It is not clear which model of case management is most likely to improve quality of life in people with severe mental illness.

To use baseline data derived from the UK700 Case Management Trial to assess the relative importance of clinical, social and unmet needs variables as predictors of subjective quality of life in patients with severe mental illness.

Patients (n=708) were assessed on quality of life (Lancashire Quality of Life Profile), needs (Camber well Assessment of Need), psychopathology and social functioning. Variables that were amenable to change through case management were investigated as predictors of quality of life.

Social variables accounted for 7% of the variance for subjective quality of life, compared with 19% for clinical variables, and 20% for unmet needs. The strongest predictors of subjective quality of life were unmet basic, social and functioning needs, depression and positive psychotic symptoms.

Subjective quality of life in severely mentally ill patients is predicted by clinical variables and unmet needs. The results identify priority areas for the attention of case managers who seek to improve quality of life in these patients.

The dopamine hypothesis proposes that antipsychotic drugs act primarily through limbic cortical D2/D2-like dopamine receptor blockade.

To evaluate this hypothesis with the D2/D3-selective SPET probe [123I]-epidepride.

[123I]-epidepride SPETscans were performed on 12 patients with schizophrenia treated with antipsychotics and 11 age-matched healthy controls. [123I]-epidepride specific binding to D2/D3 dopamine receptors was estimated, and relative percentage D2/D3 receptor occupancy by typical antipsychotic drugs determined.

Mean (s.d.) daily dose was 669.12 (516.8) mg chlorpromazine equivalents. Mean percentage D2/D3 receptor occupancy was 81.6 (8.1) and 73.2 (13.9) in the temporal cortex and striatum respectively.

Typical antipsychotic drug treatment is associated with substantial temporal cortical D2/D3 receptor occupancy. The relationship between this and efficacy is poor in patients with treatment-resistant schizophrenia.

There is conflicting evidence about the frequency of adverse pregnancy outcomes among women with schizophrenia.

To investigate the risk of preterm birth, low birth weight and intra-uterine growth retardation among women with schizophrenia.

A total of 2212 births to 1537 women with schizophrenia in Denmark were compared with a random sample of all deliveries in Denmark in 1973–1993 (122 931 births to 72 742 women)

The children of women with schizophrenia were at increased risk of preterm delivery (relative risk=1.46, 95% CI=1.19–1.79), low birth weight (relative risk=1.57, 95% 0=1.36–1.82) and small for gestational age (relative risk=1.34, 95% CI=1.17–1.53)

Women with schizophrenia are at increased risk of adverse pregnancy outcome. This may be associated with an increased mortality and general morbidity and risk of schizophrenia in their children.

Anorexia nervosa is a mental disorder with a high long-term mortality. Patients are ambivalent about treatment and often avoid it. Of necessity, compulsory treatment sometimes must be considered. A report from the Mental Health Act Commission has helped to reduce previous confusion.

To identify the premorbid and clinical features that predisposed to compulsory admissions, the short-term benefits of the treatment and the long-term mortality rates (derived from the National Register)

Eighty-one compulsory patients were compared with 81 voluntary patients.

Predisposing factors to a compulsory admission were a history of childhood sexual or physical abuse or previous self-harm. Detained patients had more previous admissions. Detained patients gained as much weight during admission as voluntary patients, but took longer. More deaths among compulsory than voluntary patients (10/79 v. 2/78) were found 5.7 years (mean) after admission.

Compulsory treatment is effective in the short term. The higher long-term mortality in the detained patients is due to selection factors associated with an intractable illness.

Does incidence of dementia follow the age pattern of prevalence? Is gender a risk factor? Do patterns of incidence differ between dementias?

To assess age-specific incidence rates of undifferentiated dementias, Alzheimer's disease and vascular dementia.

5222 individuals aged $65 years, were interviewed using the Geriatric Mental State/History and Aetiology Schedule. The AGECAT package was used to identify cases at three interviewing waves at two-year intervals. Diagnoses were made using ICD −10 Research Criteria and validated against neurological and psychological examination, with imaging and neuropathology on unselected subsamples.

