Further evidence of relation between prenatal famine and major affective disorder

OBJECTIVE

In a previous study, the authors demonstrated an association between prenatal famine in middle to late gestation and major affective disorders requiring hospitalization. In this study, they sought to examine the association by using newly identified cases from the Dutch birth cohort used previously to examine the gender specificity of the association and to assess whether this relation is present for both unipolar and bipolar affective disorders.

METHOD

The authors compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to famine during the Dutch Hunger Winter of 1944-1945. These cases of major affective disorder requiring hospitalization were newly ascertained from a national psychiatric registry. A larger data set from this registry was used for analysis by gender and diagnostic subtype.

RESULTS

For the newly ascertained cases, the risk of developing major affective disorder requiring hospitalization was increased for subjects with exposure to famine in the second trimester and was increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects. For the cases from the entire period of ascertainment, the risk of developing affective disorder was significantly increased for those exposed to famine during the second and the third trimesters of gestation. The effects were demonstrated for men and women and for unipolar and bipolar affective disorders.

CONCLUSIONS

These results provide support for the authors' previous findings on the association between middle to late gestational famine and affective disorder.

Principles of practice from the European expert panel on the contemporary treatment of schizophrenia

Providing optimal treatment for people with schizophrenia is a difficult long-term problem for clinicians and healthcare providers. Over the years a variety of approaches to treatment have evolved and, until now, there have been no widely accepted standards for care. To determine the principles underpinning the best practice for schizophrenia treatment, an Expert Panel of European psychiatrists and psychologists has worked to distil current theory, collective practical experiences and published literature into 17 basic Principles of Practice . These are not intended to duplicate or replace local treatment policies or guidelines. Instead, they describe best practice in diagnosis, patient assessment and long-term treatment of schizophrenia as it exists at the beginning of the 21st century and is likely to exist in the near future. The Principles of Practice broadly fall into four main categories: (1) assessment, diagnosis and care provision; (2) treatment in day-to-day practice; (3) building a positive therapeutic alliance; and (4) a long-term clinical commitment. Running through all the Principles are several common threads - the fundamental importance of the therapeutic alliance between the clinician and the patient, the need to plan both for treatment efficacy and avoidance of side-effects and the importance of long-term treatment planning. It is intended that psychiatrists and other healthcare professionals can use the Principles as a benchmark for optimum patient management, and as a tool when negotiating the future of local and national schizophrenia management services. Furthermore, the Principles of Practice represent a first step in the development of a new patient-centred philosophy for the care of people with schizophrenia.

From first episode to long-term care: The need for sustained clinical commitment

There is considerable evidence to suggest that many patients experience difficulties in gaining access to treatment after the onset of significant symptoms and social disability. Delay in obtaining appropriate support and treatment can have profound effects on both the patient and their family and may also be associated with a poorer long-term outcome. As stated in the Principles of Practice, prompt and comprehensive clinical assessment, by a clinician experienced in the recognition and treatment of severe mental illness, is therefore important for achieving the best possible outcome for the patient. The primary objectives of early-stage treatment for schizophrenia are to achieve a full improvement in psychopathological symptoms and a recovery of premorbid levels of function. However, even with optimal treatment, the reality for many patients is that their symptoms and impairment continue. Many patients can therefore be regarded as only partially responsive, or even resistant, to treatment. When assessing the utility of an antipsychotic treatment regimen for such patients, clinicians should not just consider the objective manifestations of the disorder but also the subjective experience of the patient. Relapse of illness is also a common and serious problem for many patients with schizophrenia, despite continual treatment. Prevention and management of relapse are two of the main challenges in the effective treatment of schizophrenia. The optimal use of antipsychotic treatment and the adherence by patients to that treatment offer valuable protection against relapse. Symptoms of depression or low mood affect a high proportion of patients with schizophrenia at some point in their illness and are also associated with an increased risk of relapse. Treatment objectives in the early stages may need to be modified if a pattern of partial response or resistance to treatment, a cycle of relapse of the illness or the presence of depressive symptoms, develops. Clinicians should continue to offer a sustained and positive clinical commitment to all.

Suicidality and substance misuse in first-admitted subjects with psychotic disorder

OBJECTIVE

The aim of this study was to examine the links between suicidality and substance misuse (abuse or dependence) in subjects with early psychosis.

METHOD

Data were collected on a sample of first-admitted subjects with psychosis (n=64).

RESULTS

More than 1 in 4 patients had a history of parasuicide, and more than 1 in 10 patients were referred to the psychiatric hospital after such an act. Parasuicide was more frequent in subjects with a history of drug misuse (OR=4, 95% CI= 1.1-14.0, P=0.03), and especially of polysubstance use (OR=6.6, 95% CI=1.2-34.7, P=0.03).

CONCLUSION

The association between substance misuse and suicidality found in subjects with psychosis is similar to that which exists in the general population. Since early psychosis is a high-risk period for substance misuse, subjects with incipient psychosis may be especially vulnerable to the devastating consequences of drug use with regard to increased risk of suicide.

Life events, ethnicity and perceptions of discrimination in patients with severe mental illness

BACKGROUND

Whilst it is commonly believed that black and ethnic minority (B&EM) people living in the UK experience social disadvantage compared with the white British (WB) population, no study has specifically addressed this issue in patients with severe mental illness. We sought to test the hypothesis that B&EM patients experience more negative life events than their WB counterparts, and to examine the extent to which they attribute these events to discrimination.

METHOD

Thirty-four WB, 78 African Caribbean (AC) and 35 other ethnic minority patients with psychotic illnesses, defined using Research Diagnostic Criteria, were asked to complete a Racial Life Event Questionnaire examining life events and perceptions of discrimination at baseline and 12 and 24 months later.

