Consensus has been achieved about how depression should be treated in primary care, and guidelines have been issued by the Royal Colleges of General Practitioners and Psychiatrists, and by the British Association for Psychopharmacology. One of the principal recommendations is to prescribe antidepressant medicine at effective doses. This study was established to investigate how current prescribing practices in primary care compared with these guidelines.

Information on prescribing of antidepressant medicines was obtained using three independent data sources: Prescribing Analysis and Cost (PACT) data; medical notes; and a large, computerised patient record database.

Data were obtained on populations in excess of 1.5 million people, and over 80 000 prescriptions were reviewed. All three data sources showed very similar patterns of prescribing, in particular that as many as 88% of prescriptions for older tricyclic antidepressants are prescribed by GPs at doses below those recommended by the consensus guidelines. Newer antidepressants – lofepramine and the SSRIs – are prescribed comparatively well.

Prescribing of antidepressants by GPs is not in line with the consensus recommendations on dosage. This may have major educational implications for GPs. A pragmatic approach to improve prescribing in the short term may be to advocate the use of lofepramine or the SSRIs as first line treatment for depression. This study validates the use of PACT data as a useful audit tool in this area of clinical practice.

Little data are available about the course or incidence of depression in dementia sufferers.

Monthly follow-up data over one year is reported regarding depression in a cohort of 124 dementia sufferers. Dementia was diagnosed according to DSM–III–R criteria. Depression was assessed with the Cornell Depression Scale and diagnosed according to RDC criteria. Cognitive functioning was assessed with the CAMCOG.

Eighty-nine of the 124 patients completed the follow-up. The annual incidence rates of RDC major depression and RDC minor depression were 10.6% and 29.8%, respectively. Twenty per cent of patients with depression experienced these symptoms for six months or longer. Patients with vascular dementia were significantly more likely to experience three or more months of depression than patients with other dementias. RDC minor depression was highly persistent among 23.8% of sufferers.

Depression is persistent in patients with vascular dementia. Some patients with minor depression have a dysthymia-like disorder.

The context memory deficit hypothesis of schizophrenia postulates that the long-term deficit associated with this disorder is related to a memory impairment for contextual information.

To test this hypothesis, memory for temporal context was assessed in 33 patients with schizophrenia and 33 normal subjects, using a recency discrimination task.

Whereas patients were able to recall and recognise target items, they were unable to recognise from among the target items those which had been most recently learned.

Schizophrenia is associated with a temporal context memory deficit.

The aim is to examine, in first episodes of schizophrenia the appropriateness of the simple two-dimensional model of schizophrenia (‘negative’ and ‘positive’ dimensions) and more complex variants.

All patients with a first episode of schizophrenia who, over a two-year period, made contact with any of the public mental health services of the autonomous region of Cantabria in northern Spain were investigated. The psychiatric evaluation included, among other instruments, the Present State Examination (PSE–9), and the scales for the assessment of the ‘positive’ and ‘negative’ symptoms of schizophrenia (SAPS and SANS respectively). The dimensionality of the SAPS/SANS item scores and sub-scales was examined through the use of principal component analysis.

The principal component solution that best fits the data obtained with the initial SANS/SAPS sub-scales reflects the existence of three different (‘negative’ ‘positive’, ‘disorganisation’) factors. The strategy adopted of repeating the analysis after extracting the principal components of the original sub-scales, revealed that although the nature and item composition of the initial ‘negative’ and ‘disorganisation’ factors were in general confirmed, the ‘positive’ dimension presented a more complex structure with at least two ‘positive’ (‘Non-Paranoid’ and ‘Paranoid’) independent factors.

The psychopathological structure of the early stages of schizophrenia, as evaluated by the SANS/SAPS, is characterised by the presence of four dimensions: two ‘positive’, one ‘negative’ and one ‘disorganisation‘.

There have been many reports of a higher incidence of ‘obstetric complications’ in the histories of schizophrenics than of controls, but because of the methodological shortcomings of most of these comparisons the relationship remains controversial.

Comprehensive records covering all psychiatric hospital admissions and all hospital deliveries in Scotland since 1971 made it possible to identify the obstetric records of people born in 1971–74 who were subsequently admitted to hospital with a diagnosis of schizophrenia, and then to compare their standardised obstetric records with those of closely matched controls.

One hundred and fifteen schizophrenic/control pairs were compared. The former showed a highly significant (P < 0.001) excess of complications of both pregnancy and delivery. In particular, there was a significant excess of pre-eclampsia (10 v. 2) and of infants detained in hospital for neonatal care (18 v. 6).

