We tested the validity of two screens for depression in older African–Caribbean adults, the 15-item Geriatric Depression Scale (GDS) and a new Caribbean Culture-Specific Screen for emotional distress (CCSS). Two independent criteria were used for validity: (a) a psychiatric diagnosis derived from GMS–AGECAT, and (b) a culturally sensitive assessment of mental disorder, derived from a tool developed with local African–Caribbean religious healers.

One hundred and sixty-four consecutive African–Caribbean primary care users, aged 60 years or older, were screened with the GDS and the CCSS. Diagnostic interviews were carried out on 80% of high scorers and 20% of low scorers.

The number of cases detected by the two separate diagnostic approaches was similar. However, the agreement between who was and who was not a case was only modest. At a cutoff of $5, the GDS was an adequate case detector for psychiatric depression, and, at a cut-off of $4, for ‘depressed/lost spirit’, as defined by culture-specific criteria. It performed as well as the new CCSS.

At a cut-off of $4 the 15-item GDS can be recommended as a case detector for significant forms of depression in older African–Caribbean people living in south London.

The PRiSM Psychosis Study investigated the outcomes of community mental health services for epidemiologically representative cases of psychosis in London.

The results presented in the preceding nine papers are interpreted.

(a) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical settings, and are more effective than hospital-oriented services which they replace, (b) Dilution does occur - these gains are less pronounced than in experimental (efficacy) studies, (c) Both models of community services produced a range of improved outcomes, (d) Some limited extra advantages (in terms of met needs, improved quality of life, and social networks) were found in the intensive sector, (e) There is no consistent evidence that community-oriented services (which include in-patient beds) fail service users, their families or the wider public. On balance the results weigh slightly in favour of the two-team model (for acute and continuing care) in terms of clinical effectiveness, but the general model is almost as effective and is less expensive.

The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models.

Mania with chronic course has been overlooked in the recent literature. Our aim was clinically to characterise and validate this form of mania.

We evaluated 155 people with DSM–III–R mania and assessed their family history, temperament, symptomatology and course. We used a semi-structured interview for mood disorders, as well as the Comprehensive Psychopathological Rating Scale and the Scale for the Assessment of Positive Symptoms.

Twenty (13%) had a chronic course arising from a background of hyperthymic temperament and recurrent mania, with a deteriorative pattern. Clinically, they were characterised by a significantly high rate of almost constant euphoria, grandiose delusions and related delusions, but had relatively low rates of sleep disturbance, psychomotor agitation and hypersexuality.

Even with current therapies a significant number of people with bipolar disorders have a deteriorative outcome associated with the gradual disappearance of acute mania with an increase in mregalomanic delusions, alienation from loved ones and decreased likelihood of medical and psychiatric care.

Aims of the Defeat Depression Campaign between 1991 and 1996 included the reduction of stigma associated with depression, education of the public about the disorder and its treatment and encouragement of earlier treatment-seeking. Newspaper and magazine articles, radio and television programmes and other media activities were employed.

Surveys of public attitudes were conducted by MORI in late 1991, early 1995 and mid-1997. Each covered approximately 2000 subjects, sampled to be representative of the population of Great Britain. Structured interviews covered views on depression, treatment and general practitioners (GPs).

There were significant positive changes regarding attitudes to depression, reported experience of it, attitudes to antidepressants, and less consistently, to treatment from GPs. Changes were of the order of 5–10%. Throughout, attitudes to depression and to treatment by counselling were very favourable, whereas antidepressants were regarded as addictive and less effective.

Positive attitude change was achieved during the Campaign, although there is still room for improvement in some aspects.

Previous studies of clozapine pharmacokinetics have shown a wide intra- and inter-individual variability of plasma levels in patients on stable clozapine doses. We investigated dose-plasma level relationships and intra-individual variability of plasma levels during maintenance treatment with clozapine.

Forty-one patients on clozapine were followed for 26 weeks with repeated plasma level measurements and assessments of co-medication and clinical symptoms. In a second step, 15 patients on stable clozapine doses between treatment Weeks 12 and 52 were followed in the same way. Coefficient of variation was used as a parameter of plasma level deviation.