RESULTS

African Caribbean patients experienced more 'Financial' life events across the study period, otherwise there were no significant differences between patient groups in number of life events experienced. The B&EM group collectively (n = 113), however, were significantly more likely than the WB group (n = 34) to attribute 'Assault', and 'Legal' life events to discrimination. The AC patient group were significantly more likely than the other two ethnic groups to attribute the 'Financial' and 'Health' life events they experienced to discrimination. The B&EM group was also significantly more likely, and particularly the AC patient group, to report that members of their own ethnic group are adversely affected by discrimination. Further analyses showed skin colour rather than ethnicity or nationality to be the major contributing factor to perception of discrimination; thus, the Irish (n = 11) had similar scores to the WB while Africans (n = 16) scored like the ACs.

CONCLUSION

Our study shows that B&EM patients do not experience significantly more life events than WB patients; however, their perception of these events is clearly different, and significantly more often attributed to racism. It is reasonable to suppose that patients may be disinclined to utilise services they believe to be prejudiced against them on the basis of their skin colour, and service providers need to be aware of this in order to create health care services that B&EM patients feel confident to use.

Increased occurrence of depression in psychosis-prone subjects: a follow-up study in primary care settings

A follow-up survey was performed with a network of general practitioners (GPs) to examine whether a higher proneness for psychosis predicts a greater incidence of depression in subjects with no history of mood disorder. At the first stage of the survey (T1), a self-report questionnaire exploring delusional ideation (Peters et al. Delusional Inventory [PDI-21]) was administered to the patients of the GPs. Information on psychiatric status at the baseline and conclusion of the 12-month follow-up period was provided by the GPs. The present study was restricted to 425 subjects with no lifetime history of depression. An incident depression was diagnosed in 18 subjects. Most items exploring delusional beliefs and hallucinations were more frequently endorsed by subjects with incident depression. Subjects with a PDI-21 score above the 90th percentile at T1 were nine times more likely to present with an incident depression during the follow-up period than those with PDI-21 scores below the 10th percentile. Psychosis proneness is associated with a greater risk for depression, suggesting that a continuum of vulnerability may exist between affective disorder and nonaffective psychosis.

Self-reported psychosis-like symptoms and the continuum of psychosis

BACKGROUND

It has been suggested that psychotic symptoms may be distributed along a continuum that extends from normality through depressive states to schizophrenia with increasing level of severity. This study examined the hypothesis that the severity of positive psychotic symptoms increases from normality, through depression/anxiety states to clinical psychosis.

METHODS

Consecutive general practice attenders completed a self-report questionnaire of 24 items of delusional ideation and hallucinatory experiences and the GHQ-12. The following groups were compared: (1) subjects with a diagnosis of psychosis (n = 57), (2) GHQ cases (n = 245), and (3) GHQ non-cases (n = 378).

RESULTS

Quantitative differences were apparent in the great majority of items on delusional ideation and hallucinatory experiences, in that normals scored lowest, psychosis patients scored highest and GHQ cases scored in between. This pattern of differences was apparent for all dimensions of psychosis-like experiences, including the more "schizophrenic" ones, with the exception of Grandiosity (GHQ cases similar to normals) and Paranormal Beliefs (no differences between the three groups).

CONCLUSIONS

Similar to findings in aetiological research, phenotypic differences between normal controls, patients with anxiety/depression and patients with psychosis appear quantitative rather than qualitative for core dimensions of psychosis.

Urbanization and risk for schizophrenia: does the effect operate before or around the time of illness onset?

BACKGROUND

Higher level of urbanicity of place of birth and of place of residence at the time of illness onset has been shown to increase the risk for adult schizophrenia. However, because urban birth and urban residence are strongly correlated, no conclusions can be drawn about the timing of the risk-increasing effect. The current study discriminated between any effect of urbanization before and around the time of illness onset.

METHODS

All individuals born between 1972 and 1978 were followed up through the Dutch National Psychiatric Case Register for first admission for schizophrenia until 1995 (maximum age 23 years). Exposure status was defined by a combination of place of birth and place of residence at the time of illness onset in the three most densely populated provinces of the Netherlands (the 'Randstad', exposed) or in all other areas (the 'non-Randstad', non-exposed). The risk for schizophrenia was examined in four different exposure groups: non-exposed born and non-exposed resident (NbNr, reference category), non-exposed born and exposed resident (NbEr), exposed born and non-exposed resident (EbNr) and exposed born and exposed resident (EbEr).

RESULTS

The greatest risk for schizophrenia was found in the EbNR group, without evidence for any additive effect of urban residence (rate ratio (RR) for narrow schizophrenia in EbNr group, 2.05 (95 % CI 1.18-3-57); in EbEr group, 1.96 (95% CI, 1.55-2.46)). Individuals who were not exposed at birth, but became so later in life, were not at increased risk of developing schizophrenia (RR for narrow schizophrenia in NbEr group, 0.79 (0.46-1.36)).

CONCLUSION

The results suggest that environmental factors associated with urbanization increase the risk for schizophrenia before rather than around the time of illness onset.

To what extent does symptomatic improvement result in better outcome in psychotic illness? UK700 Group

BACKGROUND

The effectiveness of therapeutic interventions in psychosis is increasingly reported in terms of reductions in different symptom dimensions. It remains unclear, however, to what degree such symptomatic changes are accompanied by improvement in other measures such as service use, quality of life, and needs for care.

METHODS

A sample of 708 patients with chronic psychotic illness was assessed on three occasions over 2 years (baseline, year 1 and year 2). A multilevel analysis was conducted to examine to what degree reduction in psychopathological scores derived from factor analysis of the Comprehensive Psychopathological Rating Scale (CPRS), was associated with improvement in service use, disability, subjective outcomes and measures of self-harm.

