Many patients suffering from psychosis are unaware of their disorder and symptoms.

To investigate whether insight changes with time, and how it relates to patients' psychopathology, and to examine the correlations between insight scales in patients with psychoses.

Seventy-five consecutively admitted in-patients with schizophrenia, affective disorder with psychotic symptoms, or schizoaffective disorder were examined after remission of an acute episode and at follow-up (>6 months). Three different scales were used to assess insight.

To some extent, insight into past episodes improved over time in patients with psychosis, regardless of diagnosis. Few significant relationships between insight and psychopathology remained stable at follow-up. The higher the negative and disorganisation dimensions at baseline, the less did attitudes to treatment vary when tested at follow-up. No predictive value for variability of psychopathological dimensions was found for insight dimensions. The insight scales used were highly intercorrelated, suggesting that they measure the same construct.

Insight and psychopathology seem to be semi-independent domains.

A clear distinction has been made between efficacy and effectiveness in relation to the methods of evaluation of new psychological treatments in psychiatry. Efficacy trials target patients with relatively pure conditions, who may not be representative of the patients who are usually referred for psychological treatment in a clinical setting. Few studies have explored the benefits of psychotherapy in patients with complex disorders and enduring symptoms.

To explore the rationale for the distinction between efficacy and effectiveness, particularly in relation to outcome studies of patients with complex and enduring disorders.

A narrative review with examples drawn from the literature, and an illustration of a recent naturalistic outcome study which combines features of both efficacy and effectiveness.

Studies of patients with complex and mixed disorders can be designed so that they retain internal validity, but also have external validity and are relevant to clinical practice.

Studies which evaluate psychological interventions should be carried out in populations of patients clinically representative of those who are likely to receive the intervention, should it be shown to be of benefit.

Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.

We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.

One hundred and five patients with ICD–10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.

Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.

The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms.

Psychiatrists have been criticised for failing to develop adequate treatment for personality disorder. Psychotherapeutic treatments are promising, but their effectiveness is uncertain.

To investigate the evidence for effectiveness of psychotherapeutic treatment for personality disorder.

Systematic literature review.

There is evidence for the effectiveness of psychotherapy for personality disorder. Problems of case identification, comorbidity, randomisation, specificity of treatment and outcome measurement are inadequately addressed. Authors mainly relied on cohort studies. Evidence neither suggests superiority of one type of therapy over another nor indicates which subgroups of patients should be offered psychotherapy as in-patient, day patient, or out-patient.

New research strategies are needed to show that personality change is both measurable and clinically meaningful. Effectiveness studies using randomised controlled designs are required. The literature suggests that effective treatment should be long-term, integrated, theoretically coherent and focused on compliance.

Double-blind placebo-controlled trials are the academic standard for clinical psychopharmacology research.

To identify the potential defects of current double-blind procedures in trials involving antidepressants and to investigate whether safeguards for blindness protection are used.

We reviewed the literature and devised a short seven-item checklist for evaluating the quality of blindness protection. We performed a computerised search for 1998 to identify the placebo-controlled studies that evaluated the efficacy of an antidepressant. The checklist was used to assess all traceable antidepressant trials published in 1998.

Relevant criticisms question the blindness procedures. The available methods which may bolster blindness are very seldom used.

Improvement in the blindness procedures used for antidepressant trials is necessary, feasible and measurable.

In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).

We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.

Patients with ICD–10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.

Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in ‘lower status’ roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.

Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and ‘group fit’. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed.

It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders.

To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications.

A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years.

At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05).

Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

In an earlier study we showed that a powerful emotional experience (the Kobe earthquake) reinforced memory retention in patients with Alzheimer's disease, but we could not control factors other than the emotional impact of the earthquake.

To test our previous findings in a controlled experimental study.

Recall tests consisting of two short stories were administered to 34 patients with Alzheimer's disease and 10 normal subjects. The two stories were identical except for one passage in each story: one was emotionally charged (arousing story) and the other (neutral story) was not.

In both groups, the emotionally charged passage in the arousing story was remembered better than the counterpart in the neutral story. In addition, the extent of the memory improvement was similar in the subjects and in the controls.

The results provide further evidence that emotional arousal enhances declarative memory in patients with Alzheimer's disease, and give a clue to the management of people with dementia.

Persons of African – Caribbean origin are more frequently imprisoned, and increasing evidence suggests they are detained more frequently in psychiatric hospitals, following offending behaviour.

