This paper presents a structured review of the published information on the mortality of schizophrenia.

A meta-analysis of the literature.

Schizophrenia has a significantly increased mortality from natural and unnatural causes. Twenty-eight percent of the excess mortality is attributable to suicide and 12% to accidents. The rest of the excess mortality is from the same broad range of conditions which cause deaths in the general population. Further interpretation is hampered by confounding variables, wide confidence intervals and reservations about generalising from individual cohorts.

The available evidence suggests that schizophrenia is associated with a large increased mortality from suicide and a moderate increased mortality from natural causes. A number of possible interventions have been identified, but we do not yet have reliable means of detecting any changes in mortality which might result.

The government has highlighted the service needs of mentally disordered offenders (MDOs) and has introduced policies which have driven MDO needs assessment.

Based on a literature review and a national survey of agencies likely to be conducting needs assessment, the paper reviews government policy regarding MDO needs assessment and examines the particular problems of conducting needs assessment for MDOs.

A methodological framework for MDO needs assessment is presented, and different needs assessment approaches are discussed. The methodological and practical limitations of conducting MDO needs assessment are emphasised, as is the role of subjective judgement in both research design and interpretation.

Needs assessment is value-laden. Also, no single needs assessment approach can address all the issues of importance to purchasers and providers. Substituting the term ‘perspectives on need’ for the term needs assessment would help to reflect the lack of a single ‘truth’ about need and emphasise the role of subjective political judgement in designing and interpreting research on ‘need’.

Metabolism of clozapine is complex and not fully understood. Pharmacokinetic interactions with other drugs have been described but, in some cases, their mechanism is unknown.

Published trials and case reports relevant to the human metabolism of clozapine and to suspected pharmacokinetic interactions were reviewed.

Metabolism of clozapine appears to be largely controlled by the function of the hepatic cytochrome p4501A2 (CYPIA2). Compounds which induce CYPIA2 activity (carbamazepine, tobacco smoke) may reduce plasma clozapine levels. Inhibitors of CYPIA2 (caffeine, erythromycin) have the opposite effect. Drugs which inhibit the hepatic cytochrome p4502D6 (CYP2D6) have also been reported to elevate plasma clozapine levels. The mechanism of this interaction is unclear.

The co-administration of clozapine and compounds reported to alter its metabolism should be avoided where possible. A host of other interactions can be predicted and so caution should be exercised when co-administering drugs which affect the function of CYPIA2 and CYP2D6. The pharmacokinetics of clozapine require further investigation so that its safe use can be assured.

Neuroimaging has proven useful in confirming diagnoses of certain neuropsychiatric conditions, but neuroimaging studies in learning disability are at an early stage.

A review of recent structural neuroimaging research in relation to learning disability was carried out.

Brain abnormalities can be detected in cases of idiopathic and non-idiopathic learning disability, but their significance is not clear due to discrepancies in study findings and the small cohorts involved.

Although the role of structural neuroimaging in the assessment of people with learning disability is not clear, new magnetic resonance imaging technology holds great promise for future research.

Large social networks in patients with severe mental illness have been reported to be associated with a low rate of hospitalisation. We aim to determine whether social network size is related to the likelihood of hospitalisation and the amount of service use.

As part of a prospective controlled study, baseline interview data for a random sample of one-year prevalent cases with non-organic psychosis were analysed with respect to social network characteristics and service use during a six-month period.

The likelihood of hospitalisation decreased with an increase in network size, while the number of services used by patients grew as the social network size increased.

While larger social networks may be associated with a lower likelihood of hospitalisation, they may also be related to wider use of non-hospital services.

Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies – public and private – as well as for patients, families and the wider society.

The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.

Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of £2.6 billion, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.

Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.

The aims were to investigate cross-culturally the subjective experience of long-term psychiatric patients to determine whether or not they would define their current life situation predominantly in terms of illness.

The design is a two-by-two comparison by ethnicity (Latino and Euro-American) and diagnosis (schizophrenia and unipolar depression) of 80 subjects for DSM–III–R criteria according to the SADS. Patients were interviewed using a semi-structured interview (Context of Illness Experience) yielding data coded for qualitative and quantitative analyses.

While significant ethnic differences were observed, nearly half the sample did not include illness in their description of their life situation. Other domains (e. g. activities, events) and the extent to which patients perceived themselves as in- or out-of-step with the “rhythm of life” were identified as central patient concerns.

Empirical research on the subjective experiences and representations of the life situation of patients offers clues to the course and treatment of persistent psychiatric disorder.

A series of small, mainly uncontrolled, studies have suggested that techniques adapted from cognitive–behavioural therapy (CBT) for depression can improve outcome in psychosis, but no large randomised controlled trial of intensive treatment for medication-resistant symptoms of psychosis has previously been published.

Sixty participants who each had at least one positive and distressing symptom of psychosis that was medication-resistant were randomly allocated between a CBT and standard care condition (n=28) and a standard care only control condition (n=32). Therapy was individualised, and lasted for nine months. Multiple assessments of outcome were used.

Over nine months, improvement was significant only in the treatment group, who showed a 25% reduction on the BPRS. No other clinical, symptomatic or functioning measure changed significantly. Participants had a low drop-out rate from therapy (11%), and expressed high levels of satisfaction with treatment (80%). Fifty per cent of the CBT group were treatment responders (one person became worse), compared with 31% of the control group (three people became worse and another committed suicide)

CBT for psychosis can improve overall symptomatology. The findings provide evidence that even a refractory group of clients with a long history of psychosis can engage in talking about psychotic symptoms and their meaning, and this can improve outcome.