RESULTS

Reduction in positive, negative, depressive and manic symptoms over the study period were all independently associated with lessening of social disability. Reduction in negative symptoms, and to a lesser extent in positive and manic symptoms, was associated with less time in hospital and more time living independently, whereas changes in positive and manic symptoms resulted in fewer admissions. Subjective outcomes such as improvement in quality of life, perceived needs for care and dissatisfaction with services showed the strongest associations with reduction in depressive symptoms. Reduction in positive symptoms was associated with decreased likelihood of parasuicide. Results did not differ according to diagnostic category.

CONCLUSION

The findings suggest that changes in distinct psychopathological dimensions independently and differentially influence outcome. Therapeutic interventions aimed at reducing symptoms of more than one dimension are likely to have more widespread effects.

Tardive dyskinesia in psychosis: are women really more at risk? UK700 Group

It is commonly held that women are more at risk of developing tardive dyskinesia (TD). However, recent evidence suggests that this may only be the case in samples of older patients, men being more at risk in the younger age groups. Abnormal movements were measured with the Abnormal Involuntary Movement Scale (AIMS) in a sample of 706 chronic psychotic patients aged not older than 65 years (median age 36 years). Female gender was associated with a lower risk of TD (OR, 0.5; 95% CI, 0.3-0.7). The effect of gender was independent of other risk factors such as older age, severity of negative symptoms and exposure to antipsychotic medication in the previous 2 years. There was no evidence that the effect of these risk factors differed between the sexes. In samples of relatively young patients with chronic psychotic illness, who typically represent the majority of patients in community programmes for the severely mentally ill, men are more at risk of TD than women.

Special feature: childhood personality characteristics of schizophrenia: manifestations of, or risk factors for, the disorder?

Many retrospective studies, and an increasing number of prospective studies, have identified subtle abnormalities in preschizophrenics from as early as the first year of life. Premorbid characteristics include development delays, cognitive deficits, and abnormal social interactions. Schizoid personality traits have been a particularly well documented finding, and show some specificity in their association with schizophrenia. Information about the premorbid characteristics of schizophrenia has played a major role in the reorientation of the field, from regarding schizophrenia as an adult onset degenerative disorder, to considering it, at least in part, as a neurodevelopmental condition. However, whether the childhood personality traits are a reflection of an underlying brain lesion, or whether they are independent risk factors for the disorder, is uncertain. In the future, the identification of childhood characteristics may enable us to predict those who are at high risk of developing schizophrenia, and may even be useful in formulating preventive policies. However, at present, the powers of prediction are inadequate for such purposes.

Characteristics of early- and late-diagnosed schizophrenia: implications for first-episode studies

First-episode studies of schizophrenia are being carried out in many places. However, previous work has suggested that only half of the patients with schizophrenia receive the diagnosis in the initial stages of the illness. We examined whether cases of early- and late-diagnosed schizophrenia differed with respect to key sociodemographic characteristics and indicators of service use that might bias first-episode studies. Individuals who (i) presented for the first time between 1983 and 1993 to psychiatric services in a defined urban area with a cumulative mental health case register; and (ii) received a diagnosis of schizophrenia at least once during their mental health career were identified (n = 186). This sample was divided into those who received the diagnosis of schizophrenia for the first time within the first year of service contact (early-diagnosed schizophrenia; EDS), and those who received it for the first time after the first year of service contact (late-diagnosed schizophrenia; LDS). The 10-year incidence of EDS and LDS were 10.4 and 7.0 per 100,000 person-years, respectively. EDS and LDS did not differ in their pattern of association with sex, single marital status and higher levels of neighbourhood socioeconomic deprivation. However, EDS was more incident in the higher age groups, and the level of service use was higher for EDS cases in the first years of contact with mental health services, with LDS cases gradually catching up and exceeding EDS service use later in the illness course. Although differences between EDS and LDS were few, studies of patients with schizophrenia in the 'first' episode are likely to be most representative if patients who receive the diagnosis for the first time after previous episodes of care for non-schizophrenic episodes are also included.

The ecogenetics of schizophrenia: a review

Schizophrenia is generally thought to arise as a result of interactions between genetic vulnerability and environmental risk factors. However, research methods to actually investigate the pattern of hypothesized interactions have only recently been developed. In this article, we review the evidence that genes increase the risk for schizophrenia by making individuals more sensitive to environmental risk factors (genotype-environment interaction), or by making individuals more likely to select high-risk environments (genotype-environment correlation). It is likely that at least some of the impact of genes on the occurrence of schizophrenia is mediated through (sensitivity for) environmental risk factors such as a dysfunctional early family rearing environment, cannabis, viral infections, complications of birth and pregnancy, stressful life events and unknown environmental risk factors associated with urban birth or residence and membership of certain ethnic groups. With the advent of molecular genetics, further knowledge about possible genotype-environment interactions is urgently required in order to develop and improve strategies for the prevention and early treatment of schizophrenia.

Prenatal exposure to maternal stress and subsequent schizophrenia. The May 1940 invasion of The Netherlands

BACKGROUND

It has been suggested that prenatal exposure to maternal stress increases the risk of subsequently developing schizophrenia.

METHOD

The five-day invasion and defeat of The Netherlands by the German army in May 1940 constituted a severe, well-circumscribed national stressful event. Individuals exposed and non-exposed to this stressor in the first, second and third trimester of pregnancy were followed up for lifetime schizophrenia outcome through the National Psychiatric Case Register. REGISTER: Cumulative incidence of schizophrenia was higher in the exposed cohort (risk ratio (RR): 1.15, 95% CI 1.03-1.28), especially in those exposed in the first trimester (RR: 1.28, 95% CI 1.07-1.53). Significant interaction with gender was apparent in second trimester exposed cohorts (RR men: 1.35, 95% CI: 1.05-1.74; RR women: 0.83, 95% CI: 0.61-1.12).

CONCLUSION

Maternal stress during pregnancy may contribute to the development of vulnerability to schizophrenia. The apparent longer window of exposure in male foetuses may be related to the slower pace of male early cerebral development.

