Background. The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups.

Method. A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin.

Results. Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups.

Conclusions. An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis.

Background. Previous studies suggest that separation is a major stressful life event that is linked with marked increases in depressive symptoms. Little is known, however, about the sources of variation in depressive symptoms following separation.

Method. This study examines factors moderating the effect of separation on depressive symptoms in women participating in the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective, longitudinal study of a large community sample in the west of England. Data on marital/partner status, depression, and hypothesized moderating factors were available on women (n=8264), assessed on two occasions approximately 12 months apart.

Results. Over this 1-year period, 2·7% of women experienced a separation. As expected, those who experienced a separation between assessment periods reported, on average, a significant increase in depressive symptoms, approximately 0·25 of a S.D. However, there were marked individual differences in response to separation, with 56·1% showing a increase of 0·5 S.D. or more and 21·0% showing an decrease of 0·5 S.D. or more in depressive symptoms following separation. Regression analyses identified several factors that moderated response to separation; specifically, the effect of separation on depressive symptoms was less for women who were in a cohabiting (non-marital) relationship and for women who experienced elevated marital conflict prior to separation.

Conclusion. The results underscore the wide variation in responses to separation and document the need to consider context in interpreting the effects of major life events on depressive symptoms.

Objective. In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total).

Method. Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the GAF, and comprehensive information about their sociodemographic and clinical status and care history were gathered.

Results. Of the 2962 patients living in the sampled facilities, most were males (63·2%) who had never married, more than 70% were over 40 years; 85% on a pension, most commonly because of psychiatric disability. A substantial proportion (39·8%) had never worked and very few were currently employed (2·5%); 45% of the sample was totally inactive, not even assisting with domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia; co-morbid or primary substance abuse were uncommon. Twenty-one per cent had a history of severe interpersonal violence, but violent episodes in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospects of discharge.

Conclusions. Italian RFs cater for a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should attempt to clarify how to match residential programmes with patients' disabilities.

Background. Demonstrating specific cognitive impairments in psychotic disorders is difficult. However, specific deficits in memory and executive functions have often been claimed. The Cambridge Neuropsychological Test Automated Battery (CANTAB) tasks of IDED attention-shifting (an executive task) and visuospatial paired associates learning (PAL, a memory task) require intact frontal and temporo-hippocampal functioning, respectively; both have been suggested as markers of disease progress in psychosis.

Method. Seventy-one subjects with a first-episode psychosis or at-risk mental state were assessed on these two tasks during referral to a specialist service, the Cambridge-based CAMEO early intervention team.

Results. Performance on the two tasks was dissociated. Poor performance on the PAL test was associated with increased symptom levels and poorer global function, while failure on the IDED executive test was not found to have significant clinical associations. Duration of illness was not associated with performance on either task.

Conclusions. Visuospatial PAL failure may be a marker of clinical severity at the onset of psychosis while IDED performance may reflect a more stable, trait-like impairment. Dissociated performance on the executive and associative learning tasks may reflect independent, neurally dissociated impairments that do not arise in a fixed order. This may explain some of the heterogeneity of cognitive function seen in early psychosis.

Background. To examine whether adolescent depressive symptoms predict young adult body mass index (BMI) and obesity in black and white women.

Method. Participants included 1554 black and white adolescent girls from the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS) who completed the Center for Epidemiological Studies – Depression Scale (CES-D) at ages 16 and 18 years.

Results. Regression analyses showed that depressive symptoms at both ages 16 and 18 were associated with increased risk of obesity (BMI[ges ]30) and elevated BMI in young adulthood (age 21) in both black and white girls. Black girls exhibited a significantly greater likelihood of obesity and higher BMI (i.e. a main effect of race), but the race×CES-D interaction was not significant in any analysis.

Conclusions. Depressive symptoms in adolescence appear to be predictive of obesity and elevated BMI in early adulthood for both black and white girls, even when taking prior BMI into account, indicating that depressive symptoms confer risk for obesity above and beyond the known tracking of body weight. Obesity prevention studies might consider assessing depressive symptoms in adolescence in order to more fully capture important risk variables.

Background. There are suggestions that mortality, especially that due to suicide, increases among schizophrenia patients during a period of declining psychiatric beds. We investigated the mortality of schizophrenia patients in the general population of Finland during the reduction of psychiatric beds during 1980–1996.

Method. Patients hospitalized for schizophrenia before 31 December 1996, and alive on 1 January 1980 (n=58761) were identified via the National Hospital Discharge Register. General population data came from the National Population Register, and mortality data from the National Causes of Death Register. We calculated relative risks (RR) for total mortality, mortality due to natural causes (cancer, ischaemic heart disease, respiratory disease), unnatural causes (accident, homicide, suicide), and suicide.

