Background. In order to improve care for people with depressive disorders and to reduce the increasing burden of depression, the American Regional Office of the World Health Organization has launched a major region-wide initiative. A central part of this effort was directed to the primary care system where the diagnosis and treatment of depression are deficient in many countries. This study evaluated the materials developed by the World Psychiatric Association in a training program on depression among primary care physicians by measuring changes in their knowledge, attitudes, and practice (KAP).

Method. One hundred and seven physicians and 6174 patients from five Latin American countries participated in the trial. KAP were assessed 1 month before and 1 month following the training program. In addition, the presence of depressive symptoms was measured in patients who visited the clinic during a typical week at both times using the Zung Depression Scale and a DSM-IV/ICD-10 major depression checklist.

Results. The program slightly improved knowledge about depression and modified some attitudes, but had limited impact on actual practice. There was no evidence that the diagnosis of depression was made more frequently, nor was there an improvement in psychopharmacological management. The post-training agreement between physician diagnosis and that based on patient self-report remained low. The physicians, however, seemed more confident in treating depressed patients after training, and referred fewer patients to psychiatrists.

Conclusions. Traditional means of training primary care physicians in depression have little impact on clinical practice regardless of the quality of the teaching materials.

Background. We assess claims that the documented rise in psychiatric morbidity during the nineteenth and twentieth centuries was associated with an increasing incidence of schizophrenia.

Method. Cross-sectional epidemiological comparison of the incidence of schizophrenia in one urban, industrialized community at three points over more than 100 years using new data from 1881–1902 and two pre-existing datasets, 1978–1980 and 1992–1994. For 1881–1902, 34 cases of schizophrenia were obtained through retrospective diagnosis, using Research Diagnostic Criteria, of a random 14·5% sample of first admissions to Nottingham Asylum (n=330). Inter-rater reliability and leakage analyses were performed. The administrative incidence for all three studies was directly standardized against 1991 census data. Local statistics on total psychiatric morbidity in Nottingham were taken from the asylum superintendent's register and recent data from the Office of National Statistics.

Results. Official local and national rates of total psychiatric morbidity increased exponentially. There was no significant change in the incidence of schizophrenia over the 114-year period 1881–1994.

Conclusions. The rise in both local and national official statistics of psychiatric morbidity 1881–1994 was not associated with a significant increase in the incidence of schizophrenia. Stability in the epidemiology of schizophrenia at a geographical level is found despite important demographic changes.

Background. Previous studies have suggested an association between personality traits and post-traumatic stress. These studies either focused exclusively on military veterans or assessed personality traits after the traumatic event. This study investigates to what extent personality traits as assessed before the traumatic experience predict post-traumatic stress in civilians experiencing air attacks at the end of the exposure to stressful events and 1 year later.

Method. The revised version of the NEO Personality Inventory was administered to 70 students in Belgrade, Yugoslavia. In 1999, 1 or 2 years after the assessment, all students were exposed to air attacks for 11 weeks. At the end of the attacks and 1 year later post-traumatic stress was measured on the Impact of Event Scale.

Results. Pre-trauma personality predicted 13% of the variance of intrusion scores 1 year after the attacks. There was no significant correlation between personality traits and subsequent avoidance scores at any point of time.

Conclusions. Personality traits that are assessed before a traumatic event can, to a limited extent, predict intrusive symptoms in a non-clinical sample of civilians. Pre-trauma assessments of personality might be less strongly associated with post-traumatic stress than personality traits obtained after the traumatic event.

Background. Memory impairment is not considered a core cognitive feature of attention deficit hyperactivity disorder, combined type (ADHD-CT), although it is associated with impairments in attentional and executive functions. This study investigates visuospatial memory impairment, in particular encoding and retrieval aspects, in children with ADHD-CT who are stimulant-medication naive and medicated with stimulant medication.

Method. A cross-sectional study of visuospatial memory in 6- to 12-year-old children with stimulant-medication-naive ADHD-CT (n=62) and medicated ADHD-CT (n=58) compared to an age- and gender-matched healthy control group (n=39) was completed.

Results. Both medication-naive and medicated ADHD-CT groups demonstrated subtle yet significant impairment in visuospatial memory. The memory impairment was delay-independent, which, along with other factors, suggest dysfunction of the encoding rather than retrieval phase of visuospatial memory.

Conclusions. Careful study of large ADHD-CT samples does detect deficits in a visuospatial memory task, but these reflect attentional deficits rather than being specifically due to dysfunction of the medial temporal lobe explicit memory system. Children with ADHD-CT may benefit from cognitive and behavioural strategies focused on improving encoding of relevant information rather than retrieval strategies.