Is early adulthood a critical developmental stage for psychosis proneness? A survey of delusional ideation in normal subjects

It has been hypothesized that late adolescence and early adulthood might be a brain developmental stage favoring the clinical expression of psychotic symptoms in psychiatric or neurological diseases. The aim of the present survey was to examine the relationship between age and delusional ideation in a sample of subjects with no psychiatric disorder. The survey was carried out with the Aquitaine Sentinel Network of general practitioners. Consecutive practice attenders were invited to complete the PDI-21 (Peters Delusional Inventory 21 items), a self-report questionnaire designed to measure delusional ideation in the normal population. The study concerned 444 patients who had no lifetime history of psychiatric disorder and who completed the PDI-21. A principal component analysis of the PDI-21 items was performed in order to identify delusional dimensions. An age-related decrease in the likelihood to report delusional ideas was found, younger subjects scoring higher on most dimensions of delusional ideation, such as 'persecution', 'thought disturbance', 'grandiosity' and 'paranormal beliefs'. 'Religiosity' was the only dimension positively associated with age. The results suggest that there may be a physiological neurodevelopmental stage favouring the expression of psychosis proneness in normal subjects, and support the hypothesis that the association between age and positive psychotic symptoms in functional and organic psychoses may be linked to the interaction between normal brain maturational processes and cerebral abnormalities involved in the aetiology of functional and organic psychoses.

Obstetric complications and familial morbid risk of psychiatric disorders

Obstetric complications (OCs) have been found to occur in higher frequency in patients with schizophrenia. One explanation for this finding is that the genes that contribute to the schizophrenia phenotype also influence the likelihood to experience OCs. If this were true, morbid risk of psychiatric illness should be higher in the first-degree relatives of both schizophrenic and control probands exposed to OCs, compared to probands not exposed to OCs. We set out to test this hypothesis. Information on OCs, blind to family history of psychiatric disorder, was collected retrospectively through maternal interview in 151 psychotic patients and 100 controls. Family history (FH) in relatives of cases (n = 600) and controls (n = 461) was assessed with the FH-RDC and through personal interviews. Tests for associations between family history and OCs were conducted using Cox proportional hazard regression. In the cases, familial morbid risk of affective disorder was greater in those with a history of OCs (hazard ratio (HR) = 1.9, P = 0.007). Analyses examining individual complications revealed associations between FH of affective disorder and pre-eclampsia (HR = 2.9, P = 0.003) and FH of affective disorder and breech presentation (HR = 2.8, P = 0.02), especially when family history in the relatives was confined to affective illness in the mother (HR pre-eclampsia = 4.4, P = 0.009; HR breech-presentation = 4.2, P = 0.008). In controls, affective illness in the mother was not only associated with breech presentation (HR = 7.0, P = 0.01) and pre-eclampsia (HR = 4.4, P = 0.03) but also with other complications. Familial morbid risk of schizophrenia and related psychoses was not associated with OCs. The positive associations between OCs and familial morbid risk of affective disorder suggest that the factors that contribute to familial aggregation of affective symptoms in psychotic patients also influence the likelihood to experience OCs. Although the proportion of OCs that could be attributed to these factors was very small, part of the relationship between family history of affective disorder and psychosis may be mediated by OCs.

Persons with intellectual disability receiving psychiatric treatment

Determinants of (1) referral to psychiatric services and (2) the amount of mental health care consumed were analysed in a population of individuals with intellectual disability, using data from a cumulative mental health case register in a defined geographical area. Associations between level of disability, gender, age and social environment on the one hand, and psychiatric referral and service consumption on the other were expressed as odds ratios (ORs). Being older (OR = 1.9; 95% CI = 1.5-2.5), having milder intellectual disability (OR = 1.4; 95% CI = 0.9-2.3) and living alone (OR = 5.8; 95% CI = 2.8-11.9) predicted a higher probability of receiving psychiatric treatment. Living alone (OR = 15.3; 95% CI = 1.7-136.1) was also associated with higher level of mental health service consumption.

Tardive dyskinesia: who is at risk?

Tardive dyskinesia (TD) has been associated with female gender, affective symptoms and good outcome, but also with negative symptoms, cognitive deterioration and deteriorating illness course. Furthermore, antipsychotic medication is thought to be an important risk factor, yet abnormal movements also occur in patients who have never received such medication. We followed 166 subjects with recent onset of psychotic illness and brief previous exposure to antipsychotic medication. Information on 17 previously reported risk factors was available for 125 patients at baseline and, for factors that vary over time, again at follow-up 4 years later (median, 50 months; interquartile range, 29-70). Movement disorder was assessed at follow-up using the Abnormal Involuntary Movement Scale (AIMS). Six noninteracting variables were independently associated with the 4-year risk of TD: male sex (OR, 2.5; 95% CI, 1.1-5.0), age (OR over quartiles at baseline, 1.6; 95% CI, 1.1-2.2), lack of insight at baseline (OR over four categories, 2.0; 95% CI, 1.2-3.2), time on antipsychotics during the follow-up period (OR over quartiles, 2.3; 95% CI, 1.5-3.4), an increase in negative symptoms during the follow-up period (OR over quartiles, 1.7; 95% CI, 1.2-2.5), and alcohol/drug misuse at follow-up (OR, 3.0; 95% CI, 1.3-7.4). The presence of individual risk factors was found to be of little use as a screening test for subsequent clinically relevant TD. Given the absence of a risk factor, however, the probability that an individual would not develop TD was high. These results suggest that two discrete effects may operate to increase the risk of TD, namely an exogenous factor (medication, drugs), and an illness-related factor, the highest risk being conferred by deteriorating illness course in male patients.

Developmental precursors of affective illness in a general population birth cohort

BACKGROUND

Recent evidence suggests that neurodevelopmental impairment may be a risk factor for later affective disorder.