Results. Patients with schizophrenia had an increased mortality both from natural causes (RR 2·59, 95% CI 2·55–2·63) and from suicide (RR 9·9, 95% CI 9·43–10·30). The RR for both natural and unnatural deaths was highest among patients with <5 years since onset of schizophrenia. Among them all-cause mortality rose in the 1990s, but decreased among patients with >10 years from onset. Otherwise no major changes or linear trends were found in mortality during deinstitutionalization.

Conclusions. Reduction of psychiatric beds did not generally increase the mortality of patients with schizophrenia. However, patients in their early years of illness experienced increased mortality after the steepest bed reduction. Improved recognition and treatment of somatic illness would benefit patients with schizophrenia.

Background. This study examines whether community treatment orders (CTOs) reduce psychiatric admission rates or bed-days for patients from Western Australia compared to control patients from a jurisdiction without this legislation (Nova Scotia).

Method. A population-based record linkage analysis of an inception cohort using a two-stage design of matching and multivariate analyses to control for sociodemographics, clinical features and psychiatric history. All discharges from in-patient psychiatric services in Western Australia and Nova Scotia were included covering a population of 2·6 million people. Patients on CTOs in the first year of implementation in Western Australia were compared with controls from Nova Scotia matched on date of discharge from in-patient care, demographics, diagnosis and past in-patient psychiatric history. We analysed time to admission using Cox regression analyses and number of bed-days using logistic regression.

Results. We matched 196 CTO cases with an equal number of controls. On survival analyses, CTO cases had a significantly greater readmission rate. Co-morbid personality disorder and previous psychiatric history were also associated with readmission. However, on logistic regression, patients on CTOs spent less time in hospital in the following year, with reduced in-patient stays of over 100 days.

Conclusions. Although compulsory community treatment does not reduce hospital admission rates, increased surveillance of patients on CTOs may lead to earlier intervention such as admission, so reducing length of hospital stay. However, we do not know if it is the intensity of treatment, or its compulsory nature, that effects outcome.

Background. Like individuals exposed to other life stressors, patients undergoing organ transplantation typically show elevated psychological distress initially post-transplant, with improvement thereafter. However, this ‘average’ pattern may conceal subgroups with differing profiles of psychological response. We sought to identify unique temporal distress profiles, and their predictors, after heart transplantation.

Method. A total of 156 transplant recipients (refusal rate, 6%) were enrolled and assessed at 2, 7, 12, 36, and 42 months post-transplant. Cluster analysis was used to identify distinct distress profiles over time. Multivariate analyses examined health and psychosocial predictors of the profiles.

Results. Five groups were identified, with either: (a) low distress at all time-points (45% of the sample), (b) high, clinically significant distress at all times (21%), (c) high distress over several years with low distress only at final assessment (12%), (d) high distress during the first several months with decline thereafter (6%), or (e) fluctuating distress levels (16%). Patients showing any distress (versus none) were more likely to have a pre-transplant psychiatric history, poorer social supports and more physical impairment early post-transplant, and continued physical impairment over time. Among distressed patients, those with persistent (versus declining) distress were most likely to be female, waited more briefly for transplant, and were most physically impaired early post-transplant. While persistently distressed patients had better social supports early post-transplant, these supports subsequently worsened.

Conclusions. Individuals differ in whether and when psychological distress abates after heart transplantation. Findings regarding distress profiles and their predictors may inform the design of interventions to address each transplant recipient's unique psychological needs.

Background. Subjective quality of life has gained a crucial role as a global measure of outcome in mental health care. This study aimed to investigate the impact of meeting needs for care, as assessed by both patients and mental health professionals, to improve the subjective quality of life in a sample of patients receiving community-based psychiatric care.

Method. The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community-based Mental Health Service (CMHS) was assessed at baseline and follow-up using, among other social and clinical measures, the Camberwell Assessment of Need (both staff and patient versions) and the Lancashire Quality of Life Profile. Predictors of changes of subjective quality of life were explored using block-stratified multiple regression procedures.

Results. Improvement in patients' clinical conditions as well as the reduction in patient-rated unmet needs in the social domain predicted an increase in subjective quality of life over 4 years; changes in staff-rated needs did not show any association with changes in subjective quality of life.

Conclusions. Meeting self-perceived social needs, beyond symptoms reduction, seems to be of particular importance for ensuring a better quality of life for people with mental disorders. If the main goal of mental health care is to improve the quality of life of users, a policy of actively addressing patient-rated needs should be implemented.

