Background. A better understanding of the neural basis of social cognition including mindreading (or theory of mind) and empathy might help to explain some deficits in social functioning in people with schizophrenia. Our aim was to review neuroimaging and neuropsychological studies on social cognition, as they may shed light on the neural mechanisms of social cognition and its dysfunction in patients with schizophrenia.

Method. A selective literature review was undertaken.

Results. Neuroimaging and neuropsychological studies suggest convergence upon specific networks for mindreading and empathy (the temporal cortex, amygdala and the prefrontal cortex). The frontal lobe is likely to play a central role in enabling social cognition, but mindreading and empathic abilities may require relatively different weighting of subcomponents within the same frontal-temporal social cognition network.

Conclusions. Disturbances in social cognition may represent an abnormal interaction between frontal lobe and its functionally connected cortical and subcortical areas. Future studies should seek to explore the heterogeneity of social dysfunction within schizophrenia.

Background. Repetitive transcranial magnetic stimulation (rTMS) of frontal brain regions is under study as a non-invasive method in the treatment of affective disorders. Recent publications provide increasing evidence that rTMS may be useful in treating schizophrenia. Results are most intriguing, demonstrating a reduction of negative symptoms following high-frequency rTMS. In this context, disentangling of negative and depressive symptoms is of the utmost importance when understanding specific rTMS effects on schizophrenic symptoms.

Method. Using a sham-controlled parallel design, 20 patients with schizophrenia were included in the study. Patients were treated with high-frequency 10 Hz rTMS over 10 days. Besides clinical ratings, ECD-SPECT (technetium-99 bicisate single photon emission computed tomography) imaging was performed before and after termination of rTMS treatment.

Results. High-frequency rTMS leads to a significant reduction of negative symptoms combined with a trend for non-significant improvement of depressive symptoms in the active stimulated group as compared with the sham stimulated group. Additionally, a trend for worsening of positive symptoms was observed in the actively treated schizophrenic patients. In both groups no changes in regional cerebral blood flow could be detected by ECD-SPECT.

Conclusions. Beneficial effects of high-frequency rTMS on negative and depressive symptoms were found, together with a trend for worsening positive symptoms in schizophrenic patients.

Background. Medically unexplained visual loss occurs in 1 to 5% of patients attending ophthalmology clinics and for many it runs a chronic course. A psychogenic aetiology is presumed in such cases, but little is known about the underlying neural mechanisms. Recent studies have established the value of functional magnetic resonance imaging (fMRI) in understanding the mechanisms of unexplained motor and sensory symptoms. The purpose of this study was to use a similar strategy (fMRI) to evaluate the cerebral responses to visual stimulation in a group of patients with medically unexplained visual loss, in an attempt to determine the underlying neural mechanisms.

Method. Brain activation induced by periodic (monocular) 8 Hz visual stimulation was detected by fMRI in five patients with unexplained visual loss who fulfilled DSM-IV criteria for conversion disorder, and seven normal volunteers. Between-group differences in mean power of activation were estimated by fitting a one-way analysis of variance (ANOVA) model at each intracerebral voxel in standard space.

Results. Compared with controls, patients showed reduced activation in visual cortices, but increased activation in left inferior frontal cortex, left insula-claustrum, bilateral striatum and thalami, left limbic structures, and left posterior cingulate cortex.

Conclusions. This preliminary study has identified novel neural correlates in patients with unexplained visual loss. The abnormal pattern of activation may reflect inhibition of primary visual cortex or a shift towards non-conscious (implicit) processing.

Background. There have been few large-scale epidemiological studies which have examined the prevalence of bipolar disorder. The authors report 12-month prevalence data for DSM-IV bipolar disorder from the Australian National Survey of Mental Health and Well-Being.

Method. The broad methodology of the Australian National Survey has been described previously. Ten thousand, six hundred and forty-one people participated. The 12-month prevalence of euphoric bipolar disorder (I and II) – similar to the euphoric-grandiose syndrome of Kessler and co-workers – was determined. Those so identified were compared with subjects with major depressive disorder and the rest of the sample, on rates of co-morbidity with anxiety and substance use disorders as well as demographic features and measures of disability and service utilization. Polychotomous logistic regression was used to study the relationship between the three samples and these dependent variables.