Dose-plasma level correlations stayed significant from Week 6 to Week 26 (n=41). The group of patients followed up to Week 52 showed a mean intra-individual coefficient of variation of 52.8% (s.d. =20.6), and remained stable psychopathologically.

Even though clozapine plasma levels may show a significant degree of variation, this is not necessarily reflected in a change in psychopathology.

The use of illegal drugs is seen as & major social problem. The social costs can be high.

Self-report data from interviews at intake to the National Treatment Outcome Research Study (NTORS) for 1075 drug users and cost data from various sources were used to estimate criminal behaviour and health and addiction service costs for & 12-month period. Multivariate statistical analysis was used to analyse cost variations.

Total costs for one year for the drug users amounted to over $12 million, the majority attributable to self-reported criminal behaviour. Social costs were positively related to & variety of factors including instability in living circumstances, amount of heroin used and whether or not drugs were taken intravenously.

The study clearly demonstrates the economic and social burden associated with heavy drug users and highlights the need for further investigations into the costs and benefits of policies that can reduce these social costs.

Physical symptoms and psychiatric disorder are associated. We aimed to investigate which comes first.

Data from the Medical Research Council National Survey of Health and Development, a population-based birth cohort study were used at two time points: 36 and 43 years. Six physical symptoms were reported at both time points. The Present State Examination and Psychiatric Symptom Frequency interviews were administered at 36 and 43 years respectively. Odds ratios corrected for a variety of confounders were used to describe the associations between physical symptoms and psychiatric disorder across these two time points.

Psychiatric disorder increased the odds of reporting symptoms 3–7-fold. The relationship strengthened when the outcome was defined as suffering from multiple symptoms. Population attributable risk of psychiatric disorder and subsyndromal disorder in causing multiple somatic symptoms was 40.3%. Prospectively, psychiatric disorder at 36 years was a predictor for five of the six physical symptoms. Three physical symptoms at 36 years predicted new onset of psychiatric symptoms at 43 years.

Psychiatric disorder is strongly related to physical symptoms. The direction of causality may operate in both directions. Assuming a causal relationship, psychiatric disorder (including subthreshold disorders) could account for at most 40% of cases of multiple physical symptoms.

There have been few epidemiological studies of the disabling and poorly understood disorder self-injurious behaviour among adults with learning disabilities.

Interviews were undertaken with the carers of adults known to the Leicestershire Learning Disabilities Register (n=2277). The Disability Assessment Schedule was used and information was also collected on demographic characteristics, developmental and physical status.

Self-injurious behaviour was present in 17.4% of the population. In 1.7% self-injurious behaviour occurred frequently and was severe. There was no gender difference between those with and without self-injurious behaviour. Both the chronological age and developmental quotient of individuals with self-injurious behaviour were lower than those of individuals without self-injurious behaviour. Autistic symptoms were more common among those with self-injurious behaviour. The association of self-injurious behaviour with a wide range of other maladaptive behaviours was highly significant. Logistic regression analysis retained age, developmental quotient, hearing status, immobility and number of autistic symptoms as explanatory variables for self-injurious behaviour.

Self-injurious behaviour is a prevalent and disabling disorder among adults with learning disabilities.

The National Treatment Outcome Research Study (NTORS) is the first large-scale, prospective, multi-site treatment outcome study of drug users in the UK.

Substance use, health and social problems of 1075 service users were assessed at intake to 54 agencies chosen to be representative of the main national drug treatment modalities.

Heroin dependence was the most frequently reported problem often with poly-drug and alcohol problems. Most service users injected drugs and & quarter of the injectors shared injecting equipment. Poly-drug use and heavy drinking were more common among service users admitted to residential treatments. High criminality rates were reported Psychological and physical health problems were common and many service users had prior contact with psychiatric and medical services.

The range and severity of problems adversely affect individual users, their families, and present & challenge to addiction treatment services. These problems create costs for the health care, social service and criminal justice system responses.

