliance, including carers' EE and patients' psychotic symptoms, which contributed independently to not taking medication. Carers' knowledge about schizophrenia and other groups of symptoms was not related to compliance.

Conclusions. EE may be an important factor to account for in the understanding of patients' compliance and the direction of the relationship between EE and compliance should be the subject of further study.

Background. Older adults are the main recipients of repeat prescriptions for benzodiazepine (BZD) hypnotics. BZDs can impair cognitive function and may not aid sleep when taken continuously for years. This study therefore aimed to determine if withdrawing from BZDs leads to changes in patients' cognitive function, quality of life, mood and sleep.

Method. One hundred and ninety-two long-term users of BZD hypnotics, aged [ges ]65 years, were identified in 25 general practices. One hundred and four who wished to withdraw were randomly allocated to one of two groups under double-blind, placebo controlled conditions: group A's BZD dose was tapered from week 1 of the trial; group B were given their usual dose for 12 weeks and then it was tapered. An additional group (C) of 35 patients who did not wish to withdraw from BZDs participated as ‘continuers’. All patients were assessed at 0, 12 and 24 weeks and 50% were re-assessed at 52 weeks.

Results. Sixty per cent of patients had taken BZDs continuously for >10 years; 27% for >20 years. Of all patients beginning the trial, 80% had successfully withdrawn 6 months later. There was little difference between groups A and B, but these groups differed from continuers (C) in that the performance of the withdrawers on several cognitive/psychomotor tasks showed relative improvements at 24 or 52 weeks. Withdrawers and continuers did not differ in sleep or BZD withdrawal symptoms.

Conclusions. These results have clear implications for clinical practice. Withdrawal from BZDs produces some subtle cognitive advantages for older people, yet little in the way of withdrawal symptoms or emergent sleep difficulties. These findings also suggest that, taken long-term, BZDs do not aid sleep.

Background. Disturbed immune activity and vascular inflammation are associated both with clinical depression and coronary atherogenesis, and may constitute a mechanism through which depression contributes to coronary heart disease. If this is the case, then non-clinical depressive symptoms and psychological distress should be associated with immune activation and vascular inflammation. We tested this hypothesis in a healthy middle-aged sample.

Method. Measures of depressive symptoms and hopelessness were obtained from 226 volunteers (122 men, 104 women) aged 47–59 years, drawn from the Whitehall II epidemiological cohort. C-reactive protein, fibrinogen, plasma interleukin-6, tumour necrosis factor alpha, interleukin-1 receptor antagonist, and T- and B-lymphocyte, and natural killer cells numbers and percentages were assessed.

Results. There were no associations between measures of depressive symptoms or hopelessness and markers of immune activation or inflammatory response.

Conclusions. Factors such as the measures of depressive symptoms, the choice of inflammatory and immune indices, and sample size, are unlikely to be responsible for these null effects. Associations may be confined to clinically depressed or older age populations, but there are problems of confounding by co-morbidity and health compromising behaviours in this literature. We conclude that disturbances of immune function and inflammatory processes are unlikely to be primarily responsible for the associations between depressive symptoms and coronary heart disease described in the literature, and that other pathways are involved.

Background. The symptom domain of inattention in attention deficit/hyperactivity disorder (ADHD) suggests that there are neuropsychological fields of attention in which subjects with ADHD express deficits. However, studies using differentiated neuropsychological attentional tests in ADHD are lacking.

Method. A consecutive series of 35 subjects with ADHD aged 9–12 years were assessed on a computer-driven neuropsychological test battery for attentional functions. Their performance was classified according to the data of a normative sample of 187 healthy subjects aged 9–12 years, and compared with the performance of 35 matched healthy control subjects.

Results. According to normative data, most ADHD subjects performed on all attentional measures within the normal range. Comparisons with the control group revealed that ADHD subjects reacted faster on all attentional tests, yielding statistical significance for the Go/No go test and the Divided Attention test. They also performed with significantly fewer errors on the Divided Attention test. On the Go/No go test, Visual Scanning test and Attentional Shift test ADHD subjects committed significantly more errors than control subjects.

Conclusions. Our results suggest a differential pattern rather than a deficit pattern of attentional functions in ADHD. It is suggested that the more rapid response style of ADHD subjects leads to a more erroneous performance in self-paced attentional tasks and to a better performance in externally paced attentional tasks. However, neuropsychological tests of attention do not contribute to the clinical diagnosis of ADHD.