Results. There was a 12-month prevalence of 0·5% for bipolar disorder. Compared with subjects with major depressive disorder, those with bipolar disorder were distinguished by a more equal gender ratio; a greater likelihood of being widowed, separated or divorced; higher rates of drug abuse or dependence; greater disability as measured by days out of role; increased rates of treatment with medicines; and higher lifetime rates of suicide attempts.

Conclusions. This large national survey highlights the marked functional impairment caused by bipolar disorder, even when compared with major depressive disorder.

Background. Having a ‘theory of mind’ (ToM) means that one appreciates one's own and others' mental states, and that this appreciation guides interactions with others. It has been proposed that ToM is impaired in schizophrenia and experimental studies show that patients with schizophrenia have problems with ToM, particularly during acute episodes. The model predicts that communicative problems will result from ToM deficits.

Method. We analysed 35 encounters (>80 h of recordings) between mental health professionals and people with chronic schizophrenia (out-patient consultations and cognitive behaviour therapy sessions) using conversation analysis in order to identify how the participants used or failed to use ToM relevant skills in social interaction.

Results. Schizophrenics with ongoing positive and negative symptoms appropriately reported first and second order mental states of others and designed their contributions to conversations on the basis of what they thought their communicative partners knew and intended. Patients recognized that others do not share their delusions and attempted to reconcile others' beliefs with their own but problems arose when they try to warrant their delusional claims. They did not make the justification for their claim understandable for their interlocutor. Nevertheless, they did not fail to recognize that the justification for their claim is unconvincing. However, the ensuing disagreement did not lead them to modify their beliefs.

Conclusions. Individuals with schizophrenia demonstrated intact ToM skills in conversational interactions. Psychotic beliefs persisted despite the realization they are not shared but not because patients cannot reflect on them and compare them with what others believe.

Background. People with persecutory delusions regard ambiguous data in the social domain as self-relevant and selectively attend to threatening information. This study aimed to characterize these social cognitive biases in functional neuroanatomical terms.

Method. Eight schizophrenic patients with active persecutory delusions and eight matched normal controls underwent functional magnetic resonance imaging while determining the self-relevance of ambiguous self-relevant or unambiguous other-relevant neutral and threatening statements.

Results. In determining self-relevance, the deluded subjects showed a marked absence of rostral–ventral anterior cingulate activation together with increased posterior cingulate gyrus activation in comparison to the normal subjects. The influence of threat on self-relevance determination did not yield statistically significant differences between deluded and normal subjects.

Conclusions. Abnormalities of cingulate gyrus activation while determining self-relevance suggest impaired self-reflection in the persecutory deluded state. This may contribute to persecutory belief formation and maintenance.

Background. There is a well-recognized association between substance use and psychotic disorders, sometimes described as ‘dual diagnosis’. The use of substances by people with psychosis has a negative impact in terms of symptoms, longitudinal course of illness and psychosocial adjustment. There are few validated treatments for such individuals, and those that do exist are usually impracticable in routine clinical settings. The present study employs a randomized controlled experimental design to examine the effectiveness of a manualized group-based intervention in helping patients with dual diagnosis reduce their substance use.

Method. The active intervention consisted of weekly 90-min sessions over 6 weeks. The manualized intervention was tailored to participants' stage of change and motivations for drug use. The control condition was a single educational session.

Results. Sixty-three subjects participated, of whom 58 (92%) completed a 3-month follow-up assessment of psychopathology, medication and substance use. Significant reductions in favour of the treatment condition were observed for psychopathology, chlorpromazine equivalent dose of antipsychotics, alcohol and illicit substance use, severity of dependence and hospitalization.

Conclusions. It is possible to reduce substance use in individuals with psychotic disorders, using a targeted group-based approach. This has important implications for clinicians who wish to improve the long-term outcome of their patients.

