The European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study aims to produce standardised versions in five European languages of instruments measuring needs for care, family or caregiving burden, satisfaction with services, quality of life, and sociodemographic and service receipt.

To describe background, rationale and design of the reliability study, focusing on reliable instruments, reliability testing theory, a general reliability testing procedure and sample size requirements.

A strict protocol was developed, consisting of definitions of the specific reliability measures used, the statistical methods used to assess these reliability coefficients, the development of statistical programmes to make inter-centre reliability comparisons, criteria for good reliability, and a general format for the reliability analysis.

The reliability analyses are based on classical test theory. Reliability measures used are Cronbach's α, Cohen's κ and the intraclass correlation coefficient. Intersite comparisons were extended with a comparison of the standard error of measurement. Criteria for good reliability may need to be adapted for this type of study. The consequences of low reliability, and reliability differing between sites, must be considered before pooling data.

In international research on the consequences of psychiatric illnesses for relatives of patients, the need for an internationally standardised measure has been identified.

To test the internal consistency and the test-retest reliability of the Involvement Evaluation Questionnaire (IEQ) in five European countries.

The IEQ was administered twice to a sample of relatives or friends of patients with an ICD-10 diagnosis of schizophrenia. Reliability was tested using Cronbach's α, intraclass correlation coefficients and standard error of measurement. Reliability estimates were tested between sites.

Test sample sizes ranged from 30 to 90 across sites, and retest sample sizes ranged from 21 to 77. Cronbach's α values of IEQ sub-scales and sumscore were substantial at most sites; but at two, α values were moderate. Intraclass correlation coefficients were substantial to high at all sites. The standard errors of measurement differed across sites, indicating differences in performance.

The reliability of the IEQ in five languages varies across sites, but is sufficiently high in at least four out of five.

Since their introduction as diagnostic criteria by Schneider in 1937, nuclear symptoms have played a key role in concepts of schizophrenia, but their relationship to each other and to genetic predisposition has been unclear.

To ascertain the factor structure and familiality of nuclear symptoms.

Nuclear (Schneiderian) symptoms were extracted from case notes and interviews in a study of 103 sibling pairs with DSM–III–R schizophrenia or schizoaffective disorder.

Principal components analysis demonstrated two major factors: one, accounting for about 50% of the variance, groups thought withdrawal, insertion and broadcasting, with delusions of control; and the second, accounting for <20% of the variance, groups together third-person voices, thought echo and running commentary. Factor I was significantly correlated within sibling pairs.

The correlation within sibling pairs suggests that, contrary to the conclusion of some previous studies, some nuclear symptoms do show a degree of familiality and therefore perhaps heritability.

Violence risk prediction is a priority issue for clinicians working with mentally disordered offenders.

To review the current status of violence risk prediction research.

Literature search (Medline). Key words: violence, risk prediction, mental disorder.

Systematic/structured risk assessment approaches may enhance the accuracy of clinical prediction of violent outcomes. Data on the predictive validity of available clinical risk assessment tools are based largely on American and North American studies and further validation is required in British samples. The Psychopathy Checklist appears to be a key predictor of violent recidivism in a variety of settings.

Violence risk prediction is an inexact science and as such will continue to provoke debate. Clinicians clearly need to be able to demonstrate the rationale behind their decisions on violence risk and much can be learned from recent developments in research on violence risk prediction.

Recent research progress showing the benefits of cognitive therapy in schizophrenia leaves the general psychiatrist unsure whether to attempt to use such techniques.

To test whether cognitive–behavioural techniques are beneficial in the management of patients with schizophrenia in general psychiatric practice.

A randomised controlled study comparing the use of cognitive–behavioural techniques and befriending in schizophrenia.

Significant improvement in symptoms occurred in the group treated with cognitive–behavioural techniques but not in the befriending group. During the 6-month follow-up period the cognitive–behavioural group tended to have shorter periods in hospital.

General psychiatrists could help their patients with schizophrenia by using cognitive–behavioural techniques. Such techniques are well within the capability of general psychiatrists, but their application would involve more of the consultant's time spent in direct contact with patients with psychoses.

Studies in schizophrenia suggest that a longer initial period of untreated illness is associated with a poorer clinical outcome.

To determine whether, in first-episode schizophrenia, a longer duration of untreated psychosis (DUP) or of untreated illness (DUI) (DUP plus any prodrome) is associated with clinical variables that could mediate a poor prognosis.

Clinical, social, neuropsychological and oculomotor function data on 53 patients with first-episode schizophrenia were related to the DUP and DUI.

Comparing short and long DUP groups split around the median showed no statistically significant differences (except age); patients in the latter group tended to perform worse on an executive attentional set-shifting task, and were more likely to be unemployed, and living alone or homeless.