The raised incidence of obstetric complications often reported in people with schizophrenia is genuine and probably contributes to the aetiology of the condition.

There is a lack of clear and explicit models of the way various family and social influences on children's behaviour interact with factors such as temperament to produce behaviour disturbance in young children.

The following measures had been obtained on a total population sample of 1047 families with a 3-year-old child: the child's perceived cuddliness, difficult temperament, mother's unhappy childhood, maternal disturbance, social class, behaviour problems and overactivity. A latent variable analysis using the LISREL 7 program was applied to the data.

A model that allowed the latent variables child ‘temperament’ and ‘mother's mental state’ to have separate additive effects on ‘child adaptation’ proved an excellent fit (goodness of fit index = 0.956). This model suggests that there is a common factor (‘child adaptation’) underlying behaviour problems and overactivity. Using this model 72% of child adaptation in boys could be explained. For girls however temperament and mother's mental state accounted for only 30% of the variance in child adaptation.

There is a need to investigate different mechanisms for the origins of behaviour problems in preschool boys and girls.

Controversy surrounds the relationship between tardive dyskinesia (TD) and symptoms of schizophrenia. While some studies reported that negative symptoms of schizophrenia may be a risk factor for TD, others reported a relationship between TD and positive symptoms.

Eighty-four patients were studied, of whom 47 met criteria for TD. Clinical and instrumental procedures were used to increase the sensitivity of our assessments of the presence and severity of TD. Stepwise logistic and linear regression procedures were used to identify demographic variables, psychopathology, and motor parameters associated with the presence and severity of TD.

A 3-factor model consisting of age, clinical tremor, and negative symptoms explained 25% of the variance in clinical TD severity. A 6-factor model consisting of female gender, instrumental and clinical measures of parkinsonism, positive, and negative symptoms explained 49% of the variance in severity of instrumentally derived dyskinesia.

These results suggest that the presence of TD may be associated with positive symptoms; that the severity of TD may be related to negative symptoms; and that the relationship between negative symptoms and TD severity may be influenced by the presence of parkinsonism.

This study explored the prevalence of social phobia (SP) in general health care, sociodemographic characteristics of patients with SP, the age at onset and severity of SP, its comorbidity with other psychiatric disorders, and the recognition by general practitioners.

The study was conducted in Paris as part of the WHO study on Psychological Problems in General Health Care. Among 2096 consecutive primary care patients, 405 were interviewed using the CIDI. DSM–III–R diagnoses, severity and disability were assessed.

The one-month prevalence of SP is high (4.9) in primary care, although underdiagnosed by GPs. It has an early onset and leads to substantial disability. Patients with SP are at risk of developing further depression, alcoholism or suicidal behaviour.

SP appears to be a true and frequently severe pathological condition. The awareness of GPs and the general population should be improved.

This confirmatory investigation examined the underlying structure of schizophrenia phenomenology through examination of the fit of several prominent dimensional models to observed symptom data.

Confirmatory factor analysis was conducted on a correlation matrix of schizophrenia signs and symptoms derived from case history ratings of 192 individuals with schizophrenia who were the subjects in the major twin studies of schizophrenia.

Schizophrenia phenomenology appears best described by four underlying factors, namely negative symptoms, premorbid social adjustment deficits, reality distortion, and disorganisation. Of interest, the premorbid deficit dimension was directly associated with negative symptoms and disorganisation, but was inversely associated with reality distortion.

These data clearly support the multidimensionality of schizophrenia phenomenology and provide objective support for a four-factor model over other models. This four-factor model may be useful in organising existing and future data concerning the genetic, neurobiological, neurological, and psychosocial features of schizophrenia.

A complementary approach to defining symptomatic subtypes of schizophrenia is to identify characteristic patterns of ‘problem behaviours’ associated with the capacity of patients to function in the community.

In a large epidemiological survey, patients fulfilling Feighner criteria for schizophrenia were identified by key informants and assessed using the MRC Social Behaviour Schedule (SBS) and the Manchester Scale. An exploratory factor analysis was used to extract behavioural syndromes from the SBS data in order to compare the syndrome profiles in community, acute and long-stay subgroups and to examine their associations with symptoms and social functioning.

Four behavioural syndromes were identified: Thought disturbance, ‘Social withdrawal’, ‘Depressed behaviour’ and ‘Anti-social behaviour’, which distinguished between the patient subgroups and had significant differential relationships to symptoms and social functioning variables.

The evaluation of disability in schizophrenia and effectiveness of treatment interventions is incomplete without an assessment of problem behaviours.