Background. Using the theoretical framework of the Self Regulation Model (SRM), many studies have demonstrated that beliefs individuals hold about their physical health problems are important in predicting health outcomes. This study tested the SRM in the context of a mental health problem, schizophrenia.

Method. One hundred and twenty-four people with a diagnosis of schizophrenia were assessed on measures of symptom severity, beliefs about their mental health problems, coping and appraisal of outcome at two time points, 6 months apart.

Results. Using multivariate analyses and controlling for severity of symptoms, beliefs about mental health were found to be significant predictors of outcome. Beliefs about greater negative consequences were the strongest and most consistent predictors of a poorer outcome in both cross-sectional and longitudinal analyses.

Conclusions. These results suggest that the SRM is a promising model for mental health problems and may highlight important areas for development in clinical, and especially psychosocial interventions.

Background. Since little is known about the long-term course and outcome of bulimia nervosa, the authors designed a 12-year prospective longitudinal study with five cross-sectional assessments based on a large sample of consecutively treated females with bulimia nervosa (purging type) (BN-P).

Method. One hundred and ninety-six females with BN-P were assessed (1) at the beginning of treatment, (2) at the end of treatment, (3) at 2-year follow-up, (4) at 6-year follow-up, and (5) at 12-year follow-up. In self-ratings as well as expert ratings based on interviews we assessed specific eating-disorder and general psychopathology.

Results. The general pattern of results over time showed substantial improvement during treatment, slight (in most cases non-significant) decline during the first two years after the end of treatment, and further improvement and stabilization until 12-year follow-up. At that point the majority of patients (70·1%) showed no major DSM-IV eating disorder, 13·2% had eating disorders not otherwise specified, 10·1% had BN-P and 2% had died. Very few had undergone transition to anorexia nervosa or binge-eating disorders. Logistic regression analyses showed that psychiatric co-morbidity was the best and most stable predictor for eating-disorder outcome at 2, 6 and 12 years.

Conclusions. Course and outcome of BN-P was generally more favourable than for anorexia nervosa.

Background. The co-occurrence of affective distress and back pain is well documented but the relationship between them is less certain. This study examines the relationship between lifetime occurrence of depressive disorder and incident back pain reported over a 13-year period.

Method. The Baltimore Epidemiologic Catchment Area Study is a prospective study of a household-residing cohort, selected probabilistically from East Baltimore in 1981. Between 1982–3 (wave 2) and again between 1993–6 (wave 3), a follow-up study of the original cohort was conducted. Questions on depressive disorder and back pain were drawn from the Diagnostic Interview Schedule. Logistic regression analyses were used to evaluate whether depressive disorder acts as a risk factor for incident back pain.

Results. In cross-sectional analyses, lifetime occurrence of depressive disorder was a significant correlate of lifetime prevalence of back pain at wave 1 (OR=1·6, P=0·01). During the 13-year follow-up, across three data collection points, there was an increase in the risk for incident back pain when depressive disorder was present at baseline (OR=1·9, 95% CI 1·03, 3·4). However, during the short-term follow-up period of 1 year, between baseline and wave 2, depressive disorder at baseline was unrelated to first-ever reports of back pain. Lifetime depressive disorder in both waves 1 (baseline) and 2 (1 year later) was associated with a more than three times greater risk for a first-ever report of back pain during the 12 to 13 year follow-up period, in comparison to those who did not have depressive disorder at waves 1 or 2 (OR=3·4, 95% CI 1·4, 7·8). Back pain at wave 1 was not significantly associated with an increased risk for depression in the longitudinal analysis (OR=0·8, 95% CI 0·5, 1·4).

Conclusions. Depressive disorder appears to be a risk factor for incident back pain independent of other characteristics often associated with back pain. Back pain is not a short-term consequence of depressive disorder but emerges over periods longer than 1 year. Moreover, in this study the alternative pathway of back pain as a risk factor for depressive disorder could not be supported.

Background. There are conflicting data regarding the socio-economic risk factors for bipolar disorders. The aim of the present study was to explore the association between the socio-economic status of an individual or the parent and the risk for bipolar disorder.