Background. The aim of this study was to design a self-report measure of behavioural responses during the acute phase of an illness, in order to assess the importance of these behaviours in the development of ongoing medically unexplained syndromes.

Method. An initial pool of items derived from theoretical models and clinical observation, was piloted on a group of 312 university students to assess the factor structure of the scale and the best fit items. The scale was further validated in a second study of 758 patients who were experiencing Campylobacter gastroenteritis. At 3 months post-infection, patients were sent a second questionnaire assessing symptoms of irritable bowel syndrome (IBS).

Results. Principal components analysis of the items in the student sample yielded a four-factor solution, labelled all-or-nothing behaviour, limiting behaviour, emotional support seeking and practical support seeking. The factor structure was confirmed in the Campylobacter sample, and internal reliability was good. All-or-nothing behaviour was associated with IBS at 3 months post-infection. In contrast, limiting behaviour and practical support seeking at the time of infection appeared to be protective.

Conclusion. The results suggest that this is a valid and reliable measure that can predict the development of a medically unexplained syndrome after acute infection. Overdoing things at the time of infection and then needing to rest for prolonged periods (all-or-nothing behaviour), appears to be a particular risk factor for the development of IBS. Targeted interventions at the time of infection may improve coping and prevent symptoms from becoming chronic.

Background. Schizophrenia is associated with perceptual organization deficits and abnormal neuronal connectivity has been described in early visual areas. The purpose of this study was to investigate the functional integrity of lateral connections in early visual areas of patients with schizophrenia and type I bipolar disorder with a history of psychosis.

Method. Twenty-four out-patients with schizophrenia, 22 out-patients with bipolar disorder, and 20 healthy control subjects participated in the study. Using a computer-assisted psychophysical test, contrast thresholds were measured for centrally presented target stimuli (Gabor patches), which were surrounded by two collinear flankers. Target-to-flanker distances were 0, 1, 2, 3, 4, 6, 9 and 12λ. Psychophysical measures were contrast threshold changes at each target-to-flanker distance compared with baseline thresholds determined for isolated targets with no flankers. Clinical measures included IQ, positive, negative, and depressive symptoms.

Results. In patients with schizophrenia, flankers did not facilitate contrast detection for target stimuli at 2–6λ distances compared to controls [effect size (Cohen's d): 1·25–1·42]. The inhibitory effect of flankers (0 and 1λ) and contrast thresholds in the absence of flankers were spared. Patients with bipolar disorder did not differ from the controls. Medicated and non-medicated patients displayed similar performances. Positive and negative symptoms and depression did not correlate with contrast threshold values.

Conclusions. Excitatory lateral connections in early visual cortex are specifically impaired in patients with schizophrenia, which may contribute to perceptual disorders such as unclear seeing, partial or skewed sight, disrupted rectilinearity, and abnormal figure-ground segregation.

Background. Little is known about the long-term outcome of personality disorder traits. The purpose of this study was to investigate, in a community-residing population, the longitudinal relationship between psychiatrist-assessed personality disorder scores and global functioning 13–18 years later.

Method. A stratified random sample of residents of east Baltimore were examined by psychiatrists in 1981 and asssessed for DSM-III personality disorders using a semi-structured instrument, the Standardized Psychiatric Examination. A total of 292 persons were re-examined by different psychiatrists during 1994–1999 using the Schedules for the Assessment of Neuropsychiatry (SCAN). After completion of the SCAN, the subjects' functional status was evaluated using the Global Assessment of Functioning (GAF). The relationships between personality dimensions and follow-up GAF scores were evaluated using linear regression models.

Results. All of the personality disorder scales measured in 1981 were inversely related to functioning 13–18 years later, with the exception of narcissistic and compulsive scales. After controlling for Axis I disorders diagnosed contemporaneously with GAF assessment, schizoid, antisocial, borderline, histrionic, and avoidant personality disorder scores significantly predicted GAF scores.

Conclusions. Most dimensions of DSM-III personality disorder traits were significantly associated with global functioning after an interval of 15 years. However, only schizoid, antisocial, borderline, histrionic, and avoidant personality disorder traits had long-term effects on functioning when Axis I disorders at follow-up were controlled. This suggests that the functional effect of the other personality disorder traits may be mediated through their relationship with Axis I disorders. Future research is needed using more specific and sensitive outcome measures.

Background. Research on risk factors for burnout has mainly focused on circumstances at work and on personal characteristics. The aim of this study was to investigate whether burnout clusters within families and, if so, whether this is due to genetic influences or to environmental factors shared by family members. Finally, we tried to identify specific risk factors for burnout.