Background. Follow-up studies of childhood ADHD have shown persistence of the disorder into adulthood, but no epidemiological data are yet available.

Method. ADHD DSM-IV symptoms were obtained by self-report in an adult population-based sample of 1813 adults (aged 18–75 years), that was drawn from an automated general practitioner system used in Nijmegen, The Netherlands. The structure of ADHD symptoms was analysed by means of confirmatory factor analyses. Other data used in this report are the General Health Questionnaire (GHQ-28), information about the presence of three core symptoms of ADHD in childhood, and about current psychosocial impairment.

Results. The three-factor model that allowed for cross-loadings provided the best fit in the entire sample. This result was replicated across gender and age subsamples. Inattentive and hyperactivity symptom scores were significantly associated with measures of impairment, even after controlling for the GHQ-28. Subjects with four or more inattentive or hyperactive–impulsive symptoms were significantly more impaired than subjects with two, one and no symptoms. The prevalence of ADHD in adults was 1·0% (95% CI 0·6–1·6) and 2·5% (1·9–3·4) using a cutoff of six and four current symptoms respectively, and requiring the presence of all three core symptoms in childhood.

Conclusions. These results support the internal and external validity of ADHD in adults between 18 and 75 years. ADHD is not merely a child psychiatric disorder that persists into young adulthood, but an important and unique manifestation of psychopathology across the lifespan.

Background. Drop-out, often accompanied by treatment non-compliance, is common in psychiatric trials. Methodologists have criticized the use of a traditional intention-to-treat (ITT) approach in such cases, and have proposed alternative methods. We set out to describe and assess methods for estimation of a treatment effect when the trial is ‘broken’.

Method. We describe a stratified method of moments (SMOM) estimator that assesses treatment effects on subjects who are willing to comply with all the treatments under study. A simulation study and a re-analysis of data from an antipsychotics trial are used to compare SMOM to ITT, as-treated, and adequate estimators.

Results. The new estimator retains good statistical properties under different levels of non-compliance and drop-out mechanisms. The re-analysis indicates that SMOM yields more precise results.

Conclusions. Although the traditional ITT approach provides a valid method to estimate treatment effects, it can be biased in the presence of treatment non-compliance and drop-out. It is critical that researchers move beyond traditional approaches when trials are broken. A key first step is to consider non-compliance and drop-out as two independent phenomena, tracking and reporting rates separately.

Background. Saccadic distractibility, as measured by the antisaccade task, has attracted attention as a putative endophenotypic marker for schizophrenia. Some studies have suggested that this measure is elevated in the unaffected relatives of schizophrenia patients. However, recent studies have called this into question and the topic remains controversial.

Method. Saccadic distractibility was measured in 53 patients with DSM-IV schizophrenia, 80 unaffected first-degree relatives and 41 unaffected controls.

Results. Schizophrenia patients performed worse than relatives and controls combined (p<0·00001), but relatives did not differ significantly from controls. Performance in multiply affected families was no worse than that in singly affected families. Relatives with a high presumed genetic risk for schizophrenia performed no worse than other relatives. The performance of the patients did not predict that of their relatives.

Conclusions. These results demonstrate that saccadic distractibility is strongly associated with disease status but not with genetic loading for schizophrenia. We conclude that saccadic distractibility is unlikely to be useful as an endophenotypic marker in schizophrenia.

Background. To increase access to cognitive behavioural therapy for bulimia nervosa new delivery modes are being examined. Guided Self-Help (GSH) in primary care is potentially valuable in this respect. This research aimed to compare outcomes following GSH delivered by general practitioners (GPs) in the normal course of their practice to a delayed treatment control (DTC) condition, and to examine the maintenance of treatment gains at 3 and 6 months following completion of GSH.

Method. Participants were 109 women with full syndrome or sub-threshold bulimia nervosa, randomly allocated to GSH (n=54) and DTC (n=55). The GSH group received direction and support from a GP over a 17-week period while working through the manual in Bulimia Nervosa and Binge-Eating: A Guide to Recovery by P. J. Cooper (1995). GSH and DTC groups were assessed pre-treatment and 1 week following the 17-week intervention or waiting interval. The GSH group was reassessed at 3- and 6-month follow-up.

Results. Intention-to-treat analyses at end of treatment revealed significant improvements in bulimic and psychological symptoms in GSH compared with DTC, reduction in mean frequency of binge-eating episodes by 60% in GSH and 6% in DTC, and remission from all binge-eating and compensatory behaviours in 28% of the GSH and 11% of the DTC sample. Treatment gains were maintained at 3- and 6-month follow-up.