METHODS

Associations between childhood developmental characteristics and affective disorder were examined in a prospectively studied national British birth cohort of 5362 individuals born between March 3 and March 9, 1946. Mental state examinations by trained interviewers performed at ages 36 and 43 years identified 270 case subjects with adult affective disorder (AD). Teachers' questionnaires completed at age 13 and 15 years identified 195 case subjects who had shown evidence of childhood affective disturbance (CAD).

RESULTS

Female gender and low educational test scores at ages 8, 11, and 15 years were a risk factor for AD, CAD, and AD without CAD. In addition, attainment of motor milestones was later in the CAD group (odds ratio [OR] = 1.2; 95% confidence interval [CI], 1.1-1.3), followed by, and independent of, greater risk for speech defects between the ages of 6 and 15 years (OR = 2.0; 95% CI, 1.3-3.0), decreased psychomotor alertness on medical examination between ages 4 and 11 years (OR = 4.6; 95% CI, 2.2-9.7), and an excess of twitching and grimacing motor behaviors in adolescence (OR = 3.9; 95% CI, 2.5-6.1). Persistent CAD was strongly associated with persistent AD (OR = 7.8; 95% CI, 2.6-23.2).

CONCLUSION

The findings give credence to the suggestion that affective disorder, especially its early-onset form, is preceded by impaired neurodevelopment.

Explaining sex differences in course and outcome in the functional psychoses

We addressed the following three questions: (i) are there sex differences in outcome in the functional psychoses?, (ii) what is their effect size, and which variables mediate the effect of sex on outcome?, (iii) is the effect of sex diagnosis-specific? In a prospective study of 166 patients with recent onset psychosis, we established that 4-year outcome was more favourable for women. Female patients more often had a remitting illness course (OR = 3.0; 95% CI: 1.5-5.9), were living independently 14% (4-24%) more of the time, had less evidence of negative symptoms over the follow-up period (OR = 0.3; 0.2-0.7) and were more likely to be employed at follow-up (3.6; 1.8-7.6). The findings did not appear diagnosis-specific, although the sample size was small to test for interaction with diagnostic category. Baseline occupational and social adjustment, clinical expression of illness and age and type of onset explained up to 60% of the sex effect. The processes underlying these factors mediate the effect of sex on outcome.

Relationship of birth season to clinical features, family history, and obstetric complication in schizophrenia

Birth in late winter and spring has been consistently shown to be a risk factor of schizophrenia. The relationship of late winter/spring birth to clinical characteristics and other putative risk factors, such as family history and obstetric complications, may provide clues to etiology. Data relating to season of birth, clinical features, family history, and obstetric complications were analyzed for 192 patients with schizophrenia as defined by Research Diagnostic Criteria (including schizoaffective disorder). There was no significant association of season of birth with any of the psychopathological dimensions nor was there a significant association with obstetric variables or family history. However, winter-born schizophrenic patients who had a negative family history were more likely to have a history of obstetric complications. These findings suggest that obstetric complications associated with schizophrenia are perhaps the result of some seasonal risk factors important in those without a family history of the disorder.

Dermatoglyphic a-b ridge count as a possible marker for developmental disturbance in schizophrenia: replication in two samples

The aim of this study was to conduct an epidemiological analysis of quantitative dermatoglyphic traits as a marker of prenatal disturbance during the second trimester of life in schizophrenic patients. TFRC (Total Finger Ridge Count) and TABRC (Total a-b Ridge Count) were studied in a sample of 38 schizophrenic patients and 69 healthy individuals. A significant decrease of the a-b ridge count was found in patients compared to controls, with a significant linear trend across the population distribution (OR linear trend = 1.6; 95% CI = 1.0-2.4), indicating that the effect was not confined to a subgroup of cases with values in the lowest range. This finding was replicated in a second, larger sample (OR linear trend = 1.3; 95% CI = 1.0-1.8). The suggestion that a-b ridge count is associated with genetic risk for schizophrenia needs to be investigated further. TFRC did not distinguish between patients and controls. The a-b ridge count may be a continuous risk factor for later schizophrenia, pointing towards a disturbance occurring during the second trimester of prenatal life, a period of critical CNS growth.

Allelic association analysis of the 5-HT2C receptor gene in bipolar affective disorder

We have examined a structural variant of the 5-HT2C receptor (Cys23Ser) for allelic association with bipolar affective disorder in 88 cases and 113 controls. Overall, there was no significant difference in allele frequencies between the two groups, indicating that the 5-HT2C gene is not a major risk factor for bipolar affective disorder. However, when the subjects were analysed according to sex, there was a small excess of the serine ser23 allele in female cases (P = 0.04) and this effect was also seen if the ser23 allele was considered recessive (P = 0.03). A small increase in significance was found if only female cases with a known family history were included (P = 0.01). These results suggest that the ser23 allele may increase susceptibility to bipolar affective disorder in women.

Life events before psychotic episodes: do clinical and social variables affect the relationship?

We have previously used data from the Camberwell Collaborative Psychosis Study to demonstrate a strong relationship between life events and subsequent episodes of schizophrenic, manic and depressive psychoses. In the current paper, we confirmed the robustness of this relationship, which was not vitiated by controlling for clinical and social variables. Thus, the event-onset association was not affected by the type of onset or the number of previous episodes. The influences of social variables, such as social class, ethnicity and marital status, did not seriously diminish the importance of events, although there may be a role for other forms of social disadvantage as reflected in these variables.

The incidence of mania: time trends in relation to gender and ethnicity

In order to investigate conflicting reports about possible changes in the incidence of mania, we established first contact rates for mania in the defined area of Camberwell between 1965 and 1984. There was some evidence for an increase in the first contact rate of mania, especially in females. This rise may be associated with the influx into Camberwell of individuals of Afro-Caribbean origin who showed significantly higher rates than the white group [adjusted rate ratio 3.1; 95% confidence interval (CI) 1.4-6.9] and more often displayed mixed manic and schizophrenic symptomatology (risk ratio 2.2; 95% CI 1.1-4.3). We conclude that the incidence of mania has not decreased and may actually have increased. High rates of mental illness among members of ethnic minorities are not specific to schizophrenia, suggesting that a risk factor common to both manic and schizophrenic illness is more prevalent among these groups.