Background. High rates of psychopathology and of personality problems have been reported in children and adolescents with chronic fatigue syndrome (CFS). It is not clear whether this is consequent on the experience of chronic physical ill health. We compare psychiatric adjustment in children with CFS and in children suffering from another chronic physical disorder (juvenile idiopathic arthritis or JIA).

Method. Our sample consisted of 28 children with CFS and 30 with JIA attending tertiary paediatric centres (age range, 11 to 18 years, mean 15, S.D. 2·3). In order to assess psychiatric status and functioning, we used the K-SADS psychiatric interviews, CGAS and Harter Self-Esteem Questionnaire with child subjects; behavioural questionnaires (CBCL) and child personality assessment interviews (PAS) with parent informants.

Results. Psychiatric disorders in the year prior to interview had been present significantly more commonly in the CFS group (72% v. 34% in JIA) and were more impairing to them (CGAS scores of 45 v. 77). Most common diagnoses in both groups were depressive and anxiety disorders. Personality problems were also significantly more frequent in CFS subjects (48% disorder and 26% difficulty v. 11% and 11% in JIA). There were few differences between the two groups in self-esteem.

Conclusions. Psychopathology and personality problems are common in children and adolescents with severe forms of CFS and cannot be explained strictly through the experience of chronic physical illness.

Background. Infectious mononucleosis (IM) is a risk factor for chronic fatigue. Reduced activity is the most consistent factor found to be associated with poor outcome following the onset of infectious mononucleosis. However, little is known about the biological mechanisms involved in the pathogenesis of chronic fatigue following IM and no study, so far, has examined the relation between certain illness beliefs and poor outcome. This study explored immunological, endocrine, behavioural and cognitive responses to the acute illness and assessed which components of these groups of risk factors predicted a chronic course.

Method. Using a prospective cohort design, 71 primary care patients with IM were enrolled onto the study and interviewed. Their recovery was explored by postal questionnaire up to 1 year later.

Results. In the univariate analysis, increased baseline levels of immune activation were associated with fatigue at baseline and 3 months. Cortisol levels were not associated with fatigue at any point. Using multivariate models of clinical and psychosocial baseline factors, severity of symptoms and illness perceptions were found to predict fatigue 3 months later. At 6 months, fatigue was best predicted by female gender and illness perceptions, and at 12 months by female gender and a symptoms–disability factor.

Conclusions. In the multivariate analysis no factors were found to predict poor outcome at all time-points. Instead the pattern of predictors changed over time, partly but not completely consistent with our a priori predictions. Larger studies are needed to explore further the predictive nature of biopsychosocial factors in the pathogenesis of chronic fatigue related to IM. The psycho-behavioural predictors found in this study are amenable to intervention. Such interventions should be tested in randomized controlled trials.

Background. Major depressive disorder (MDD) is highly co-morbid with other Axis I disorders, which commonly precede its onset. We sought to determine the level and periods of risk for MDD posed by prior or co-occurring psychiatric disorders.

Method. Using retrospective data from a longitudinal, population-based sample of 2926 male and 1929 female adult twin subjects, we predicted the hazard rates for MDD from a Cox proportional hazards model with same-year or prior onsets of co-morbid Axis I disorders as time-dependent covariates.

Results. All axis I disorders studied (generalized anxiety disorder, panic disorder, phobia, alcohol dependence, psychoactive substance use disorders and conduct disorder) significantly predicted increased risk for developing MDD. The highest hazard rates occurred for MDD onsets that co-occurred with those of the co-morbid disorder. However, the risk for onset of MDD subsequent to that of prior disorders is also significantly increased and remains relatively unchanged over time. Although the risk for onset of MDD is significantly higher in women than men, this was not explained by gender differences in prior disorder prevalence or increased sensitivity in women to the effects of prior disorders on risk for depression.

Conclusions. Prior psychiatric disorders are significant risk factors for the development of MDD, independent of the length of the intervening period between the onset of the first disorder and that of MDD.

Background. Early diagnosis of dementia is important for those who might benefit from treatment. We designed a brief comprehensive neuropsychological test battery to help differentiate control subjects from patients with mild cognitive impairment (MCI) and dementia.

Method. The battery included tests of memory, attention, executive function, speed, perception and visuospatial skills. It was administered to subjects from the OPTIMA cohort: 51 controls, 29 with MCI, 60 with ‘possible’ or ‘probable’ Alzheimer's disease (AD) (NINCDS/ADRDA) and 12 with cerebrovascular disease (CVD). Mann–Whitney U tests were used to compare performance of controls with other diagnostic groups. The sensitivity and specificity of the tests were determined using Receiver Operating Characteristic curve analyses. The effects of age, gender and years of education on test performance were determined with Spearman's rank correlations.

