There is a lack of cross-national research on care for people with schizophrenia.

To produce standardised European versions of five instruments in key areas of mental health service research in five languages, and to compare data from five European countries regarding patients with schizophrenia and mental health care provision and costs.

Five centres, in Amsterdam, Copenhagen, London, Santander and Verona, participated. Instruments assessing needs, service use, informal carer involvement, quality of life, and service satisfaction were subjected to a conversion procedure including translation, back-translation, focus group discussion and reliability assessment. Patients of local mental health services with a Schedules for Clinical Assessment in Neuropsychiatry diagnosis of schizophrenia were interviewed.

Service provision varied between sites; 404 patients were studied. instrument reliability was found to be good.

The instruments developed were reliable across the range of countries, and will facilitate future comparative health service research.

The 20th century has seen the globalisation and homogenisation of substance misuse problems, blurring traditional boundaries between producer and consumer countries and forcing the international community to consider new responses to substance misuse.

To highlight the importance of the principles of illicit drug demand reduction and related activities in tackling global drug problems and to discuss the commitment made by United Nations (UN) Member States at the highest political level towards meeting the objectives set in their Declaration on the Guiding Principles.

A review of international responses to substance misuse.

Traditionally, the focus has been on reducing the supply of controlled drugs, while maintaining adequate supplies of narcotic and psychotropic drugs for clinical and scientific purposes. However, it has become apparent that supply reduction in isolation is insufficient and demand reduction is now receiving greater emphasis – culminating in the UN General Assembly adopting the Declaration on the Guiding Principles of Demand Reduction in 1998.

This declaration offers a genuinely holistic approach to the complexities of substance misuse. To be successful, it requires the commitment of governments at the highest level and the willing participation of small communities.

Preliminary studies have suggested that paroxetine may be effective in social phobia/social anxiety disorder.

To assess the efficacy and tolerability of paroxetine in the acute (12-week) treatment of social phobia.

Two-hundred and ninety patients with social phobia were assigned randomly to paroxetine (20–50 mg/day flexible dose) or placebo for 12 weeks of double-blind treatment. Primary efficacy outcomes were the Liebowitz Social Anxiety Scale (LSAS) total score (patient-rated) and the Clinical Global Impression (GGI) scale global improvement item. The secondary efficacy variables included CGI scale severity of illness score and the patient-rated Social Avoidance and Distress Scale.

Paroxetine produced a significantly greater reduction in LSAS total score (mean change from baseline: –29.4 v. –15.6; P 0.001) and a greater proportion of responders (score $2 on CGI global improvement) (65.7% v. 32.4%; P < 0.001) compared with placebo at the end of the 12-week study period. Both primary efficacy variables were statistically significant compared with placebo from week 4 onwards. Paroxetine was generally well tolerated.

Paroxetine is an effective, well-tolerated treatment for patients with social phobia.

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

Previous attempts to decide whether there is significant year-to-year variation in the birth rate of people who subsequently develop schizophrenia have given conflicting results, probably because of differences in the statistical methods employed.

To determine whether there is significant year-to-year variation in the birth rate.

Variation in the birth rate for the period 1921–1960 was studied in three separate national data sets – English, Danish and Scottish – using cubic splines to smooth the distribution curve before calculating residuals from a Poisson distribution.

Over-dispersion was found in all three data sets, particularly in the Danish and Scottish data. However, the correlation between the sets of standardised residuals derived from the three data sets was only statistically significant for Denmark v. England.

There was statistically significant year-to-year variation in the birth rate of people who subsequently developed schizophrenia in three countries in north-west Europe in the years 1921–1960. This is potentially a clue to the nature of the environmental determinants of schizophrenia, but better data will be needed before useful explanatory hypotheses can be generated and tested.

A previous report by Crow of a left-sided increase in temporal horn volume in schizophrenia implies a left-sided loss of tissue.

To elucidate the structural nature of schizophrenia.

The volume of grey matter in the temporal pole and inferior, middle and superior temporal gyri was measured, in addition to the total volume of grey and white matter, in the temporal lobes of the brains of 29 patients with schizophrenia and 27 controls.

We found a significant left-sided reduction in the superior temporal gyrus in both males and females with schizophrenia, which was related to increasing age of onset in the males. The total volume of temporal lobe grey and white matter was also significantly reduced. Although being more marked on the left than the right, the lateralisation for these total grey and white measures (by contrast with the superior temporal gyrus alone) did not attain formal statistical significance.

Confirmation of a lateralised reduction in the superior temporal gyrus, which is differentially related to age of onset according to gender, adds to evidence that the changes in schizophrenia are in systems that are lateralised. The findings implicate language as the relevant function.

No interventions have been shown to be effective in reducing deliberate self-harm (DSH) repetition in this group of patients as a whole.