Does familiality predispose to both emergence and persistence of psychosis? A follow-up study

BACKGROUND

It as been suggested that in schizophrenia an association exists between family history of schizophrenia and poor outcome on the one hand, and family history of affective disorders and good outcome on the other.

METHOD

We tested for associations between four-year outcome and familial loading for psychotic disorders in a mixed sample of 150 consecutively admitted patients with functional psychosis (schizophrenia, psychotic affective disorders, other psychotic disorders) of recent onset. For each proband, a familial loading score for (i) broadly defined psychotic disorder, (ii) schizophrenia, and (iii) affective disorder was calculated using information on relatives obtained through the Family History Research Diagnostic Criteria method and direct interviews of relatives with the Schedule for Affective Disorders and Schizophrenia.

RESULTS

In our sample of psychotic patients, familial loading for psychotic disorder predicted persistent negative symptoms over the follow-up period (OR 1.5; 95% CI 1-2.2), especially in schizophrenia, and was also associated with more time hospitalised (P < 0.05) [corrected], and more social disability at follow-up (P < 0.05). Greater familial loading for schizophrenia predicted a greater likelihood of non-recovery (OR 2.2; 95% CI 1.1-4.4) and a greater likelihood to have had persistent negative symptoms over the follow-up period (OR 1.7; 95% CI 0.9-3.1). No association was found between outcome and familial loading for affective disorder.

CONCLUSIONS

We conclude that familial loading may be a continuous risk factor for some dimensions of clinical outcome in the functional psychoses. This suggests that there is a continuum of genetic liability not only to the emergence of psychotic illness, but also the subsequent chronicity of the disorder.

Psychopathological syndromes in the functional psychoses: associations with course and outcome

The aim of this study was to identify underlying dimensions of psychopathology in a cohort of patients with functional psychosis of recent onset, and to examine their prognostic value. Factor analysis of the psychopathological features of 166 consecutively admitted patients with functional psychosis of recent onset revealed seven psychopathological dimensions, which explained 63% of the variance. Five of these seven syndromes bore differential associations with subsequent treatment and illness course, independent of: (i) associations with DSM-III-R diagnosis; (ii) associations with other prognostic factors; and (iii) associations with the baseline values of outcome variables. The most striking associations were shown for an early and insidious onset syndrome with affective flattening, which predicted a more disabled course of illness on three of four outcome dimensions, and which was more common in males and unmarried individuals. A second syndrome, characterized by bizarre behaviour, inappropriate affect, catatonia, and poor rapport showed similar, slightly less striking, associations with illness course, as well as with poor pre-morbid social functioning. A third syndrome, characterized by positive psychotic symptoms was to a lesser degree associated with poorer outcome, whereas a fourth syndrome distinguished by manic symptomatology predicted a more benign illness course. A fifth syndrome identified by lack of insight predicted more time in hospital and admission under a section of the Mental Health Act during the follow-up period. A further finding was that dimensional representations of psychopathological features were considerably more useful than categorical representations (DSM-III-R and ICD-10) as predictors of illness course and treatment decisions.

Minor physical anomalies in psychoses: associations with clinical and putative aetiological variables

This study of patients with functional psychoses set out to examine associations between minor physical anomalies (MPAs) and demographic, clinical, CT scan measures, and putative aetiological variables. 157 psychotic patients had minor physical anomalies assessed using a modified Waldrop scale. RDC diagnoses for these patients were: schizophrenia (n = 79), schizoaffective disorder (n = 31), mania (n = 24), major depression (n = 13), unspecified functional psychosis (n = 8), other organic psychosis (n = 2). 63 healthy white controls were also assessed with the modified Waldrop scale. Minor physical anomalies were not associated with any particular diagnosis. For white subjects, patients had significantly more MPAs than well controls. Anomalies of the palate were the most frequent item reported in patients and controls. For males, there was a weak association between the presence of MPAs and positive family history of a major psychiatric disorder. Those with MPAs required more frequent and longer psychiatric admissions, and showed impaired ability on a test sensitive to left parietal system function. Within the patient group, there were no associations between MPAs and gender, age at onset, negative symptoms, premorbid level of functioning, estimated premorbid intelligence, pregnancy and birth complications, and selected CT variables. Minor physical anomalies are found in a range of functional psychoses. There may be overlap between the various genes that predispose to psychiatric illness (especially in males) and those genes that predispose to developmental instability.

An association study of a neurotrophin-3 (NT-3) gene polymorphism with schizophrenia

Since abnormalities of brain development play a role in the aetiology of schizophrenia, growth factors, known to play a role in neurodevelopment, such as neurotrophin-3 (NT-3), are therefore candidate genes for this disorder. The A3/147 bp allele of a dinucleotide repeat polymorphism in the promoter region of the NT-3 gene has been reported as occurring more frequently in a sample of Japanese schizophrenics compared to controls. We have determined the frequency of alleles of this polymorphism in 175 Caucasian schizophrenic patients and 147 control subjects. The patient and control samples showed no significant deviation from Hardy-Weinberg equilibrium and, in a test of allalleles, the patients and controls did not differ significantly in allele frequencies. However, the male schizophrenics were more likely than male controls to have the A3/147 bp allele (P = 0.029).

Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom

OBJECTIVES

To compare the course and outcome of psychotic illness in a group of Afro-Caribbean patients resident in the United Kingdom and a group of white British patients.

DESIGN

Cohort study of consecutive admissions followed up for four years.

SUBJECTS

113 patients with psychotic illness of recent onset admitted to two south London hospitals.