To estimate population-based prevalence rates of treated mental disorder in different ethnic groups compulsorily admitted to secure forensic psychiatry services.

A survey was recorded of 3155 first admissions, from 1988 to 1994, from half of England and Wales, with 1991 census data as the denominator adjusted for under-enumeration.

Compulsory admissions for Black males were 5.6 (CI 5.1–6.3) times as high as, and for Asian males were half, those for White males; for Black females, 2.9 (CI 2.4–4.6) times as high and for Asian females one-third of those for White females. Admissions of non-Whites rose over the study period. Patterns of offending and diagnoses differed between ethnic groups.

Variations in compulsory hospitalisation cannot be entirely attributed to racial bias. Community-based services may be less effective in preventing escalating criminal and dangerous behaviour associated with mental illness in African–Caribbeans.

HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents) is a recently developed measure of outcome for use in child and adolescent mental health services (CAMHS).

To examine HoNOSCA's sensitivity to change, convergent validity and clinical usefulness.

Prospective study of new CAMHS attenders. Questionnaires completed by clinicians, parents and referrers at initial assessment and after 6 months.

Follow-up HoNOSCAs on 203 children indicated statistically significant change. There were significant associations between change in HoNOSCA scores, changes in other clinician- and parent-rated scales (r=0.51 to 0.32) and in global outcome ratings by referrers, parents and clinicians. Intraclass correlation coefficients for the summated HoNOSCA scores were high. HoNOSCA change was positively correlated with initial HoNOSCA score (r=0.46, P<0.001) and it was linked to psychiatric diagnosis.

HoNOSCA is a sensitive, valid measure of change among CAMHS attenders.

Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.

To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.

Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.

Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.

The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

Cognitive deficits are a core aspect of schizophrenia but there has been no study of cognitive function in a catchment-area-based population of patients with schizophrenia.

To assess cognitive function in a population of patients with schizophrenia, and relate it to community functioning.

All patients with schizophrenia in Nithsdale, south-west Scotland, were identified (n=182). Measures of assessment were: National Adult Reading Test (NART), Mini-Mental State Examination (MMSE), Rivermead Behavioural Memory Test (RBMT), Executive Interview (EXIT), FAS Verbal Fluency and Health of the Nation Outcome Scales (HoNOS).

We assessed 138 patients, mean age 48 years (standard deviation (s.d.) 15). Only 14% were in-patients. The mean premorbid IQ as assessed by NART was 98 (s.d. 14); 15% of patients had significant global cognitive impairment (MMSE); 81% had impaired memory (RBMT); 25% had executive dyscontrol (EXIT); and 49% had impaired verbal fluency (FAS). Scores on the functional impairment sub-scale of HoNOS correlated with all measures of cognitive impairment.

Cognitive dysfunction is pervasive in a community-based population of patients with schizophrenia.

There has been relatively little research on caregivers of people experiencing their first episode of psychosis.

To investigate dimensions of caregiving and morbidity in caregivers of people with first-episode psychosis.

Caregivers of 40 people with first-episode psychosis were interviewed at home about their experience of caregiving, coping strategies and distress.

Caregivers used emotional and practical strategies to cope with participants' negative symptoms and difficult behaviours and experienced more worry about these problems. They increased supervision when the participants displayed difficult behaviours. Twelve per cent of caregivers were suffering from psychiatric morbidity as defined by the General Health Questionnaire. Those living with the participant had more frequent visits to their general practitioner.

At first-episode psychosis, caregivers are already having to cope with a wide range of problems and are developing coping strategies. Caregivers worried most about difficult behaviours and negative symptoms in participants.

After exposure to traumatic stressors, a subgroup of survivors (20–30%) will develop post-traumatic stress disorder (PTSD).

Since the incidence and prevalence rates for PTSD in the community are significant, it is important that general practitioners and psychiatrists be familiar with possible therapeutic options. In this review we shall look at the published evidence about the effectiveness of psychological treatments for PTSD.

The psychopathological mechanisms involved in PTSD are discussed. Studies of the effectiveness of different psychological therapies are reviewed.

The review suggests that persistent fear or shame reactions are key aspects of PTSD. Evidence from systematic reviews suggests that psychotherapeutic treatments are effective in the therapy of reactions based on fear, and may increase the effectiveness of pharmacological therapy. There is less systematic evidence for the efficacy of interventions for symptoms based on shame.

Although a proportion of patients with complex or chronic PTSD may require specialist interventions, most patients can be treated effectively by a general psychiatric service which can offer both pharmacological and psychological interventions.