Conclusion. Outcomes in GSH compare favourably with those of specialist-delivered psychological treatments. These findings are considered in light of the nature of the therapy offered and the primary care context.

Background. Subjective well-being (SWB) can be partitioned into the components life satisfaction and affect. Research on factors influencing these components of well-being has mainly focused on environmental characteristics. The aim of this study was to investigate the relative contribution of genes and environment to individual differences in life satisfaction in a large sample of Dutch twins and their singleton siblings.

Method. Life satisfaction of 5668 subjects registered with The Netherlands Twin Registry (NTR) was measured with a Dutch version of the self-reported Satisfaction with Life Scale. An extended twin design was used to obtain correlations in life satisfaction scores for monozygotic twins, dizygotic twins and sibling pairs and to estimate the contribution of genes and environment to the variation in life satisfaction.

Results. No differences between males and females were found in the mean level of life satisfaction. Broad-sense heritability was 38%. Non-additive genetic factors explained all or most of the genetic influences. The remaining 62% of the variance in life satisfaction could be attributed to unique environmental factors, both persistent and transitory, plus measurement error.

Conclusions. Individual differences in life satisfaction are determined in part by genetic factors that are largely or entirely non-additive in nature.

Background. Although diurnal variation of mood is a widely recognized symptom of depression, the clinical, neurobiological and psychopharmacological significance of this symptom has not previously been reported.

Method. A total of 195 depressed out-patients underwent a detailed clinical and neurobiological assessment, and were then randomized to treatment with either fluoxetine or nortriptyline.

Results. Of the 195 depressed patients, 62 had a pattern of reversed diurnal variation (i.e. worse in the evening). Those with reversed diurnal variation had a poorer response to a serotonergic antidepressant, were less likely to have bipolar II disorder, had a higher tryptophan:large neutral amino acid ratio and had different allele frequencies of the polymorphisms in the promoter region of the serotonin transporter.

Conclusions. These findings raise the possibility of serotonergic influence on diurnal variation, and that the symptom of reversed diurnal variation is of relevance to antidepressant prescribing.

Background. There is a large literature indicating that the offspring of mothers with Major Depressive Disorder (MDD) are at increased risk for depression. However, much less is known about the effects of paternal MDD on offspring psychopathology.

Method. We addressed this issue using a large community sample of parents and their adolescent and young adult offspring (n=775). Parents and offspring were independently assessed with semi-structured diagnostic interviews. Offspring were interviewed three times from mid-adolescence to age 24 years.

Results. Maternal MDD was significantly associated with offspring MDD. Paternal MDD was also significantly associated with MDD in offspring, but only among offspring with depressive episodes of moderate or greater severity. These effects persisted after controlling for socio-economic status, family intactness, and non-mood disorders in both parents. Rates of MDD were particularly elevated in offspring of mothers and fathers with early-onset MDD, and offspring of fathers with recurrent MDD. The magnitude of the associations between MDD in parents and offspring was generally in the small-to-medium range.

Conclusions. These results confirm previous findings of elevated risk of MDD in the offspring of depressed mothers. In addition, the results suggest that MDD in fathers is associated with increased risk of depression in offspring, but that it is limited to MDD episodes in offspring of moderate or greater severity.

Background. Euthymic bipolar-I disorder (BP I) patients and their siblings have shown impairments in verbal learning and memory functions compared with controls, suggesting that these impairments may be genetic in origin. Reduced information-processing speed has been associated with impaired memory in the elderly, and recently in schizophrenia. The authors compared verbal learning and memory functioning in twins with BP I and co-twins to control twins, and examined whether the observed deficits are related to information-processing speed.

Method. Finnish Medical and Population Registers and Twin Cohorts were used to identify the BP I and control twins. Neuropsychological tests assessing verbal learning and memory, working memory, facial recognition, visual memory, and information-processing speed were administered to 26 BP I twins, 19 non-bipolar co-twins, and 114 controls. Group differences were analyzed by generalized estimation equation modeling.

Results. BP I patients, but not co-twins, showed impairments in all memory tests compared with controls. Female co-twins showed impairment in verbal learning and memory. Information-processing speed had a significant effect on encoding and learning efficiency.

Conclusions. This study showed for the first time that information-processing speed is related to memory functioning and verbal learning in BP I in a population-based, representative and euthymic sample. Furthermore, the data support the view that defects in verbal memory may be related to the genetic factors predisposing to BP I in females.

Background. Deficits in prepulse inhibition (PPI) of the acoustic startle response have been suggested as a potentially useful endophenotype for schizophrenia spectrum disorders and may explain certain symptoms and cognitive deficits observed in the psychoses. PPI deficits have also been found in mania, but it remains to be confirmed whether this dysfunction is present in the euthymic phase of bipolar disorder.