Method. Two Danish registers were merged. From the data source, we extracted those born in 1960 or later, and those with a first-ever admission to, or contact with, a Danish psychiatric facilities during 1981–1998 with a diagnosis of bipolar disorder. Fifty time-matched controls per case were chosen by the incidence-density sampling method. Effects of marital status, occupation, education, income, and wealth, of both subjects and the parents, were estimated using conditional logistic regression.

Results. A total of 947 cases were matched to 47 350 controls. Those at high risk of bipolar disorders were: single subjects, those in receipt of social assistance, pension or sickness payments, unemployed, subjects with a shorter educational history, and subjects with lower income. Conversely, parental higher education and higher level of paternal wealth were associated with increased risk. These associations remained significant after adjustment for gender, family history of psychiatric diagnoses, and other socio-economic variables, and are unlikely to be explained by known biases.

Conclusions. The associations of lower socio-economic indices of subjects may be explained as a consequence of the disease. The association of higher socio-economic indices of parents may be explained by socio-economic achievement in the family of origin.

Background. The present paper describes a component of a large population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive–compulsive disorder).

Method. Outcome was calculated as averted ‘years lived with disability’ (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997–8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs.

Results. Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at $400 million, resulting in a cost per YLD averted ranging from $7761 for generalized anxiety disorder to $34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to <$20 000 for all disorders.

Conclusions. Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.

Background. Patients frequently present with unexplained fatigue in primary care, but there have been few treatment trials in this context. We aimed to test cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for patients presenting to their family doctor with fatigue. Secondly, we described the outcome for a cohort of patients who presented to the same doctors with fatigue, who received standard care, plus a booklet.

Method. This was a randomized trial, followed by a prospective cohort study. Twenty-two practices in SE England referred 144 patients aged 16 to 75 years with over 3 months of unexplained fatigue. Self-rated fatigue score, the hospital anxiety and depression rating scale, functional impairment, physical step-test performance and causal attributions were measured. In the trial six sessions of CBT or GET were randomly allocated.

Results. In the therapy groups the mean fatigue score decreased by 10 points (95% confidence interval (CI)=−25 to −15), with no significant difference between groups (mean difference=−1·3; CI=−3·9 to 1·3). Fewer patients attended for GET. At outcome one-half of patients had clinically important fatigue in both randomized groups, but patients in the group offered CBT were less anxious. Twenty-seven per cent of the patients met criteria for CFS at baseline. Only 25% of this subgroup recovered, compared to 60% of the subgroup that did not meet criteria for CFS.

Conclusions. Short courses of GET were not superior to CBT for patients consulting with fatigue of over 3 months in primary care. CBT was easier ‘to sell’. Low recovery in the CFS subgroup suggests that brief treatment is too short.

Background. In order to investigate whether correlated but separable symptom dimensions that have been identified in clinical samples also have a distribution in the general population, the underlying structure of symptoms of depression, mania and psychosis was studied in a general population sample of 7072 individuals.

Method. Data were obtained from the three measurements of the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Symptoms of depression, mania and the positive symptoms of psychosis were assessed using the Composite International Diagnostic Interview. Confirmatory factor-analysis was used to test statistically the fit of hypothesized models of one, two, three or seven dimensions.

Results. The seven-dimensional model comprising core depression, sleep problems, suicidal thoughts, mania, paranoid delusions, first-rank delusions and hallucinations fitted the data best, whereas the unidimensional model obtained the poorest fit. This pattern of results could be replicated at both follow-up measurements. The results were similar for the subsamples with and without a lifetime DSM-III-R diagnosis. The seven dimensions were moderately to strongly correlated, with correlations ranging from 0·18 to 0·73 (mean 0·45).

Conclusions. In the general population, seven correlated but separable dimensions of experiences exist that resemble dimensions of psychopathology seen in clinical samples with severe mental illness. The substantial correlations between these dimensions in clinical and non-clinical samples may suggest that there is aetiological overlap between the different dimensions regardless of level of severity and diagnosable disorder.