Method. In 2707 twins, 736 of their siblings and 575 of their spouses from a population-based twin-family sample, burnout was measured using a self-report questionnaire. Correlations in burnout scores were obtained for monozygotic and dizygotic twin pairs and sibling pairs conditional on the pairs' sex. Correlations for twins and their spouses were derived conditional on the length of the relationship.

Results. In the final model, correlations of the monozygotic and dizygotic twin pairs and sibling pairs were significantly different from zero, but not significantly different from each other. The correlation was estimated at 0·22. The correlation between spouses was also significant. This was mainly due to the group with a relationship longer than 5 years in which the correlation was 0·24. Burnout scores were higher in subjects whose parents had a high level of education.

Conclusions. There is familial clustering for burnout due to environmental factors shared by family members, explaining 22% of the variance. Genetic factors do not seem to be of importance. The significant correlation between spouses supports the conclusion that common environment plays a role in burnout. A high parental education is one of the familial risk factors.

Background. We present results of a study of treated rates of schizophrenia among the Iban of Sarawak, Malaysia. Most Iban live in longhouses, each comprising a kindred group of up to 300 individuals. Cultural practices such as minimal intermarriage with members of adjacent ethnic groups and in-depth genealogical knowledge make them a population suitable for genetic investigation. Iban culture is conducive to a focus on symptoms and illness, and to patterns of treatment-seeking behaviour that are enthusiastic and persistent.

Method. We identified all known cases of psychotic disorder within a defined catchment area based on an exhaustive survey of available medical records. From corresponding Malaysian census data (91056 persons), we report rates of treated schizophrenia in the Iban population, using three diagnostic systems, as well as the demographic and clinical characteristics of these individuals.

Results. The most frequent presenting complaints were insomnia and aggression. We found higher treated rates for narrowly defined schizophrenia among males, but no significant gender difference for age of onset. Estimates of treated rates to age 55 years (per 10000) for narrow schizophrenia were 41·9 (ICD-10), 56·5 (DSM-IV), and 83 (RDC), while the rates for broad schizophrenia were 105·5, 103·2, and 107·5 respectively.

Conclusions. Treated rates of schizophrenia were higher than the reported prevalence for many populations at risk, including many small-scale societies, although different methodological approaches may partly explain these findings. Given the cultural patterns of Iban treatment-seeking behaviour, treated rates of schizophrenia reported here may closely approximate the population prevalence of this disorder.

Background. The vegetative symptoms of depression resemble the symptoms of malaise associated with activation of the inflammatory response system (IRS), and can be regarded as an expression of a central motivational state that resets the organism's priorities to promote recovery from infection. Early vegetative symptoms, however, may also contribute to the high rates of depression seen later in the course of immune activation. We hypothesized that the onset of vegetative-depressive symptoms early in the treatment with the pro-inflammatory cytokine IFN-α in chronic hepatitis C patients would increase the risk for subsequent depressive cognitions.

Method. Sixteen patients eligible for IFN-α treatment and free of psychiatric disorders were recruited. The DSM-IV, the Multidimensional Fatigue Inventory, and the Montgomery–Asberg Depression Rating Scale (MADRS) were administered at baseline and 1, 2, 4, 8, 12 and 24 weeks after treatment was initiated. Cognitive-depressive and vegetative-depressive symptom clusters were constructed.

Results. Fatigue and depression scores increased significantly during IFN-α treatment. Depression scores were highest at week 8 of treatment. First week increase in vegetative-depressive symptom score predicted cognitive-depressive symptom score at week 8 and at week 24.

Conclusions. During IFN-α treatment, vegetative symptoms of depression appear earlier than, and are predictive of, their cognitive counterparts. This finding suggests that low mood state may in part be driven by the increase in early vegetative-depressive symptoms in the course of IFN-α-induced immune activation.

Background. Studies about the effect of time on the degree of psychological distress among immigrants have reported conflicting findings. We investigated this issue in Israel, which supports actively the absorption of immigrants, and also looked for risk and protective factors for psychological distress 5 years post-immigration.

Method. A nationwide sample of 600 subjects who emigrated from the former Soviet Union to Israel in 1990 were interviewed in 1995, with the demoralization subscale of the Psychiatric Epidemiologic Research Interview (PERI-D) for psychological distress, and with a series of questions regarding sociodemographic characteristics, personal assets and their absorption experience. The results were compared with those obtained in a previous study for a sample of the same cohort of immigrants in their first year post-immigration. A multivariate analysis was carried out to examine the relation between the PERI score and the different independent variables.