Incidence rates of the dementias increase with age. Age patterns are similar between Alzheimer's disease and vascular dementia. Gender appears influential in Alzheimer's disease. In England and Wales, 39 437 new cases of Alzheimer's disease (4.9/1000 person-years at risk); 20 513 of vascular dementia (2.6/1000 person-years) and 155 169 of undifferentiated dementia (19/1000 person-years) can be expected each year.

Incidence rates for Alzheimer's disease and vascular dementia appear to behave differently with an increased risk of Alzheimer's disease for women compared to vascular dementia.

The greater frequency of mental illness in deprived and inner-city populations is well recognised; allocation of funds in the UK health service makes some allowance for this. However, it is not clear whether the differences are similar for all levels of mental health care need.

To study the range in prevalence of mental health problems and care at primary care, general secondary care and forensic care levels.

We used mainly descriptive statistics to study evidence available from existing sources – some based on indicators of likely need, some on observed prevalance of treatment.

Among English health authority areas, the most morbid have about twice the prevalence of primary care level mental illness of the least morbid. For secondary care the ratio is between 2.5 and 4 to 1, while for services for mentally disordered offenders it is in excess of 20:1.

Where needs indices are used for resource allocation, responsible authorities should ensure that they produce ranges reflecting the full compass of services funded. For forensic services the range of morbidity levels may be so great that funding needs to rest at a larger population level than that of health authorities.

An increased incidence of psychotic disorders has repeatedly been reported among African–Caribbeans in the UK.

To test whether the increased incidence of psychotic disorders in first-and second-generation African–Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.

Thirty-three patients of African–Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.

There was a trend for better outcomes in African–Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio=0.9 (–0.50 to –2.00)). Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio=0.59 (–0.21 to –1.66)). Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African–Caribbean group.

Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African–Caribbeans.

The Care Programme Approach (CPA) and supervision register policies in England are intended to prioritise patients to receive specialist mental health care.

To describe and evaluate the practical application of the policies.

A questionnaire survey of key informants in mental health provider trusts and an analysis of aggregated data collected by health authorities using the Mental Illness Needs Index as a measure of population need.

On average, 1175 per 100 000 total population are subject to the CPA (95% Cl=1055–1309) and 8.6 per 100 000 (95% Cl=7.5–9.9) are on supervision registers. Wide local variations in the number of people subject to the CPA and supervision registers are not explained by variations in population need.

Prioritisation to receive specialist mental health services is carried out inconsistently, and inequitable use of resources may result.

The assumption that patients with bipolar disorder make a full inter-episode recovery has been challenged by limited evidence that suggests that neuropsychological dysfunction in bipolar disorder may persist beyond episodes of illness.

To test the hypothesis that patients with euthymic bipolar disorder show neuropsychological impairment.

A battery of neuropsychological tests (assessed attention, working memory, learning and executive function) was administered to three matched groups of subjects: good-outcome patients with bipolar disorder (n=21); poor-outcome patients with bipolar disorder (n=20); controls (n=20). All patients were clinically euthymic, although some had low levels of depressive symptoms.

Patients performed worse than controls on a number of neuropsychological tests. When age, premorbid IQ and depressive symptoms were controlled for, the results indicated impairment of executive function.

These findings provide good evidence for the existence of neuropsychological impairment in patients with euthymic bipolar disorder, although the possible effect of medication should not be overlooked. This may be of clinical relevance and raises questions about the course and outcome of the illness.

A recent review showed that opioid users' deaths from suicide were 10 times as common as expected on the basis of age and gender. Surveys showing prisoners' high prevalence of injecting or opioid dependence have led to a new statistical approach to prison suicides.

To estimate the expected number of UK prison suicides annually, having taken account of inmates' age, gender and opioid dependence.

By gender, estimate the effective number of individuals (in terms of community-equivalent suicide risk) for whom prisons have a duty of care as 10 times the number of opioid-dependent inmates plus the number of non-opioid user inmates. Apply the gender and age-appropriate national suicide rates to work out the expected number of prison suicides.