Background. Recent reviews of randomized controlled trials have concluded that cognitive behaviour therapy (CBT) is effective, as an addition to standard care, in the treatment of people suffering from schizophrenia. Most of the trials have been conducted with stabilized out-patients. The aim of this trial was to evaluate the effectiveness of CBT for in-patients suffering acute psychotic episodes, when delivered under conditions representative of current clinical practice.

Method. Consecutive admissions meeting criteria were recruited. After screening, 43 were assigned at random to a treatment-as-usual (TAU) control group and 47 were assigned to TAU plus CBT. At baseline, 6 months and 12 months, patients were rated on symptoms and social functioning. CBT (maximum 25 sessions) began immediately after baseline assessment.

Results. The CBT group gained greater benefit than the TAU group on symptoms and social functioning. A larger proportion of the CBT group (60%) than the TAU group (40%) showed reliable and clinically important change, and none of them (v. 17%) showed reliable deterioration compared with baseline.

Conclusions. CBT for patients suffering acute psychotic episodes can produce significant benefits when provided under clinically representative conditions.

Background. Previous studies of personality characteristics in women with eating disorders primarily have focused on women who are acutely ill. This study compares personality characteristics among women who are ill with eating disorders, recovered from eating disorders, and those without eating or other Axis I disorder pathology.

Method. Female participants were assessed for personality characteristics using the Temperament and Character Inventory (TCI): 122 with anorexia nervosa (AN; 77 ill, 45 recovered), 279 with bulimia nervosa (BN; 194 ill, 85 recovered), 267 with lifetime histories of both anorexia and bulimia nervosa (AN+BN; 194 ill, 73 recovered), 63 with eating disorder not otherwise specified (EDNOS; 31 ill, 32 recovered), and 507 without eating or Axis I disorder pathology.

Results. Women ill with all types of eating disorders exhibited several TCI score differences from control women, particularly in the areas of novelty-seeking, harm avoidance, self-directedness, and cooperativeness. Interestingly, women recovered from eating disorders reported higher levels of harm avoidance and lower self-directedness and cooperativeness scores than did normal control women.

Conclusions. Women with eating disorders in both the ill and recovered state show higher levels of harm avoidance and lower self-directedness and cooperativeness scores than normal control women. Although findings suggest that disturbances may be trait-related and contribute to the disorders' pathogenesis, additional research with more representative community controls, rather than our pre-screened, normal controls, is needed to confirm these impressions.

Background. Chronic fatigue is a common condition, frequently presenting in primary care. The aim of this study was to compare the cost-effectiveness of cognitive behavioural therapy (CBT) and graded exercise therapy (GET), and to compare therapy with usual care plus a self-help booklet (BUC).

Method. Patients drawn from general practices in South East England were randomized to CBT or GET. The therapy groups were then compared to a group receiving BUC recruited after the randomized phase. The main outcome measure was clinically significant improvements in fatigue. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves.

Results. Costs were available for 132 patients, and cost-effectiveness results for 130. Costs were dominated by informal care. There were no significant outcome or cost differences between the therapy groups. The combined therapy group had significantly better outcomes than the standard care group, and costs that were on average £149 higher (a non-significant difference). Therapy would have an 81·9% chance of being cost-effective if society were willing to attach a value of around £500 to each four-point improvement in fatigue.

Conclusion. The cost-effectiveness of cognitive behavioural therapy and graded exercise were similar unless higher values were placed on outcomes, in which case CBT showed improved cost-effectiveness. The cost of providing therapy is higher than usual GP care plus a self-help booklet, but the outcome is better. The strength of this evidence is limited by the use of a non-randomized comparison. The cost-effectiveness of therapy depends on how much society values reductions in fatigue.

Background. The processing of facial emotion involves a distributed network of limbic and paralimbic brain structures. Many of these regions are also implicated in the pathophysiology of mood disorders. Behavioural data indicate that depressed subjects show a state-related positive recognition bias for faces displaying negative emotions. There are sparse data to suggest there may be an analogous, state-related negative recognition bias for negative emotions in mania. We used functional magnetic resonance imaging (fMRI) to investigate the behavioural and neurocognitive correlates of happy and sad facial affect recognition in patients with mania.