Results. Although, 5 years after immigration, a favorable change in objective parameters of absorption was found, no decrease in psychological distress was observed. The main risk factors remaining significantly associated with psychological distress in the final model were: adverse life events, lack of perceived social support, poor family functioning, external locus of control, poor physical health status, non-identification with host society and, to a lesser degree, poor material conditions.

Conclusion. Psychological readjustment apparently takes longer than other processes of adaptation. Several years after immigration, social and psychological factors have a more important role for the well-being of immigrants than their material conditions.

Background. While there are many studies showing working-memory deficits in schizophrenia there are only a few that disentangle impairments for working-memory subprocesses such as perceptual, attentional, mnemonic and executive function.

Method. In this study of delay-dependent memory, 55 patients with schizophreniform psychosis, 50 with established schizophrenia and 56 healthy controls were investigated. Using the delayed matching-to-sample task from the Cambridge Neuropsychological Test Automated Battery (CANTAB), performance deficits were found in both patient groups after controlling for age and pre-morbid IQ.

Results. Even after controlling for simultaneous matching-to-sample ability (i.e. perceptual matching), impaired performance in both patient groups was found as soon as the stimuli were no longer present. Impaired performance was not due to different types of errors in patients versus controls. Performance in both patient groups was comparable, except for a slight decrease of overall task performance. This suggests that the deficit is relatively stable during the course of the illness.

Conclusions. Our results suggest a deficit in patients with psychotic illness in the initial processes necessary to actively maintain information, such as the ability to form an internal representation of complex objects.

Background. Although parents with psychiatric disorders are likely to have children with psychiatric problems, the nature of disorder risk to offspring of antisocial parents has received limited attention.

Method. We examined the prevalence of common externalizing and internalizing disorders in the pre-adolescent and late adolescent offspring of antisocial parents. Lifetime diagnoses for a sample of 11-year-old twins (958 males, 1042 females) and a sample of 17-year-old twins (1332 males, 1434 females), as well as their parents, were obtained through in-person interviews. Odds ratios were calculated for the effect of the parent's diagnosis on the child's diagnosis, controlling for the effect of the co-parent's diagnosis.

Results. We found that parental antisociality places the child at increased risk for developing a range of externalizing and internalizing disorders. This increase is evident by pre-adolescence and extends to a wide range of disorders by late adolescence. Each parent has an effect net any effects of the co-parent.

Conclusions. Antisocial parents have children who have an increased likelihood of developing a broad range of psychiatric disorders.

Background. Several lines of evidence indicate a role of the brain-derived neurotrophic factor (BDNF) in the modulation of eating behaviour. Therefore, alterations in the physiology of this neurotrophin may be involved in the pathogenesis of eating disorders. In the present study, we investigated serum levels of BDNF in patients with anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED).

Method. Ninety-nine drug-free women (27 with AN, 24 with BN, 24 with BED and 24 healthy controls) underwent both a blood sample collection in the morning and diagnostic and psychopathological assessments by means of structured clinical interviews and ad-hoc rating scales. Serum levels of BDNF, 17β-oestradiol, FT3 and FT4 were measured.

Results. Compared to healthy controls, serum levels of BDNF were significantly reduced in underweight AN women and in normal weight BN women, but not in overweight BED women. Changes in circulating BDNF levels were not affected by the presence of co-morbid depressive disorders. No significant correlation emerged between neurotrophin concentrations and psychopathological, nutritional, demographic and hormonal variables.

Conclusions. These findings evidentiate alterations in serum BDNF levels in malnourished patients with AN or BN, but not in well-nourished individuals with BED. Since BDNF seems to exert a satiety effect, its reduction may represent an adaptive change to counteract the decreased calorie ingestion of AN and BN individuals.

Background. Belief that depression and other psychological factors predict breast cancer is common, but there have been few prospective epidemiological studies on this relationship.

Method. The relationship between depression, personality traits, illness attitudes, life events and health history, and breast cancer risk was studied in a prospective, 6–9 year follow-up of a cohort study of 10892 Finnish women of 48–50 years of age at the baseline. Cancer cases were obtained from the Cancer Registry of Finland. Multivariate logistic regression analysis was performed controlling for socioeconomic factors, family history of cancer, parity, and health behaviours.

Results. Breast cancer incidence in the cohort was 1·15 times the average in age group 50–59. There was no evidence of depression, trait anxiety, cynical distrust, or coping being significant predictors of breast cancer incidence.

Conclusion. In this cohort study with the 6–9 year follow-up, psychological factors such as depression, trait anxiety, cynical distrust, or coping did not increase breast cancer risk.