Despite growing evidence of the effectiveness of cognitive–behavioural therapy (CBT) for psychosis, typically only about 50% of patients show a positive response to treatment. This paper reports the first comprehensive investigation of factors which predict treatment outcome.

In a randomised controlled trial of CBT for medication-resistant psychosis (see Part I) measures were taken at baseline of demographic, clinical and cognitive variables. Changes over time were assessed on the Brief Psychiatric Rating Scale and the relationship between potential predictor variables and outcome was investigated using analysis of variance and covariance.

A number of baseline variables were identified as predictors of good outcome in the CBT group. Key predictors were a response indicating cognitive flexibility concerning delusions (P=0.005) and the number of recent admissions (P=0.002). Outcome was less predictable in the control group and was not predicted by any cognitive variable.

Good outcome is strongly predicted in patients with persistent delusions by a cognitive measure, while this was not the case in controls. Thus we argue that positive outcome in CBT is due in part to specific effects on delusional thinking.

It is widely suggested that many National Health Service (NHS) workers experience high levels of minor psychiatric disorder. However, inadequacies of sampling and measurement in studies to date have not allowed this suggestion to be properly evaluated.

The present study was designed to overcome these methodological weaknesses by using a sample of over 11 000 employees from 19 NHS trusts and a well-established measure of minor psychiatric disorder for which there are comparative data.

The findings show that 26.8% of the health service workers reported significant levels of minor psychiatric disorder, compared with 17.8% of people in the general population. Psychiatric morbidity was highest among managers, doctors, nurses and professions allied to medicine, with each of these groups recording higher rates than their professional counterparts outside the health service. It was lower among those in support occupations, such as administrative and ancillary staff. A feature of the findings was that female doctors and managers showed a much higher prevalence of minor psychiatric disorder than their male colleagues.

Studies are required to establish the organisational, occupational and individual determinants of minor psychiatric disorder among NHS employees.

Schizophrenia is highly expensive in calculable and incalculable costs. Measures which impact the cost in the most severely affected are likely to produce the greatest cost reductions. Studies regarding clozapine in the USA have demonstrated clear cost-effectiveness, despite the high prescription costs. There are no prior UK studies.

We performed a cost-effectiveness analysis comparing the three years prior to commencing clozapine to the period following establishment of clozapine treatment (mean 36.4 months) for 26 patients with chronic schizophrenia or schizoaffective disorder.

There was a significant improvement in all clinical ratings applied (and a mean net saving of £3768 per annum). The cost-effectiveness of clozapine was double that of conventional neuroleptics (15.2 pre-, 33.0 post-clozapine, P < 0.005).

As a naturalistic study our data provide valuable information on the cost-effectiveness of clozapine in the UK. Our methodology could be applied in a community setting or in the study of another atypical neuroleptic.

Psychiatric morbidity studies in developing countries have used diagnostic procedures of low reliability, without a clinical definition of caseness, producing descriptive data with limited application for mental health planning.

A two-stage cross-sectional design (with a sample size of 6476) was conducted to estimate the prevalence of DSM–III psychiatric diagnoses in three metropolitan areas of Brazil (Brasília, São Paulo and Porto Alegre). All subjects were screened for the presence of psychopathology with a 44-item instrument (the QMPA) and a subsample was selected for a psychiatric interview.

Age-adjusted prevalence of cases potentially in need of care ranged from 19% (São Paulo) to 34% (Brasília and Porto Alegre). Anxiety disorders comprised the highest prevalences (up to 18%). Alcoholism yielded the most consistent prevalence levels, around 8% in all sites. Depression showed great variation between areas: from less than 3% (São Paulo and Brasília) to 10% (Porto Alegre)

Overall prevalences were high in comparison with previous studies conducted in Brazil. A female excess of non-psychotic disorders (anxiety, phobias, somatisation and depression) and a male excess for alcoholism were consistently found.

We report a randomised controlled trial, in both the acute and maintenance stage of treatment, in 75 outpatients with recurrent major depression.

Patients were allocated to three groups: 16 weeks of acute treatment and two years' maintenance treatment in the following way: antidepressants and maintenance antidepressants; cognitive therapy and maintenance cognitive therapy: antidepressants and maintenance cognitive therapy. Both completers' and end-point data were analysed.

In the acute phase of treatment, all patients improved significantly and there was no significant difference among treatments, or in the pattern of improvement over time. In the maintenance stage of treatment, patients kept improving over time in all three groups and there was no significant difference among treatments. Cognitive therapy was consistently superior to medication.

The results indicate that maintenance cognitive therapy has a similar prophylactic effect to maintenance medication and is a viable option for maintenance after acute treatment with medication in recurrent depression.

It is argued that coping theory may be useful in attempting to understand how relatives adapt to the demands of living with a schizophrenia sufferer.

In a prospective study, univariate and multivariate relationships were explored between appraisal variables (appraisal of symptom threat (primary appraisal) and perceived symptom control (secondary appraisal)) and (a) expressed emotion, and (b) psychological distress in relatives of schizophrenic patients. The profile of relatives who showed sustained distress over time was also examined.

The appraisal variables were found to be related to both the concurrent distress (GHQ scores), EE ratings of relatives at the time of the patients relapse and hospitalisation, as well as the subsequent GHQ scores of relatives when the patient was discharged back home. Relatives who showed sustained distress were likely to show high EE and have a longer caring history.

The study gives some support to the theory that appraisal processes underlie how relatives react to having a family member with schizophrenia, and may have implications both for identifying those at risk of poor adaptation, and for understanding strategies that improve well-being.