Results. The AD group performed worse than controls on all tests except an attention task. The Hopkins Verbal Learning Test and The Placing Test for episodic memory showed significant discriminative capacity between controls and other groups. Attention and processing speed tests discriminated CVD from controls. Category fluency, episodic memory tests and the CLOX test for executive function distinguished MCI from AD. Spearman's correlations showed negative associations between age and processing speed. Years of education affected performance on all tests, except The Placing Test.

Conclusions. Certain neuropsychological tests have been shown to be sensitive and specific in the differential diagnosis of various types of dementia and may prove to be useful for detection of MCI.

Background. Social disadvantage and lack of social support have been identified as important risk factors for the onset and continuance of episodes of common mental illness. This study aimed to identify the social precursors to episodes of and recovery from common mental illness in a large, general population sample over eight yearly intervals.

Method. The analytical samples were drawn from those aged [ges ]16 in the British Household Panel Survey from 1991 to 1998. The samples were: (1) onset – over 42 000 paired years from 10 204 persons; (2) recovery – over 10 000 paired years from 4878 persons; and (3) 1812 spells with observed onset and recovery. Markov and discrete-time complementary log–log models were used. Common mental illness was measured using the 12-item General Health Questionnaire.

Results. Sex, age, changes in marital and employment status, physical health, family care and social support were all associated with differential rates of onset and recovery. Severity of disorder was associated with less likelihood of recovery and longer time to recovery.

Conclusions. The study confirms many previous findings concerning social factors associated with onset and recovery. Low social support acted as expected by increasing chances of onset and decreasing chances of recovery. Other social factors such as separation or divorce, becoming and remaining unemployed, health limiting daily activities, caring for a sick relative all decreased chances of recovery. The chances of observing a change in state (either onset or recovery) decreased with the number of prior observations in that state. Reduced rates of recovery with increasing degrees of severity of distress was expected, but not previously demonstrated.

Background. Outcome studies of chronic fatigue, neurasthenia and other unexplained fatigue syndromes are few and have been carried out in developed Western countries. This paper aimed to study the outcome of unexplained fatigue syndromes in an international primary care sample and to identify risk factors for persistence.

Method. We used data from the WHO collaborative study of psychological problems in general health care, in which 3201 primary care attenders from 14 countries were followed-up for 12 months. The assessment included a modified version of the Composite International Diagnostic Interview.

Results. Unexplained fatigue persisted in one-fifth to one-third of the subjects depending on the definition of fatigue. From the factors studied only severity of fatigue and psychiatric morbidity at baseline were associated with persistence 12 months later. Outcome did not differ between countries of different stages of economic development.

Conclusions. The prognosis of fatigue syndromes in international primary care is relatively good. The study underlines the importance of psychological factors in influencing short-term prognosis.

Background. The objective of this study was to determine whether older adults with first-ever onset of depression after age 60 years (late onset depression, LOD) have smaller frontal lobes than elderly patients with early-onset depression (EOD) and aged controls.

Method. Twenty-seven subjects with LOD, 24 with EOD and 37 controls underwent volumetric MRI to determine right and left frontal lobe volumes and total brain volume.

Results. The right frontal volume of subjects with LOD was 8·0% and 5·6% smaller than that of patients with EOD (P<0·01) and controls (NS) respectively. Volume of the left frontal lobe was not significantly different from EOD or controls. All analyses were adjusted for age, gender and total brain volume. Unlike controls and those with EOD, patients with LOD did not display a significant positive correlation between cognitive scores and total brain, left frontal or right frontal volumes.

Conclusion. LOD is associated with right frontal lobe atrophy and loss of the correlation between cognitive performance and brain volume. This adds support to the fronto-striatal hypothesis of depression and suggests that structural brain changes have a particular role in cases of LOD.

Background. Working memory has been identified as a core cognitive deficit in schizophrenia that is associated with negative symptoms, but it is unclear whether it is impaired prior to onset of psychosis in symptomatic patients.

Method. Thirty-eight young people at ultra high-risk (UHR) of developing psychosis (of whom nine later became psychotic) were compared with 49 healthy controls on tests of spatial working memory (SWM) and delayed matching-to-sample (DMTS).