More treatment for substance misuse should be provided within prisons.

To examine differences between prisoners on remand with substance misuse problems and other prisoners on remand.

Random selection and interview of unconvicted male prisoners (n=750, a 9.4% sample), plus examination of the prison medical record.

Of the sample of 750, 253 subjects (33.7%) reported either drug- or alcohol-related health problems or dependency. Compared with other prisoners on remand, they reported more childhood adversity, conduct disorder, self-harm, past psychiatric treatment and current mood disorder, and had fewer qualifications, were more likely to be unemployed and have more housing difficulties.

One-third of unconvicted men in prison report substance-related problems, and these are a marker for vulnerability within a disadvantaged population. Health care providers should involve this group in treatment and rehabilitation, both inside prison and following release.

Third rather than lateral ventriculomegaly may be a more specific finding in psychosis. The relevance of ventricular abnormality remains unclear.

To investigate the developmental correlates of ventricular enlargement.

Information on childhood development and magnetic resonance images in 1.5-mm contiguous sections were collected on 21 patients experiencing a first episode of psychosis.

Patients (n=21) had significantly less whole brain volume and enlarged third and lateral ventricles compared to controls (n=25). Third ventricle (r=0.48, P < 0.03) and lateral ventricle (r=0.65, P < 0.01) volumes correlated with developmental score. Patients with developmental delay had significantly larger third and lateral ventricles than those without.

Enlargement of both third and lateral ventricles is found in first-episode psychosis and is related to developmental delay in childhood. Insult to periventricular areas is relevant to the neurobiology of the disease. These findings support the view that schizophrenia involves disturbance of neurodevelopmental processes in some patients.

For children referred to mental health services future functioning may be hampered.

To examine stability and prediction of behavioural and emotional problems from childhood into adulthood.

A referred sample (n=789) aged 4–18 years was followed up after a mean of 10.5 years. Scores derived from the Child Behavior Checklist, Youth Self-Report and Teacher Report Form were related to equivalent scores for young adults from the Young Adult Self-Report and Young Adult Behavior Checklist.

Correlations between first contact (T1) and follow-up (T2) scores were 0.12–0.53. Young adult psychopathology was predicted by corresponding TI problem scores. Social problems and anxious/depressed scores were predictors of general problem behaviour.

Problem behaviour of children and adolescents referred to outpatient mental health services is highly predictive of similar problem behaviour at young adulthood. Stability is higher for externalising than for internalising behaviour and for intra-informant than for inter-informant information. Stabilities are similar across gender. To obtain a comprehensive picture of the young adult's functioning, information from related adults may prove valuable.

Child psychiatric disorders are common and treatable, but often go undetected and therefore remain untreated.

To assess the Strengths and Difficulties Questionnaire (SDQ) as a potential means for improving the detection of child psychiatric disorders in the community.

SDQ predictions and independent psychiatric diagnoses were compared in a community sample of 7984 5- to 15-year-olds from the 1999 British Child Mental Health Survey.

Multi-informant (parents, teachers, older children) SDQs identified individuals with a psychiatric diagnosis with a specificity of 94.6% (95% CI 94.1–95.1%) and a sensitivity of 63.3% (59.7–66.9%). The questionnaires identified over 70% of individuals with conduct, hyperactivity, depressive and some anxiety disorders, but under 50% of individuals with specific phobias, separation anxiety and eating disorders. Sensitivity was substantially poorer with single-informant rather than multi-informant SDQs.

Community screening programmes based on multi-informant SDQs could potentially increase the detection of child psychiatric disorders, thereby improving access to effective treatments.

The identification of fluctuating confusion is central to improving the differential diagnosis of the common dementias.

To determine the value of two rating scales to measure fluctuating confusion.

The agreement between the clinician-rated scale and the scale completed by a non-clinician was determined. Correlations between the two scales were calculated; variability in attention was calculated on a computerised cognitive assessment and variability in delta rhythm on an electroencephalogram (EEG).

The Clinician Assessment of Fluctuation and the computerised cognitive assessment were completed for 155 patients (61 Alzheimer's disease, 37 dementia with Lewy bodies, 22 vascular dementia, 35 elderly controls). A subgroup (n=40) received a further evaluation using the One Day Fluctuation Assessment Scale and an EEG. The two scales correlated significantly with each other, and with the neuropsychological and electrophysiological measures of fluctuation.

Both scales are useful instruments for the clinical assessment of fluctuation in dementia.