The Adolescent to Adult Personality Functioning Assessment (ADAPFA) a modification of the Adult Personality Functioning Assessment (APFA) is described. It may be used to assess specific and general social dysfunction in the transition from childhood to adult life.

Two raters independently rated 38 audiotaped interviews to test the interrater reliability of the instrument. The relationship between dysfunction in specific domains and overall psychosocial dysfunction was examined.

Interrater reliabilities for the total ADAPFA score and for the majority of the domains were high. Agreement on type of dysfunction and on categorical ratings indicating the presence of personality disorder were good.

The ADAPFA is a useful measure of interpersonal and social role performance in the transition between adolescent and adult life.

Despite the problems involved in treating depression and concomitant medical disease, there are virtually no longitudinal studies on drug utilisation among depressed patients.

Use of prescription drugs among all first-time users of antidepressants in a defined population five years before and six years after the index (first) treatment was compared to a referent group without antidepressant treatment. The generalised estimating equations (GEE) method was used for analysis.

The antidepressant-treated group used considerably more non-psychotropic drugs during the whole study period than the referent group. They also used more psychotropic drugs, a use which increased in connection with the initiation of antidepressant treatment and stayed high for a further five years.

The high use of prescription drugs indicated widespread somatic and psychiatric health problems during the whole study period. Antidepressant-treated patients are at risk for drug interactions and adverse effects, and would benefit from a closer collaboration between psychiatry and medicine.

It is widely believed that people in remote areas of the world suffer less emotional distress and fewer psychiatric disorders. Previous studies offer contradictory evidence.

First stage screening of two mountain villages in Chitral used the Bradford Somatic Inventory (BSI). Psychiatric interviews were conducted with stratified samples using the ICD–10 Diagnostic Criteria for Research.

The BSI was an effective screening test, with sensitivity of 80% and specificity of 77%. At a conservative estimate, 46% of women and 15% of men suffered from anxiety and depressive disorders. Literate subjects had lower levels of emotional distress than the illiterate. Higher socio-economic status was associated with less emotional distress. Members of joint and nuclear families were similar.

The study offers no support for the belief that people who live in Chitral lead stress-free lives or have low rates of psychiatric morbidity. Women may suffer more anxiety and depressive disorders than in Western societies.

Various problems are associated with schizophrenia which may theoretically lead to impaired educability about treatment.

The Understanding of Medication Questionnaire, designed to measure knowledge about treatment in schizophrenia, is described and presented. An educational programme based on a specially designed information booklet was developed. Sixty-four patients with DSM–III–R diagnosis schizophrenia were randomly allocated to groups receiving none (control), one session or three sessions of education.

Pre-intervention low levels of knowledge about illness and treatment increased significantly immediately after a standard education session. Three education sessions led to significantly greater knowledge gain than one session. There was no significant change in the control group. Only the PANSS negative syndrome score independently and consistently explained a significant proportion of the education effect. The influence on educability of attitudes to education, impaired insight, cognitive impairment and other variables were considered. Three sessions of education led to significantly increased insight, but no change in compliance.

Techniques appropriate for educating schizophrenic patients were discussed, and the value of involving patients in education emphasised. A series of patient education sessions is needed to consolidate learning, rather than a single informing process. The strong association between impaired learning and more severe negative schizophrenic syndrome emphasises the need for responsible prescribing of antipsychotic treatment in schizophrenia.

We investigated whether antagonism of α2 adrenergic receptors would augment treatment response in schizophrenia, by administering idazoxan, an α2 antagonist drug, to treatment-resistant patients on typical neuroleptics.

Seventeen hospitalised treatment-resistant patients with DSM–III–R schizophrenia or schizoaffective disorder were studied on typical neuroleptic treatment, on treatment with idazoxan plus typical neuroleptic, and after discontinuation of idazoxan, in fixed, non-random order, and under double-blind, placebo-controlled conditions.

The addition of idazoxan to fluphenazine treatment resulted in significant reductions of global psychosis and total, positive and negative symptoms on the Brief Psychiatric Rating Scale, compared to neuroleptic treatment alone. Symptom improvement significantly correlated with idazoxan-induced changes in indices of noradrenergic function. In a subgroup of patients, idazoxan plus typical neuroleptic treatment compared favourably with clozapine treatment, when both were compared to typical neuroleptic treatment alone.

The antagonism of α2 receptors augmented therapeutic response to typical neuroleptic treatment in treatment-resistant patients with schizophrenia. This antagonism may contribute to clozapine's superior antipsychotic effects.