Results. Both SWM and DMTS performance was significantly poorer in the UHR groups. Those who later became psychotic generally performed more poorly than those who did not, although this did not reach significance for any measure. A significant association between SWM errors and negative symptoms was seen in the later-psychotic group only (P=0·02).

Conclusions. Spatial working memory abilities are impaired in those at high-risk for psychosis. The relationship between working memory and negative symptoms may be useful as a predictive tool.

Background. This study examined whether alcohol abuse patients are characterized either by enhanced schematic processing of alcohol related cues or by an attentional bias towards the processing of alcohol cues.

Method. Abstinent alcohol abusers (N=25) and non-clinical control participants (N=24) performed a dual task paradigm in which they had to make an odd/even decision to a centrally presented number while performing a peripherally presented lexical decision task. Stimuli on the lexical decision task comprised alcohol words, neutral words and non-words. In addition, participants completed an incidental recall task for the words presented in the lexical decision task.

Results. It was found that, in the presence of alcohol related words, the performance of patients on the odd/even decision task was poorer than in the presence of other stimului. In addition, patients displayed slower lexical decision times for alcohol related words. Both groups displayed better recall for alcohol words than for other stimuli.

Conclusions. These results are interpreted as supporting neither model of drug cravings. Rather, it is proposed that, in the presence of alcohol stimuli, alcohol abuse patients display a breakdown in the ability to focus attention.

Background. Relatively few predictors of outcome in first-episode psychosis are potentially malleable and duration of untreated psychosis (DUP) is one. However, the degree to which DUP is mediated by other predictors of outcome is unclear. This study examines the specific effects of DUP on 12-month outcome after adjusting for effects of potential confounders and moderating variables.

Method. The sample comprised 354 first-episode psychosis patients followed up 12-months after remission/stabilization of their psychotic symptoms. Outcome measures included functional outcome, severity of positive symptoms and negative symptoms. Hierarchical multiple regression assessed whether DUP significantly predicted 12-month outcome after adjusting for other predictors. Contrast analysis further clarified the differential effects of DUP on 12-month outcome.

Results. DUP remained a significant predictor of outcome after adjusting for the effects of other variables. This finding remained robust for the subset of patients with schizophrenia or schizophreniform disorder. Functional outcome appeared to decline substantially even after very short treatment delays (>7 days), with more gradual deterioration in functioning until very long DUP (>1 year). Good outcome was variably associated with good pre-morbid adjustment, female gender, diagnosis of affective disorder, short duration of prodromal symptoms, and treatment within the Early Psychosis Prevention and Intervention model in contrast to other models of care.

Conclusions. DUP consistently predicts outcome independently of other variables, and is not simply a proxy for other factors. As one of the few potentially malleable factors influencing outcome, DUP could prove to be a target for secondary preventive efforts in early psychosis.

Background. Few data are available with which to evaluate the association between depressed subgroups, type of treatment and patient retention during episodes of major depression.

Method. This observational study followed 1117 depressed patients over a 12-month period in the primary care setting of six different international sites. The patients were divided into three severity-linked subgroups: moderate to severe depression; moderate depression co-morbid with serious medical conditions; and mild depression.

Results. In general, a low dropout rate was found, with significant differences in the rates across the six sites. However, while there was no statistical significance in the association between the three subgroups of depression and overall dropout rates, we did find that older patients were less likely to drop out, more depressed patients were more likely to drop out, and if patients were on antidepressants they were less likely to drop out. Among the three subgroups of depression, patients with moderate depression co-morbid with serious medical conditions received the lowest amount of antidepressants and had the lowest quality of life.

Conclusion. Although the overall dropout rate in this study was found very low and did differ between the six sites, an association between the use of antidepressants and patient retention was seen. The group of patients with serious co-morbid medical conditions received fewer antidepressants even when the level of their depressive states was taken into consideration. This group was the least satisfied with treatment and had the lowest self-reported quality of life.

Background. It has been proposed that delusions of persecution are caused by the tendency to over-attribute malevolent intentions to other people's actions. One aspect of intention attribution is detecting contingencies between an agent's actions and intentions. Here, we used simplified stimuli to test the hypothesis that patients with persecutory delusions over-attribute contingency to agents' movements.

Method. Short animations were presented to three groups of subjects: (1) schizophrenic patients; (2) patients with affective disorders; and (3) normal control subjects. Patients were divided on the basis of the presence or absence of delusions of persecution. Participants watched four types of film featuring two shapes. In half the films one shape's movement was contingent on the other shape. Contingency was either ‘intentional’: one shape moved when it ‘saw’ another shape; or ‘mechanical’: one shape was launched by the other shape. Subjects were asked to rate the strength of the relationship between the movement of the shapes.