MAIN OUTCOME MEASURES

Course of illness, history of self harm, social disability, treatment received, and hospital use adjusted for socioeconomic origin.

RESULTS

The Afro-Caribbean group spent more time in a recovered state during the follow up period (adjusted odds ratio 5.0; 95% confidence interval 1.7 to 14.5), were less likely to have had a continuous illness (0.3; 0.1 to 0.8), were less at risk of self harm (0.2; 0.1 to 0.8), and were less likely to have been prescribed antidepressant treatment (0.3; 0.1 to 0.9). There were no differences in hospital use, but the Afro-Caribbean group had more involuntary admissions (8.9; 2.1 to 35.6) and more imprisonments over the follow up period (9.2; 1.6 to 52.3).

CONCLUSIONS

Afro-Caribbean patients in the United Kingdom have a better outcome after psychiatric illness than do white people. The combination of high incidence and more benign course of illness of psychotic illness in this group may be due, at least in part, to a greater exposure to precipitants in the social environment.

Premorbid abnormalities in mania, schizomania, acute schizophrenia and chronic schizophrenia

The aim of this study was to examine the hypothesis that differences in outcome among affective and non-affective psychoses are associated with differences in the degree of developmental deviance. We conducted a retrospective survey of first contact cases treated over a 20-year period in a psychiatric hospital serving a catchment area in South London. All patients with non-depressive functional psychosis residing in the catchment area who received their first psychiatric treatment between 1965 and 1984 were included in the study. Cases were classified according to the relative chronicity of their illness into four non-overlapping groups: mania, schizomania, acute schizophrenia and chronic schizophrenia. There was a linear trend in the association between illness chronicity and proxy measures of development deviance, such as premorbid unemployment, single status and poor academic achievement. Compared to individuals with mania, schizophrenic patients had a 3-6 times increased risk of premorbid abnormality. For patients with schizomania and acute schizophrenia, the risk was 1.5-3 times greater than for manic subjects. We conclude that the prevalence of premorbid abnormalities is highest among chronic schizophrenia, but similar disturbances also occur, to a lesser degree, in less disabling affective and non-affective psychotic disorders.

Insight and psychotic illness. Cross-sectional and longitudinal associations

BACKGROUND

Insight has recently re-emerged as an important aspect of psychopathology amenable to empirical study. We sought to examine the relationship between various aspects of insight into illness and clinical, sociodemographic and neuropsychological variables.

METHOD

From an inner-London catchment area population, 150 in-patients with recent onset of psychosis were assessed on a variety of measures, including the Present State Examination (PSE). Subjects were followed up for a mean of four years and reassessed.

RESULTS

High IQ was associated with better insight as rated on the PSE, while gender, ethnicity and a diagnosis of schizophrenia appeared to be unrelated. At follow-up, similar associations were found, as well as correlations with attitudes to treatment and a more elaborate measure of insight. Cerebral ventricular enlargement and tests of frontal lobe function did not correlate with insight, but there was a curious, strong association with left-handedness at both assessment points. Initial insight correlated significantly but weakly with insight at follow-up.

CONCLUSIONS

The assessment of insight in psychosis has concurrent validity and is a distinct aspect of psychotic phenomenology. It may, in part, have a neuropsychological basis.

Increasing age is a risk factor for psychosis in the elderly

We examined the association between ageing and the administrative incidence rate of late onset (after age 59) non-organic, non-affective psychosis in two samples of patients aged 60 years or older who were first admitted to hospital in (1) The Netherlands between 1978 and 1992 (n = 8010) and (2) nine regional health authorities in England and Wales (n = 1777) between 1976 and 1978. There was a linear trend in the association between increasing age and first admission rates for non-organic, non-affective psychosis in the elderly, after adjustment for the possible confounding effects of time trend and gender, corresponding to an 11% increase in the incidence with each 5-year increase in age. These observations support a connection between degenerative brain processes and onset of non-affective psychosis in the elderly.

Increased intracerebral cerebrospinal fluid spaces predict unemployment and negative symptoms in psychotic illness. A prospective study

BACKGROUND

It has been suggested that the dimensions of cerebral ventricles are a risk factor for poor outcome in psychotic illness.

METHOD

A cohort of 140 patients with functional psychoses of recent onset who had undergone CT scanning, were followed up for an average of 46 months and assessed on six dimensions of course and outcome of illness.

RESULTS

Left and right sylvian fissure volumes and, to a lesser extent, third ventricular volume predicted negative symptoms and unemployment over the course of follow-up, the latter association being mediated by poor cognitive functioning. There was significant linear trend in risk over the distribution of sylvian fissure volumes in the cohort, and associations were especially evident in schizophrenic patients. No associations were found with global severity of illness, duration of hospital stay, homelessness, or affective symptoms.

CONCLUSIONS

These findings support the notion that dimensions of the cerebral ventricles are a continuous risk factor for some measures of outcome in the functional psychoses.

Gender, psychopathology, and development: from puberty to early adulthood

We tested the hypothesis that the expression of schizophrenic psychopathology is dependent on the stage of adolescent development. The study had a retrospective design, using high-quality case-note material of cases of schizophrenia at first admission. Patients with onset of illness between the age of 11 and 21 years were included. Sexual delusions were more apparent in females (OR = 3.6;95% CI 1.6-8.0), but otherwise no gender differences in the frequency of a range of positive symptoms were apparent. There was evidence that the age at which positive symptoms first appeared differed between males and females. The frequency of typical, 'first rank' schizophrenic symptoms such as auditory hallucinations, passivity phenomena and though interference, increased linearly with age in male patients, but did not vary with age in their female counterparts. The likelihood of displaying delusional beliefs such as persecutory delusions, explanatory delusions, delusions of reference and grandiose delusions increased with age in both sexes, but the association was stronger in males. The observation that typical schizophrenic symptoms in male patients are relatively uncommon during early adolescence, but increase as they grow older, could be explained by the later manifestation of puberty and associated maturational processes in boys.