Method. Twenty-three adult patients with DSM-IV bipolar disorder were compared to 20 controls on tests of acoustic startle reactivity and PPI of the startle response. Sociodemographic and treatment variables were recorded and symptom scores assessed using the Hamilton Depression Inventory and the Young Mania Rating Scale.

Results. Overall, the patient and control groups demonstrated similar levels of startle reactivity and PPI, although there was a trend for the inter-stimulus interval to differentially affect levels of PPI in the two groups.

Conclusions. In contrast to bipolar patients experiencing a manic episode, general levels of PPI were normal in this euthymic sample. Further studies are required to confirm this finding and to determine the mechanisms by which this potential disruption/normalization occurs. It is suggested that an examination of PPI in a high-risk group is required to fully discount dysfunctional PPI as a potentially useful endophenotype for bipolar disorder.

Background. The loss of a spouse has been found to have a negative effect on physical and mental health and leads to increased mortality. Whether conjugal bereavement also affects memory functioning has largely been unexamined. The present study investigates the effect of widowhood on memory functioning in older persons.

Method. The sample consisted of 474 married women and 690 married men aged 60–85 years in 1992, followed up in 1995 and 1998. During the study 135 (28%) of the women and 69 (10%) of the men lost their spouse. Linear regression analysis was used to examine whether widowed men and women differed from those who had not been widowed in rate of memory change over 6 years. Cross-domain latent-change models were subsequently used to evaluate the extent to which changes in memory are related to changes in other domains of functioning that may be affected by widowhood.

Results. Older adults who lost a spouse during follow-up showed a greater decline in memory over 6 years than those who remained married. A higher level of depressive symptoms at baseline was related to lower levels of memory functioning and a greater decline. Memory decline was unrelated to changes in depressive symptoms and physical health.

Conclusions. Loss of the spouse is related to a greater decline in memory in older adults. The absence of an association with physical functioning and the weak association with mental functioning suggest that losing a spouse has an independent effect on memory functioning.

Background. We test the hypothesis that the neuregulin 1 (NRG1) gene at chromosome 8p22-p12, which has been implicated as a susceptibility gene to schizophrenia, is associated with variations in schizotypal personality in non-clinical populations.

Method. A randomly selected sample of 905 adolescents were assessed for their personality features using the Perceptual Aberration Scale (PAS) and the Schizotypal Personality Questionnaire (SPQ) and genotyped for three single nucleotide polymorphisms (SNP8NRG221533, rs3924999, and rs2954041) at the NRG1 gene. Relations between the three genetic variants and continuous schizotypal personality scores were evaluated using ANOVA for single-locus analyses and haplotype trend regression test for multi-locus analyses.

Results. Single locus analysis showed that the A allele of rs3924999, a functional polymorphism in exon 2, had the largest effect size and exhibited a prominent allele–dose trend effect for the PAS score. Haplotype analyses using the haplotype trend regression test indicated that the A allele of rs3924999 was mainly responsible for the association with the PAS but not with the SPQ or its three factors, and the magnitude of significance was not strengthened by the combination of this allele with adjacent locus.

Conclusions. Our study provides the first evidence for the association of NRG1 with schizotypal personality and indicates a possible role of NRG1 in the genetic etiology of schizophrenia through perceptual aberrations.

Background. Previous findings of increased rates of psychotic disorders among immigrants to Sweden are primarily based on hospital samples. The aim of the current study was to compare the risks of first contact for psychotic and schizophrenic disorders among first- and second-generation immigrants to the risks in native ‘Swedes’.

Method. During a 3-year period, diagnostic information was collected on all patients with a possible psychotic disorder who made a first-in-lifetime contact with both in-patient and out-patient psychiatric services in Malmö.

Results. First-generation immigrants to Sweden had an increased risk of developing psychotic and schizophrenic disorders compared to Swedes (age- and gender-adjusted relative risk, RR 2·9, 95% CI 2·0–4·0 and RR 4·0, 95% CI 1·8–8·6 respectively). Risks for these disorders were not significantly increased in second-generation immigrants. The highest risks of developing psychotic disorder compared to Swedes were found in first-generation immigrants with ‘black’ (versus ‘neither black nor white’, or ‘white’) skin colour (RR 5·8, 95% CI 2·8–13·4) and birthplace in a developing (versus developed) country (RR 3·3, 95% CI 2·3–4·8).

Conclusion. The increased risks of psychosis obtained especially in immigrant groups having relatively disadvantaged status in Sweden suggest that psychosocial factors may contribute to the development of psychotic disorders.