Results. Normal control subjects and patients without delusions of persecution rated the relationship between the movement of the shapes as stronger in both mechanical and intentional contingent conditions than in non-contingent conditions. In contrast, there was no significant difference between the ratings of patients with delusions of persecution for the conditions in which movement was animate. Patients with delusions of persecution perceived contingency when there was none in the animate non-contingent condition.

Conclusions. The results suggest that delusions of persecution may be associated with the over-attribution of contingency to the actions of agents.

Background. The importance of somatization among older primary care attenders is unclear. We aimed to establish the prevalence, persistence and associations of somatization among older primary care attenders, and the associations of frequent attendance.

Method. One hundred and forty primary care attenders over 65 years were rated twice, 10 months apart, on measures of somatization, psychiatric status, physical health and attendance.

Results. The syndrome of GMS hypochondriacal neurosis had a prevalence of 5% but was transient. Somatized symptoms and attributions were persistent and associated with depression, physical illness and perceived poor social support. Frequent attenders (top third) had higher rates of depression, physical illness and somatic symptoms, and lower perceived support.

Conclusion. Somatization is common among older primary care attenders and has similar correlates to younger primary care somatizers. Psychological distress among older primary care attenders is associated with frequent attendance. Improved recognition should result in benefits to patients and services.

Background. Lack of insight is frequently observed in schizophrenia. Relationships have been noted between poor insight, clinical symptoms and cognitive impairments but the findings are inconsistent. There have been some recent attempts to relate poor insight to neuro-anatomical measures.

Method. We assessed insight, positive and negative symptoms of schizophrenia, cognitive performance, and whole brain volumes in a sample of 78 DSM-IV male schizophrenics and 36 normal male comparison subjects matched for age and IQ. Subjects underwent a dual-echo MRI brain scan to establish grey, white and whole brain volumes.

Results. Poor Wisconsin Card Sorting Test performance inversely correlated with insight in schizophrenic patients, as did the symptoms alogia, anhedonia, avolition/apathy, affective flattening, inappropriate affect, thought disorder and delusions. The presence of inappropriate affect, delusions and thought disorder, showed the most significant impact on insight levels. There were no significant correlations between whole brain, white and grey matter volume and degree of insight.

Conclusions. The results suggest that poor insight is significantly related to schizophrenic psychopathology, and confirm that there is a relationship between insight and executive performance. Awareness of illness is not related to any global brain measures, suggesting future investigations should pay attention to more specific cortical regions such as the frontal cortex.

Background. A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms.

Method. Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms.

Results. Intervention patients had significantly greater self-efficacy for managing depression (P<0·01) and were more likely to keep track of depressive symptoms (P<0·0001), monitor early warning signs (P<0·0001), and plan for coping with high risk situations (P<0·0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0·0001), keeping track of depressive symptoms (P=0·05), monitoring for early warning signs (P=0·01), engaging in pleasant activities (P<0·0001) and engaging in social activities (P<0·0001) positively predicted improvements in depression symptom scores.

Conclusions. A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.

Background. Generalized anxiety disorder is a common condition of excessive worry and tension which tends to run a chronic course associated with significant psychiatric and medical problems. Cognitive behaviour therapy (CBT) has been shown to be of clinical value in about 50% of cases with treatment gains maintained over follow-up periods ranging from 6 to 12 months. The potential value of CBT over the longer term has not been subject to rigorous investigation.

Method. Results are reported of 8–14 year follow-up of two randomized controlled trials of cognitive-behaviour therapy for generalized anxiety disorder employing structured interview with an assessor blind to initial treatment condition. Comparison groups included medication and placebo in one study based in primary care, and analytical psychotherapy in the other based in secondary care. Follow-up samples (30% and 55% of trial entrants) were broadly representative of the original cohorts.

Results. Overall, 50% of participants were markedly improved of whom 30–40% were recovered (i.e. free of symptoms). Outcome was significantly worse for the study based in secondary care in which the clinical presentation of participants was more complex and severe. For a minority (30–40%), mainly from the secondary care study, outcome was poor. Treatment with CBT was associated with significantly lower overall severity of symptomatology and less interim treatment, in comparison with non-CBT conditions, but there was no evidence that CBT influenced diagnostic status, probability of recovery or patient perceptions of overall improvement.

Conclusions. Both CBT and the complexity and severity of presenting problems appear to influence the long-term outcome of GAD.