Although cocaine use in women has increased substantially over the past half-century, we understand little about the aetiology in women of cocaine use and abuse, and know almost nothing about the role of genetic factors.

We obtained by telephone interview a history of lifetime cocaine use, abuse and dependence from 1934 individual twins from female–female pairs ascertained through a population-based registry, including both members of 485 monozygotic (MZ) and 335 dizygotic (DZ) pairs.

The prevalence of lifetime cocaine use, abuse and dependence were 14.0%, 3.3% and 2.3%. Probandwise concordance rates, in MZ and DZ twins, respectively, were: cocaine use 54% and 42%; cocaine abuse 47% and 8% and cocaine dependence 35% and 0%. In MZ and DZ twins, odds ratios were: cocaine use 14.2 and 6.7 and cocaine abuse 40.8 and 2.7. Biometrical model-fitting suggested that twin resemblance for liability to cocaine use was due to both genetic and familial–environmental factors while twin resemblance for cocaine abuse and symptoms of dependence was due solely to genetic factors. Estimated heritabilities were: cocaine use 0.39, cocaine abuse 0.79 and symptoms of dependence 0.65.

The vulnerability to cocaine use and particularly cocaine abuse and dependence in women is substantially influenced by genetic factors.

We sought to determine the extent and appropriateness of benzodiazepine use in an elderly community, by measuring prevalence and incidence of benzodiazepines and examining mental health status as a predictor of benzodiazepine use.

Data were collected from two longitudinal studies of people from the same community, sampled in 1982–1983 and again in 1989–1991.

Benzodiazepine prevalence did not decrease during the period under study, but there was a significant reduction in anxiolytic use. Prevalence of benzodiazepines in women is twice that in men, and incidence of hypnotics is slightly higher in women. Prevalence and incidence of hypnotics are strongly associated with increasing age. There were high proportions of long-term users (61 and 70%), and continued use was high (52%) among new users. A large proportion of benzodiazepine use was by those who were concurrently depressed. Similarly, anxiety predicted both current and subsequent use of hypnotics.

Many older people still use benzodiazepines, contrary to official guidelines with regard to their mental health. Our findings add to the weight of opinion that persistent and long-term use should be discouraged.

Somatisation is a common and frustrating clinical problem in primary care.

Using structural diagnoses and functional measures, we examined the prevalence and associated features of somatisation disorder defined by three current nosologies and an abridged construct in subjects using primary care services.

Somatisation disorder, diagnosed according to the standard criteria, was found to have a very low prevalence (range 0.06–5%), while more than one-fifth of the sample (22%) met the criteria for the abridged diagnosis. There was poor agreement between succeeding versions of the DSM system for identifying cases of somatisation disorder, each system ending up with rather disparate sets of individuals as well as variable levels of psychopathology and disability.

According to these data, standard somatisation disorder diagnoses add little to the prediction of disability/psychopathology beyond the contributions of an abridged construct of somatisation.

We aimed to examine the hypotheses that major depression is aetiologically heterogeneous consisting of a mixture of ‘genetic’ and ‘non-genetic’ forms or, alternatively, a mixture of one form that is ‘pure’ depression and another that has a familial relationship with alcohol dependency or other disorders.

One hundred and eleven twin pairs (44 monozygotic, 67 dizygotic) where the proband had received treatment for DSM–IV major depression were ascertained via a hospital register. Family history information on parents and siblings was obtained from the proband, co-twin or both. Diagnoses on parents and siblings were made blind to twin zygosity or concordance and compared in the relatives of concordant versus discordant twins.

The lifetime prevalence and age-corrected risk of depression were no different in the relatives of concordant and discordant twin pairs. There was a marginally significant increase in the rate of alcohol abuse or dependence among the relatives of concordant twins but no difference between concordant and discordant pairs in respect of other axis I diagnosis among family members.

The results argue against genetic heterogeneity and suggest that major depression cannot usefully be divided into genetic and non-genetic forms or into ‘pure’ depression and depression associated with other disorders such as alcohol dependency.