The Scottish Prison Service can expect 7.1 suicides per annum, and annual totals up to 12 without exacerbation of suicides due to incarceration. For the Prison Service in England and Wales, 19.3 suicides per annum can be expected in prisons, and annual totals may range up to 28 without indicating incarceration; the total of self-inflicted deaths was 47 in 1993–94

Prisons cannot prevent all suicides. An alert may be warranted if prison suicides exceed 12 per annum in Scotland, or 28 in England and Wales.

The Operational Criteria Checklist (OPCRIT) generates diagnoses according to 12 operational diagnostic systems (e. g. DSM–III, DSM–III–R, Research Diagnostic Criteria, ICD–10)

To examine the agreement between diagnoses generated by the OPCRIT, as completed by the interviewer, with a best-estimate lifetime procedure using the OPCRIT.

Subjects came from large mufti-generational bipolar or schizophrenia pedigrees (n=100), and from a sample of unrelated subjects with schizophrenia (n=40). We analysed the diagnostic agreement between OPCRIT diagnoses generated by the interviewer and our best-estimate OPCRIT diagnoses, according to DSM–III–R and ICD–10, using Cohen kappa statistics.

Excellent agreement was found between interviewer OPCRIT diagnoses and OPCRIT diagnoses made by the best-estimate lifetime consensus procedure for DSM–III–R (κ=0.83) and ICD-10 (κ=0.81)

Results suggest that this procedure for diagnostic assessment is an efficient alternative to classic best-estimate diagnosis procedures.

The Townsend index is a measure of social deprivation. It can be applied to postal districts and has been employed in studies examining the ecological associations of mental illness.

We examine the utility of the Townsend index in identifying older populations with a high prevalence and risk of developing depression.

The study was carried out in the context of a cohort study of an age- and gender-stratified sample of 5222 community residents aged 65 years and over. Subjects were interviewed at intervals of two years. The relationships between Townsend score and psychiatric diagnoses (in particular, depression) were examined.

High Townsend scores were associated with increased prevalence and incidence of depression and prevalence of organic psychiatric illness.

The Townsend index can be used to prioritise psychiatric and primary care resources so as to cater for older populations likely to suffer from depression and organic psychiatric conditions.

Previous studies have suggested that cognitive therapy is effective in modifying delusions.

To assess the effectiveness of cognitive therapy on patients seen in routine clinical work.

Eighteen patients with chronic delusions were treated using cognitive therapy, after the method of Chadwick and Lowe. A single-case multiple-baseline experimental design was used, including a control treatment. Each subject was used as their own control.

Six patients reduced conviction in their delusions during cognitive therapy and not during the control treatment. Seven patients' conviction ratings did not change. Five patients showed a variable response. Degree of conviction did not fall to zero in any patient. All patients reported that the therapy had been helpful; six spontaneously mentioned changes in psychotic thinking.

One-third of patients with chronic delusions whom we treated responded to delusion modification with a reduction in degree of belief. Change within therapy sessions predicted outcome, as did variation in the conviction during baseline. Cognitive therapy with delusions should aim at reducing distress as well as conviction.

Depression in older people is common and has a high mortality, but effective treatments exist.

To describe drug prescribing in older community residents in relation to depression status.

The MRC–ALPHA community cohort aged 65 and over were interviewed using the Geriatric Mental State examination drug data collected at index interview and at two and four years.

Antidepressants were used by 10.9% of the depressed population. Benzodiazepines were used frequently. Of the antidepressant users, 59.6% took low-dose antidepressants for two years, had a poor outcome and few drug changes.

Trends of increasing antidepressant use have cost implications for primary care groups. Benzodiazepines may be mis-prescribed for treatment of depressive symptoms. Antidepressant users have poor outcome and follow-up.

Rates of, and risk factors for, lithium-associated clinical hypothyroidism are uncertain.

To determine prevalence of and risk factors for clinical hypothyroidism in patients treated with lithium carbonate.