Method. Functional MRI and an explicit facial affect recognition task were used in a case-control design to measure brain activation and associated behavioural response to variable intensity of sad and happy facial expressions in 10 patients with bipolar I mania and 12 healthy comparison subjects.

Results. The patients with mania had attenuated subjective rating of the intensity of sad facial expressions, and associated attenuation of activation in the subgenual anterior cingulate and bilateral amygdala, with increased activation in the posterior cingulate and posterior insula. No behavioural or neurocognitive abnormalities were found in response to presentation of happy facial expressions.

Conclusions. Patients with mania showed a specific, mood-congruent, negative bias in sad facial affect recognition, which was associated with an abnormal profile of brain activation in paralimbic regions implicated in affect recognition and mood disorders. Functional imaging of facial emotion recognition may be a useful probe of cortical and subcortical abnormalities in mood disorders.

Background. The German National Health Interview and Examination Survey (GHS) is the first government mandated nationwide study to investigate jointly the prevalence of somatic and mental disorders within one study in the general adult population in Germany. This paper reports results from its Mental Health Supplement (GHS-MHS) on 4-week 12-month, and selected lifetime prevalence of a broad range of DSM-IV mental disorders, their co-morbidity and correlates in the community.

Methods. The sample of the GHS-MHS (n=4181; multistage stratified random sample drawn from population registries; conditional response rate: 87·6%) can be regarded as representative for the German population aged 18–65. Diagnoses are based on fully structured computer assisted clinical interviews (M-CIDI), conducted by clinically trained interviewers.

Results. 12-month prevalence for any DSM-IV study disorder is 31% (lifetime: 43%; 4-week: 20%) with anxiety disorders, mood disorders and somatoform syndromes being the most frequent diagnoses. Retrospective age of onset information reveals that most disorders begin early in life. Co-morbidity rates among mental disorders range from 44% to 94%. Correlates of increased rates of mental disorders and co-morbidity were: female gender (except for substance disorders), not being married, low social class, and poor somatic health status. Health care utilization for mental disorders depended on co-morbidity (30% in ‘pure’, 76% in highly co-morbid cases) and varied from 33% for substance use disorders to 75% for panic disorder.

Conclusions. Results confirm and extend results from other national studies using the same assessment instruments with regard to prevalence, co-morbidity and sociodemographic correlates, covering a broader range of DSM-IV disorders [i.e. somatoform disorders, all anxiety disorders (except PTSD), mental disorders due to substance or general medical factor, eating disorders]. Intervention rates were higher than in previous studies, yet still low overall.

Background. Mental disorders are associated with disability, but the long-term effects of low subjective well-being on work ability in general population are not known. In this study we investigated whether self-reported life dissatisfaction predicts work disability.

Method. A nationwide sample of Finnish twins aged 18–54 years (N=22 136), unselected for health status responded to a health questionnaire with a four-item life satisfaction scale (range 4–20) covering interest, happiness, easiness and loneliness of life in 1975 and 1981. Cox regression for all subjects and conditional logistic regression for discordant twin pairs were used to compare the risk of subsequent work disability (N=1200) (Nationwide Disability Register) between the dissatisfied and satisfied.

Results. Life dissatisfaction predicted subsequent (1977–87) work disability pension due to psychiatric and non-psychiatric causes among the healthy at baseline, and that due to psychiatric causes among the ill. After controlling for age, marital status, social class and health behaviour, these risks remained significant. Repeatedly reported (1975 and 1981) life dissatisfaction was strongly associated with increased (age-adjusted) risk of subsequent (1982–87) work disability due to psychiatric and also that due to non-psychiatric causes among the healthy. When twin pairs discordant for end-point disability status were analysed, risk differences related to life satisfaction were only slightly decreased, but they did not differ significantly between monozygotic and dizygotic pairs.

Conclusion. Life dissatisfaction predicts subsequent work disability especially among the healthy.