There was little evidence of any association between either DUP or DUI and progressive deterioration in the schizophrenic illness or the development of resistance to initial drug treatment. Social variables that augur a poor prognosis may be associated with delayed presentation of schizophrenia to psychiatric services.

With few exceptions, the prevalence, incidence and morbidity risk of depressive disorders are higher in females than in males, beginning at mid-puberty and persisting through adult life.

To review putative risk factors leading to gender differences in depressive disorders.

A critical review of the literature, dealing separately with artefactual and genuine determinants of gender differences in depressive disorders.

Although artefactual determinants may enhance a female preponderance to some extent, gender differences in depressive disorders are genuine. At present, adverse experiences in childhood, depression and anxiety disorders in childhood and adolescence, sociocultural roles with related adverse experiences, and psychological attributes related to vulnerability to life events and coping skills are likely to be involved. Genetic and biological factors and poor social support, however, have few or no effects in the emergence of gender differences.

Determinants of gender differences in depressive disorders are far from being established and their combination into integrated aetiological models continues to be lacking.

Better methods of assessing patients' and family members' causal models of illness are needed to improve adherence with biomedical interventions and to design services that meet the needs of consumers.

To develop a quantitative measure suitable for assessing the relationship of causal beliefs to expressed emotion, stigma, care-seeking and adherence.

The Causal Models Questionnaire for Schizophrenia, which includes 45 causes identified during in-depth interviews with family members, was administered to 245 family members of 135 patients with DSM–III–R schizophrenia in Suzhou and Siping, China at the time of admission to hospital.

Respondents, who identified a mean of 2.5 causes (range 1–10, mode 2), attributed 84% of the cause of schizophrenia to social, interpersonal and psychological problems. Hence, their beliefs do not concur with Chinese professionals' ideas about the biomedical causes of schizophrenia. Multivariate analyses identified the socio-economic factors that influence family members' causal beliefs.

Despite the complexity of causal models, measures can be developed that will help improve clinicians' communication with patients and understanding of help-seeking behaviours.

The excess mortality of schizophrenia is well recognised, but its precise causes are not well understood.

To measure the standardised mortality ratio (SMR) and examine the reasons for any excess mortality in a community cohort with schizophrenia.

We carried out a 13-year follow-up of 370 patients with schizophrenia, identifying those who died and their circumstances.

Ninety-six per cent of the cohort was traced. There were 79 deaths. The SMRs for all causes (298), for natural (232) and for unnatural causes (1273), were significantly higher than those to be expected in the general population, as were the SMRs for disease of the circulatory, digestive, endocrine, nervous and respiratory systems, suicide and undetermined death. Smoking-related fatal disease was more prominent than in the general population.

Some of the excess mortality of schizophrenia could be lessened by reducing patients' smoking and exposure to other environmental risk factors and by improving the management of medical disease, mood disturbance and psychosis.

Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required.

To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care.

Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods.

Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory – European Version (CSSRI–EU). This was subsequently administered to 404 people with schizophrenia across five countries.

The CSSRI – EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.

There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

The Department of Health defines needs as “the ability to benefit from healthcare interventions”. Outcome measurement is an integral component of needs assessment because it underpins ‘ability to benefit’.

To propose a framework for addressing the measurement of outcome in relation to mentally disordered offenders (MDOs).

Based on a literature search, the paper reviews the definition and measurement of outcome in general mental health care and specifically in relation to MDOs. It analyses the problems of conducting outcome research in relation to MDOs.

A framework for outcome measurement in relation to MDOs is presented. Outcome is placed within a broader framework that relates to service evaluation.

Current measurement of outcome in relation to MDOs is inadequate. A comprehensive framework that acknowledges the multi-dimensional nature of outcome is essential. Researchers must be able to justify the dimensions they prioritise.

Factors underlying premature discontinuation of psychosocial in-patient treatment are still unclear.

Investigation of early discontinuation of specialised in-patient psychosocial treatment in a sample of people with personality disorder.

Out of 134 consecutive admissions to the Cassel Hospital, 42 early drop-outs and 92 patients who remained were compared on demographic and clinical variables. Early drop-outs were invited for in-depth interviews, to explore their hospital experiences.

The early drop-out group and the group which remained showed significant differences in occupational status, borderline personality disorder (BPD) and the treatment programme to which they were allocated. All three independent variables predicted early discontinuation of treatment. The qualitative analysis of interview transcripts identified significant problems in institutional dimensions.

Important subjects and process variables contributing to early drop-out in people with personality disorder were identified, with potential implications for clinical practice.

The hypercortisolaemia and dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis associated with mood disorders have been attributed to a breakdown in the glucocorticoid-receptor-mediated negative feedback mechanism regulating HPA activity. Reinstating normal feedback may be therapeutic in mood disorders.

To review the evidence for the involvement of the glucocorticoid receptor in the pathogenesis and treatment of mood disorders.