To investigate the effect on repetition of offering emergency telephone support in a group of hospital-admitted DSH patients.

Atotal of 827 DSH patients admitted to medical wards were randomly allocated to either control or intervention (green card) groups. In addition to treatment as usual, the intervention group was offered telephone support should any further crises occur. The main outcome measure was DSH repetition within six months of the index event.

The intervention had no significant effect on the overall DSH repetition rate (odds ratio 1.20, 95% CI 0.82–1.75). Sub-group analysis suggested that response to the intervention differed according to the past history of DSH – subjects with a previous history repeating more often and first-timers appearing to benefit.

No overall effect of the intervention was shown. Conclusions concerning sub-groups must be regarded as speculative, but they suggest that further assessment of the value of telephone support in first-timer DSH patients is indicated.

A considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals.

To examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security.

Re-conviction data for a f ive-to nine-year follow-up were collected for a four-year (1988–1991) special hospital discharge cohort of patients with personality disorder.

Individuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals.

Formal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

Late-onset schizophrenia (LOS) may have a basis in age-related coarse brain disease, but empirical support for this is conflicting.

Is LOS characterised by more neurological disease than early-onset schizophrenia (EOS)?

DSM–III–R–defined LOS subjects (n=27) were compared with 30 EOS and 34 volunteer control subjects on neurological status, neuropsychological test performance and brain magnetic resonance imaging (MRI)

LOS and EOS groups had more ‘soft’ neurological signs and drug-induced movement abnormalities, and performed more poorly on tests assessing speed of information processing, memory and frontal executive functioning. On MRI, the LOS and EOS groups had greater lateral ventricular size than the control group. The LOS subjects also had more signal hyperintensities in periventricular white matter and subcortical nuclei than controls.

LOS and EOS subjects were very similar on neuropsychological, neurological and structural neuroimaging parameters, except that there were more MRI periventricular hyperintensities in LOS subjects.

This is the first long-term follow-up of patients discharged from a medium secure unit.

To describe the short– and long-term outcomes of admission for all patients discharged during a 14-year period.

A longitudinal cohort study of all 234 patients discharged from the Denis Hill Unit, Bethlem Royal Hospital, between 1980 and 1994, followed for an average 6.6 years.

Although 48% of admissions were from prison, only 8% returned there, with most being transferred to another psychiatric bed. One-fifth of patients spent none of the follow-up time in the community; 75% of patients had at least one readmission; only 24% were convicted of further offences.

Re-offending rates are comparable with those for patients discharged from high-security hospitals, and much lower than those for released prisoners. The high readmission rates indicate the need for a range of services to maintain former patients in the community.

A follow-up of patients discharged from medium secure psychiatric units is used to compare outcome in patients of different ethnic origin.

To test the hypothesis that there are systematic differences in clinical outcome between ethnic groups.

A descriptive, longitudinal cohort study of discharges from a medium secure unit is used to compare the 125 patients of White/European ethnic origin and the 104 patients of Black/African–Caribbean origin.

Patients of African – Caribbean origin were admitted at three times the rate of White patients, had a higher prevalence of psychosis and a lower prevalence of personality disorder. There was no difference in outcome as measured by location at follow-up, readmission or re-offending.

The higher rate of admission of African–Caribbean patients is consistent with a higher level of demand. There is a need for studies of the pathways by which patients from ethnic minorities reach medium-security accommodation, with a view to early intervention.

Low cognitive ability and developmental delays have been implicated in the causation of mental illness.

To examine the prevalence, socio-demographic characteristics, psychopathology and social functioning profiles of people with low intelligence and recurrent psychotic illness.

A multi-centre randomised controlled trial of case management provided the opportunity to explore associations between mental illness and borderline intellectual functioning (assessed using the National Adult Reading Test)

Overall prevalence of borderline intelligence was 18%. Significant positive associations were shown with: being Black Caribbean; having a father who worked in a manual occupation; lower educational achievement; having had special education; longer course of illness. Those with borderline intelligence had greater disability and were more likely to suffer extrapyramidal side-effects and show evidence of negative symptoms. Educational achievement, history of special education and social class were the best socio-demographic predictors of intellectual level.

Many patients who attend generic psychiatric services have considerable intellectual deficits. This may lead to difficulties in other domains of adaptive functioning, and merits further investigation as well as clinical vigilance.

Since 1991, English mental health policy guidelines have been explicit in recommending inter-professional working, involvement of patients and carers, harmonisation between health and social services and targeting at people with severe mental illness.

To explore the structure and operation of mental health services in practice and relate them to measurable data.

A survey of mental health trusts was conducted in 1997–1998. Responses were compared with a concurrent survey of social services departments. Some qualitative data were collected. Harmonisation and targeting scores were devised and tested for association.