Background. Disasters are believed to have large effects on the mental health of adolescents but the lack of prospective pre- and post-disaster data on affected and control populations have limited our knowledge on the validity of these claims. We examined the medium-term, 12 months' effects of a severe disaster on the mental health of adolescents, and compared them to effects after 5 months.

Method. A café fire in The Netherlands injured 250 adolescents and killed 14. We obtained data 15 months before and 12 months after the disaster about behavioural and emotional problems (using the Youth Self-Report) and substance misuse, in 124 students of an affected school of whom 31 were present at the fire (response 77·5%) and 830 other students (56·4%); mean age at baseline, 13·8 years.

Results. We found differences between students from the affected school and others for excessive use of alcohol (odds ratio 3·42, 95% confidence interval 2·00–5·85, p<0·0001), but not for behavioural and emotional problems and use of other substances. Effects had decreased compared to those after 5 months.

Conclusions. In the long run, the effects of disaster decrease regarding self-reported behavioural and emotional problems, but they remain regarding alcohol misuse among those present at the disaster, and their peers.

Objectives. Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and preventing or alleviating secondary morbidity in the wake of the first psychotic episode. The present study reports on the outcomes of a controlled trial comparing two conditions: COPE versus No-COPE.

Method. Ninety-one people participated in the trial which was analysed by intention-to-treat, including 12 people who were assigned to COPE but refused to participate. Assessments were conducted at pre-treatment, mid-treatment and post-treatment. Hospital readmission data were obtained through a Psychiatric Case Register. The study was conducted in a front-line public mental health service, the Early Psychosis Prevention and Intervention Centre (EPPIC). Clients in both COPE and No-COPE were provided with full access to the complete range of EPPIC services.

Results. There were no significant differences between the two conditions on the nine primary outcome variables. Hospital readmissions were assessed for each client at yearly intervals up to 4 years following the completion of treatment and again there were no significant between-group differences.

Conclusions. The study indicated that there was no significant advantage to COPE over and above routine care at EPPIC.

Background. A limited number of psychotherapy sessions in combination with medication is preferable to pharmacotherapy only in the treatment of ambulatory patients with major depression. Whether there is a relation between the number of sessions and the efficacy of the treatment is uncertain.

Method. Randomized clinical trial comparing two treatment conditions in outpatients with major depression. All patients studied had a baseline score of at least 14 points on the 17-item Hamilton Depression Rating Scale. The two conditions consist of 8-session or 16-session Short Psychodynamic Supportive Psychotherapy, both in combination with pharmacotherapy. Efficacy was assessed using the 17-item HDRS, the CGI of Severity and of Improvement, the depression subscale of the SCL-90 and the Quality of Life Depression Scale.

Results. The rate of change would seem to indicate that eight sessions are preferable for both moderately and severely depressed patients, although the results converged again at the end. Furthermore, in terms of satisfaction with the number of sessions and drop-out percentages during treatment, no differences were found between the conditions.

Conclusion. In the light of the outcome analysis (faster remission after fewer sessions), a short version of the psychotherapy treatment in a combined course of treatment seems to be justified.

Background. Schizophrenia is associated with impaired visual information processing. The aim of this study was to investigate the relationship between anomalous perceptual experiences, positive and negative symptoms, perceptual organization, rapid categorization of natural images and magnocellular (M) and parvocellular (P) visual pathway functioning.

Method. Thirty-five unmedicated patients with schizophrenia and 20 matched healthy control volunteers participated. Anomalous perceptual experiences were assessed with the Bonn Scale for the Assessment Basic Symptoms (BSABS). General intellectual functions were evaluated with the revised version of the Wechsler Adult Intelligence Scale. The 1–9 version of the Continuous Performance Test (CPT) was used to investigate sustained attention. The following psychophysical tests were used: detection of Gabor patches with collinear and orthogonal flankers (perceptual organization), categorization of briefly presented natural scenes (rapid visual processing), low-contrast and frequency-doubling vernier threshold (M pathway functioning), isoluminant colour vernier threshold and high spatial frequency discrimination (P pathway functioning).

Results. The patients with schizophrenia were impaired on test of perceptual organization, rapid visual processing and M pathway functioning. There was a significant correlation between BSABS scores, negative symptoms, perceptual organization, rapid visual processing and M pathway functioning. Positive symptoms, IQ, CPT and P pathway measures did not correlate with these parameters. The best predictor of the BSABS score was the perceptual organization deficit.

Conclusions. These results raise the possibility that multiple facets of visual information processing deficits can be explained by M pathway dysfunctions in schizophrenia, resulting in impaired attentional modulation of perceptual organization and of natural image categorization.