Caring for mentally ill people

Despite legislation to harmonise mental health practice throughout Europe and convergence in systems of training there remains an extraordinary diversity in psychiatric practice in Europe. Approaches to tackling substance misuse vary among nations; statistics on psychiatric morbidity are affected by different approaches to diagnosis and treatment of psychiatric disorders; attitudes towards mental illness show definite international differences. Everywhere, though, mental health care for patients with psychotic illnesses is a "cinderella service," and there is a general move towards care falling increasingly on the family and the community.

The influence of life events on the subsequent course of psychotic illness. A prospective follow-up of the Camberwell Collaborative Psychosis Study

Fifty-nine psychotic patients with acute onset of illness, who had been interviewed about their experience of stressful life events before the episode, were followed up for an average of 42 months. Thirty patients (51%) had experienced a stressful life event in the 3 months immediately before onset (EV+), 29 had not (EV-). In patients with an RDC diagnosis of affective disorder or unspecified functional psychosis, the presence of stressful life events was associated subsequently with milder symptom severity, less time spent in hospital, more treatment for depressive symptoms and less for psychotic symptoms. In schizophrenia, differences were less apparent, but patients with event associated episodes had less need of anti-psychotic maintenance medication over the follow-up period and tended to have spent more time in complete remission. EV+ schizophrenic subjects also had higher morbid risk for schizophrenia in their first degree relatives, and tended to be female and to have less typical symptoms than EV- schizophrenic patients.

An association study of debrisoquine hydroxylase (CYP2D6) polymorphisms in schizophrenia

The cytochrome P450 mono-oxygenases are a group of enzymes that metabolize a variety of exogenous and endogenous compounds, some of which are potentially toxic. Individual variations in the metabolism of potential toxins could influence susceptibility to disorders having genetic and environmental components, such as schizophrenia. The frequency of two common mutant alleles of the gene for the cytochrome P450 enzyme debrisoquine-4-hydroxylase (CYP2D6) was determined in 264 Caucasian schizophrenic patients and 217 controls, using the polymerase chain reaction and restriction enzyme digestions. The patient and control samples showed no significant deviation from Hardy-Weinberg equilibrium and the frequency of each mutant allele (CYP2D6A and CYP2D6B) did not differ between patients and controls.

Schizophrenia sans frontieres: concepts of schizophrenia among French and British psychiatrists

OBJECTIVE

To compare the first admission rates for schizophrenia in England and France, and to compare the concept of schizophrenia held by practising British and French psychiatrists.

DESIGN

Comparative study of incidence rates in England and France; and postal questionnaire survey of a sample of about 1 in 30 psychiatrists in the United Kingdom and in l'Aquitaine, France.

SUBJECTS

All first admissions for schizophrenia to psychiatric hospitals in England and France 1973-82; 92 psychiatrists in the United Kingdom and 69 in France.

MAIN OUTCOME MEASURES

Age adjusted first admission rates for schizophrenia between 1973-82; and opinions on the aetiology, diagnosis, and management of schizophrenia.

RESULTS

First admission rates were much higher in France than in England before the age of 45, but lower after that age. Rates were falling in England over the 10 year period, while they were rising in France. In the questionnaire study English and French psychiatrists showed prominent differences of opinion for 31 out of 38 statements. The French sample did not diagnose schizophrenia after the age of 45 and endorsed psychoanalytical concepts.

CONCLUSIONS

British and French psychiatrists use different diagnostic criteria and contrasting methods of treatment for schizophrenia. Differences in diagnostic criteria probably contribute towards the disparity in administrative incidence rates and time trends for schizophrenia in the two countries. Doctors in the European Community can now work in any country. Further work is needed to ensure psychiatrists are talking a common language.

[2 families with meningococcal infection and a hereditary disorder of the 5th component of the complement system]

Within a period of six months, a 20-year-old female with a homozygous deficiency of the C5 component of complement developed meningococcal meningitis twice (different serogroups). Additional C5 deficiencies were not found in relatives. Homozygous deficiency of C5 was also present in another family in which a 16-year-old female and an 18-year-old sister suffered from meningococcal meningitis. Some characteristics of meningococcal disease in patients with C5 deficiency differed from meningococcal disease in patients with a normal complement system: meningitis occurred at a relatively advanced age, was associated with serogroups W-135, B and X and recurred in two of three patients.

Hyperthermic regional perfusion using membrane- instead of bubble-oxygenators. An experimental and clinical study

To achieve adequate tissue perfusion during hyperthermic regional perfusion, perfusion pressures should be maintained at near normal mean systemic arterial pressures. During experimental as well as during clinical perfusions however, unphysiologically high perfusion flows were needed to keep the perfusion pressure at the desired level. Since both high perfusion flows and high perfusion pressures have been associated with the post-operative complications such as severe edema and tissue damage, as well as with an increased leakage of perfusate to the systemic circulation, low perfusion flows have been used in regional perfusion. High perfusion flows in our previous experimental studies were attributable to a marked reduction in vascular resistance. This decrease is believed to be caused by the release of vasodilatory constituents of damaged blood cells, and it is the extra-corporeal circuit, and in particular the bubble-oxygenator that is thought to be responsible. The superior haemocompatibility of membrane-oxygenators over bubble-oxygenators has been established in cardio-pulmonary bypass. We compared the use of a membrane-oxygenator with that of a bubble-oxygenator in regional perfusion to see if more normal haemodynamics could be maintained and vasodilatation prevented. In the experimental as well as in the clinical perfusions the use of a bubble-oxygenator required unphysiologically high perfusion flows to maintain the perfusion pressure at the level required to obtain an adequate microcirculation. In contrast the use of a membrane-oxygenator permitted a nearly physiological perfusion flow to maintain an adequate perfusion pressure as well as an adequate micro-circulation.(ABSTRACT TRUNCATED AT 250 WORDS)