Medline and hand searches were carried out, selecting literature relevant to psychiatrists and psychopharmacologists.

A dysfunction in glucocorticoid receptors is integral to the HPA abnormalities of mood disorders. Antidepressant and mood-stabilising drugs can up-regulate glucocorticoid receptors, restoring glucocorticoid function. Preliminary clinical studies targeting the glucocorticoid receptor are encouraging.

Drugs designed specifically to up-regulate glucocorticoid receptors may be integral to future strategies in treating mood disorders.

The extent of premorbid changes associated with the onset of schizophrenia are debated.

The study examined cognitive and behavioural functioning prior to, and after, first hospitalisation for schizophrenia.

Data from the Israeli Draft Board Register of intelligence, social functioning and behaviour testing for all Israeli males aged 16–17 was linked with data from the National Psychiatric Hospitalisation Case Register. This identified 692 men who had been admitted to hospital for schizophrenia. Cases and non-cases matched on age and school were compared, as were cases aggregated by the time that had elapsed between testing and first admission to hospital.

Cases performed worse than non-cases on all measures. On Social Functioning and on Raven's Progressive Matrices–R, differences between cases and non-cases were progressively greater for cases admitted closer to the time of testing. These differences were greatest for persons tested after first psychiatric hospitalisation.

The results confirm premorbid deficits associated with schizophrenia and support the hypothesis that decline is progressive.

The five-country European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study aimed to develop standardised and reliable outcome instruments for people with schizophrenia. This paper reports reliability findings for the Camberwell Assessment of Need – European Version (CAN-EU).

The CAN – EU was administered in each country, at two points in time to assess test – retest reliability, and was rated by two interviewers at the first administration. Cronbach's α, test–retest reliability and interrater reliability were compared between the five sites. Reliability coefficients and standard errors of measurement for summary scores were estimated.

Sites varied in levels and spread of needs. Alphas were 0.48, 0.58 and 0.64 for total, met and unmet needs respectively. Test–retest reliability estimates, pooled over sites, were 0.85 for the total needs, 0.69 for met needs and 0.78 for unmet needs. Pooled estimates for interrater reliability were higher, at 0.94, 0.85 and 0.79 for total, met and unmet needs respectively. There were statistically significant differences in interrater reliability between sites.

The results confirm the feasibility of using CAN–EU across sites in Europe and its psychometric adequacy.

It is not clear whether cortisol or dehydroepiandrosterone (DHEA) hypersecretion increases the risk for major depression in the presence of undesirable life events.

To determine whether there is a specific pattern of psychoendocrine factors that predicts the onset of major depressive disorder.

180 adolescents (73 boys, 107 girls) at high risk for psychopathology were assessed for cortisol, DHEA, depressive symptoms, life events and psychiatric disorder at entry and 12 months later.

Major depression was predicted for both genders by the additive effects of: higher depressive symptoms; personal disappointments and losses only in the month before onset; one or more daily levels of cortisol at 08.00 h or DHEA at 20.00 h greater than the 80th percentile of the daily mean.

A subgroup of adolescents may carry a physiological risk for major depression which may be either of genetic and/or earlier psychosocial origin.

Although the benefits of public knowledge of physical diseases are widely accepted, knowledge about mental disorders (mental health literacy) has been comparatively neglected.

To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area.

A narrative review within a conceptual framework.

Many members of the public cannot recognise specific disorders or different types of psychological distress. They differ from mental health experts in their beliefs about the causes of mental disorders and the most effective treatments. Attitudes which hinder recognition and appropriate help-seeking are common. Much of the mental health information most readily available to the public is misleading. However, there is some evidence that mental health literacy can be improved.

If the public's mental health literacy is not improved, this may hinder public acceptance of evidence-based mental health care. Also, many people with common mental disorders may be denied effective self-help and may not receive appropriate support from others in the community.

It has been proposed that breast-feeding might have a protective effect against the development of adult schizophrenia.

To test this hypothesis.

Using prospective data from two UK national birth cohorts, the feeding histories of those who later developed schizophrenia were compared with the remaining population at risk. Analyses in each cohort were considered to be independent tests of the hypothesis.

There were no differences in feeding histories. In the 1946 birth cohort (n=4447) 30 cases of DSM–III–R schizophrenia arose by age 43; 24.1% of cases v. 23.6% of controls were entirely bottle-fed; 17.3% v. 12.3% were breast-fed for under I month; 58.6% v. 64.1% were breast-fed beyond I month. In the 1958 cohort (n=18 856), 40 cases of CATEGO nuclear schizophrenia arose by age 28; 24.1% of cases v. 31.7% of controls were entirely bottle-fed; 27.6% v. 24.9% were breast-fed for under 1 month; 48.3% v. 43.4% were breast-fed beyond 1 month.

These findings provide no evidence of any effect of breast-feeding in protecting against the risk of later schizophrenia.