Retrospective case-note review of 718 patients who had undergone serum lithium estimation during a 15-month period. Patients on thyroxine had a more detailed review.

The prevalence of clinical hypothyroidism during lithium treatment was 10.4%. The main risk factor was female gender (women 14% v. men 4.5%). Women were at highest risk during the first two years of lithium treatment, and women starting lithium aged 40–59 years had the greatest prevalence (> 20%). No equivalent risk factors emerged in men, although, like women, their prevalence of hypothyroidism was substantially higher than community rates.

The high rates of clinical hypothyroidism identified may call for a review of the drug information given to women, particularly to those starting lithium in middle age. Consideration should be given to screening for thyroid antibodies before treatment in high-risk cases. Monitoring of thyroid function should take into account gender, age and stage of lithium treatment.

The opioid addiction test is based on the measurement of pupil dilatation in opioid-dependent people in response to conjunctivally applied naloxone hydrochloride. A positive response (pupil dilatation) indicates that the subject is dependent on opioids.

To evaluate the test in an out-patient setting and to identify factors affecting its outcome.

Pupil size was measured using binocular pupillometry in 100 new patients attending an out-patient clinic for assessment and treatment of opioid use. Measurement was repeated 40 minutes after the unilateral instillation of naloxone drops into the conjunctival sac.

We performed 127 tests, of which 103 (81.1%) were positive. Males, and those not on methadone at the time of the test, were more likely to have a negative test result.

The opioid addiction test proved to be a very useful tool for the rapid diagnosis of opioid dependence in the out-patient clinic. Specialist pupillometric equipment increases the number of patients correctly identified as opioid-dependent on the first visit, but is not essential.

Good interview and diagnostic measures for autism and other pervasive developmental disorders (PDDs) are available but there is a lack of a good screening questionnaire.

To develop and test a screening questionnaire based on items in the best available diagnostic interview – the Autism Diagnostic Interview – Revised (ADI–R)

A 40 -item scale, the Autism Screening Questionnaire (ASQ), was developed and tested on a sample of 160 individuals with PDD and 40 with non-PDD diagnoses.

The ASQ has good discriminative validity with respect to the separation of PDD from non-PDD diagnoses at all IQ levels, with a cut-off of 15 proving most effective. The differentiation between autism and other varieties of PDD was weaker.

The ASQ is an effective screening questionnaire for PDD.

Imaging studies in depression of the elderly are often small and highly selective.

To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up.

Patients (n=175, age range 65–91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECT scans were carried out at referral and at two-year follow-up.

Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up.

The patient group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age.

Family members of patients with schizophrenia frequently report burdens associated with caring for their relatives.

We evaluate the impact of illness beliefs on the burden reported by family care-givers of people with bipolar illness.

The multivariate relationships between patient symptomatology and family illness beliefs and report of burden were examined at baseline among care-givers of 266 patients with Research Diagnostic Criteria-diagnosed bipolar illness who were subsequently followed for 15 months.

At baseline, 93% of care-givers reported moderate or greater distress in at least one burden domain. As a group, care-giver illness beliefs (illness awareness, perception of patient and family control) explained an additional 18–28% of variance in burden experienced beyond the effects of the patients clinical state and history.

Care-givers of patients with bipolar illness report widespread burden that is influenced by beliefs about the illness.

Post-partum depression in the developing world has received tittle research attention, and its association with disturbances in the mother–infant relationship is unknown.

To determine the prevalence of post-partum depression and associated disturbances in the mother–infant relationship in Khayelitsha, a South African peri-urban settlement.

The mental state of 147 women who had delivered two months previously was assessed, and the quality of their engagement with their infants was determined.

The point prevalence of DSM–IV major depression was found to be 34.7%. Maternal depression was associated with poor emotional and practical support from the partner. It was also associated with insensitive engagement with the infants.

The rate of post-partum depression in Khayelitsha was around three times that found in British post-partum samples, and these depressions were strongly associated with disturbances in the mother–infant relationship.