The response rate was 79%. The frequency with which different professionals, patients and carers were involved in the care process is described. Reasons for this are discussed briefly. Levels of harmonisation and targeting were found to vary widely and to be positively associated.

This survey portrays mental health services' practice in relation to Government policy. However, adherence to guidelines cannot be taken as a guarantee of service quality or efficiency.

The incidence rate for broad schizophrenia among second-generation African–Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors.

To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997)

A12-month study of all persons in the 18–54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using World Health Organization screening and measurement instruments.

On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10 000 (95% CI 1.97–3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10 000 (95% CI 2.3–4.1), which is significantly lower than the comparable rate for London's African–Caribbeans of 6.6/10000 (95% CI 4.5–8.7)

The very high rate for broad schizophrenia among African–Caribbean people in the UK is probably due to environmental factors.

Electroconvulsive therapy (ECT) is a controversial treatment for psychiatric disorders, particularly when it is administered to young people.

To assess how frequently ECT is administered to people under the age of 18 years in the UK, and why it is given.

Electroconvulsive therapy clinics, private hospitals, adolescent units and UK members of the Royal College of Psychiatrists were surveyed to ask if they were aware of ECT being administered during 1996 to a young person under the age of 18 years. Consultants identified as having prescribed ECT were sent a follow-up questionnaire.

Twelve young people were identified as having received ECT; three were aged 15 years or younger and eight were female. Nine patients were rated as improved following ECT. The indications for its use were similar to those for adults.

Electroconvulsive therapy is rarely administered to young people in the UK.

Treatment of patients with personality disorder remains controversial and severe mental illness is prioritised in secure forensic psychiatry services.

To compare patients with personality disorder and mental illness according to demography, referral, criminality, previous institutionalisation and diagnostic comorbidity.

A record survey of 511 patients with personality disorder and 2575 with mental illness admitted to secure forensic psychiatry services between 1 January 1988 and 31 December 1994 from half of England and Wales.

Personality disorder admissions declined over time; more were female, White, younger and extensively criminal (specifically, sexual and arson offences). Personality disorder was highly comorbid; antisocial, borderline, paranoid and dependent personality disorder were most prevalent.

Patients with personality disorder were highly selected and previously known to psychiatric services. Referrer, diagnostic comorbidity and behavioural presentation determined their pathways into care. Future research must determine whether their continuing admission represents effective use of scarce resources and whether new services are required.

An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.

To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.

A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.

Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.

The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

There have been few large-scale studies of long-term suicide risk in mental disorders in the UK.

To estimate the long-term risk of suicide in psychiatric patients.

A sample of 7921 individuals was identified from the Salford Psychiatric Case Register. Mortality by suicide or undetermined external cause during a follow-up period of up to 18 years was determined using the NHS Central Register; suicide risks were estimated as rate ratios.

Suicide risk was increased more than ten-fold in both genders: the rate ratio for males was 11.4; for females it was 13.7. The risk was highest in young patients, but high risk continued into late life. The diagnoses with the highest risk were schizophrenia, affective disorders, personality disorder and (in males) substance dependence. Risk was also associated with recent initial contact and number of admissions but not comorbidity.

The suicide risks estimated in this study are generally higher than those previously reported, notably in schizophrenia and personality disorder, and in previous in-patients. Patients with these high-risk diagnoses, an onset of illness within the previous 1–3 years, or more than one previous admission should be regarded as priority groups for suicide prevention by mental health services.

The temporal stability of a diagnosis is one measure of its predictive validity.

To measure diagnostic stability in first-episode psychosis using ICD–10 and DSM–III–R.

Between 1992 and 1994 we ascertained a cohort of persons with first-episode psychosis (n=168), assigning to each a consensus diagnosis. At three-year follow-up, longitudinal consensus diagnoses, blind to onset diagnoses, were made. Stability was measured by the positive predictive values (PPVs) of onset diagnoses. For onset schizophrenia, we also calculated sensitivity, specificity and concordance (κ).

First-episode ICD–10 and DSM–III–R schizophrenia had a PPV of over 80% at three years. Over one-third of cases with ICD–10 F20 schizophrenia at three years had non-schizophrenia diagnoses at onset. Manic psychoses showed the highest PPV (91%). For onset schizophrenia, both systems had high specificity (ICD–10: 89; DSM–III–R: 93%), but low sensitivity (ICD–10: 64%; DSM–III–R: 51%) and moderate concordance (ICD–10: 0.54; DSM–III–R: 0.46).

Bipolar disorders and schizophrenia showed the highest stability. DSM–III–R schizophrenia did not have greater stability than ICD–10 schizophrenia.

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.