The Iowa 500. I. Diagnostic validity in mania, depression, and schizophrenia

Associations of independent living and labor force participation with impairment indicators in schizophrenia and bipolar disorder at 20-year follow-up

BACKGROUND

Since the Iowa 500 study, residential and occupational status have been frequently used as indicators of everyday achievements in research on schizophrenia and bipolar disorder. The relationships of residential and occupational status with impairment in multiple domains including physical health indicators across these two diagnoses, however, have rarely been studied. We examined these relationships at the 20-year follow-up assessment of a first-admission sample.

METHODS

We included 146 participants with schizophrenia and 87 with bipolar disorder with psychosis who participated in the 20-year follow-up of the Suffolk County Mental Health Project. In addition to interviewer-based ratings of employment and residential independence, we examined self-reported impairment derived from the WHODAS, standard measures of current psychopathology, indicators of obesity, as well as performance-based measures of physical and cognitive functioning.

RESULTS

Participants with bipolar disorder were more likely to live independently and be gainfully employed; they also performed significantly better on each indicator of impairment apart from balance ability. In both groups, unemployment, but not residential independence, was associated with greater self-reported disability on the WHODAS. Residential independence, gainful employment, and subjective disability were also associated with better physical functioning. Across the two groups, psychiatric symptoms and physical functioning were the major determinants of subjective disability.

DISCUSSION

People with psychotic bipolar disorder were more likely to be gainfully employed and living independently than participants with schizophrenia but as a group, much less frequently than population standards. Interventions aimed at physical fitness may have the potential to improve both objective functioning and perceived disability.

Monoamine Oxidase Activity: A Genetic Marker of Schizophrenia?

The results of pilot studies of the activities of platelet monoamine oxidase (MAO) and catechol-0-methyl transferase (COMT) in the blood of selected schizophrenics and the families of schizophrenics is presented.

No statistically significant difference was found between the blood COMT levels of 21 control subjects and 26 schizophrenics, whereas the values found for platelet MAO activity were significantly lower for the schizophrenic group than for the control group.

In one acutely disturbed first-admission schizophrenic the platelet MAO activity increased to a normal level in parallel with the clinical improvement, whereas in the relapsing schizophrenics the platelet MAO activity remained at its initial level although the clinical picture improved. No consistent findings with regard to the platelet MAO activity emerged from the study of 3 families having a history of schizophrenia.

Predictive value of thought disorder in new-onset psychosis

OBJECTIVE

This research addresses the relationship of formal thought disorder in the early stages of psychotic illness to the long-term outcome of mental health many years later. The specific topic of concern was to evaluate the prognostic significance of thought disorder on the severity of psychosis over time.

METHODS

Subjects with new-onset psychosis were evaluated on a variety of measures including education, physical health, Brief Psychiatric Rating Scale scores. They were also given the Thought, Language, and Communication Scale to evaluate thought disorder. Subjects were interviewed again at 10 and 20 years to evaluate variations in outcome. Appropriate statistical methods were used to evaluate changes in the level of functioning over time.

RESULTS

Thought disorder was not unique to schizophrenia. Bipolar patients presented with significant positive thought disorder at the onset of psychosis. Overtime positive thought disorder gradually improved in most patients. Negative thought disorder was more persistent, especially in subjects with schizophrenia. Initial psychosis with thought disorder characterized by poverty of content seemed to be associated with poor long-term outcome.

CONCLUSION

Formal thought disorder can predict outcome in some cases of psychosis. Not all types of thought disorder have the same prognostic implication. Positive forms of thought disorder (pressured speech, tangentiality) had no significant predictive value. Negative thought disorder (particularly poverty of speech and poverty of content) tend to predict a chronic, more unrelenting course of illness.

Long-term outcome of patients with schizophrenia: a review

OBJECTIVE

To review empirical studies that assess outcome of patients with schizophrenia and evaluate the degree to which reported outcome is affected by research methodology, treatment variables, prognostic factors, epidemiologic factors, and patient resilience.

METHOD

We reviewed studies that used control subjects and lasted for a decade or more, comparing them with respect to research methodology and choice of outcome variables.

RESULTS

Like other mental illnesses and medical illness in general, the natural course of schizophrenia showed itself to have a threefold division of mild, moderate, and severe. Although a great deal of variance in outcome occurred across the studies reviewed, schizophrenia is nevertheless a disorder with relatively poor outcome. Patients with schizophrenia consistently showed poorer courses and outcomes than patients with other psychotic and nonpsychotic psychiatric disorders. On the positive side, subgroups of schizophrenia patients had extended periods of recovery-some without the benefit of extensive mental health aftercare treatment-and patients with schizophrenia did not show a progressive downhill course.

CONCLUSION

While documenting the heterogeneity in outcome and the generally poorer outcomes of patients with schizophrenia, the studies reviewed also alert us to the danger of suicide and early death in schizophrenia. In addition, they expose problems in clinical management and treatment and also help us anticipate the possibility of intervals or periods of recovery, some of which appear spontaneously and may be tied to individual patient factors such as resilience.

Genetic heterogeneity may in part explain sex differences in the familial risk for schizophrenia

The purpose of this study was to attempt, in part, to explain significant sex differences in the familial risk (FMR) for schizophrenia found in previous studies. We hypothesized that, like probands, relatives of male vs. female probands may express different forms or subsyndromal symptoms of schizophrenia, i.e., differential expression of flat affect. Studied were 332 schizophrenic probands defined by Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III), criteria and 725 first-degree relatives from well-known retrospective cohort family studies. Results showed that relatives of male probands were at significantly higher risk for expressing flat affect than relatives of female probands, which did not hold for relatives of normal controls. Logistic regression was used to show that when flat affect was incorporated into the definition of affected among relatives, sex differences in FMR disappeared.

Gender differences in age at onset of schizophrenia

Numerous studies have found that male schizophrenic patients have earlier ages at onset than females. However, none of these studies have corrected the observed ages for known gender differences in the age distribution of the population. Using a pre-existing data set, we applied a non-parametric method to correct the male and female distributions of observed age at onset for sex-specific age distributions. The distributions of observed age at onset indicated earlier onset among males. After correction, the age-at-onset distributions shifted toward older ages, but the difference between males and females remained statistically significant. Thus, gender differences in the age at onset of schizophrenia are not artefactual.

Elevated cerebrospinal fluid protein in men with unipolar or bipolar depression

We studied a large sample of rigorously diagnosed, generally unmedicated patients with major depressive disorder (n = 179), bipolar affective disorder (n = 102), or schizophrenia (n = 125) to determine if increased cerebrospinal fluid (CSF) protein is associated with a particular diagnosis or gender. Men had a higher mean CSF protein level than women across all diagnoses (p < 0.001). There were no differences across diagnosis among the female patients. Men with unipolar depression had a higher mean CSF protein content than other male patients (n = 0.029), but depressed bipolar males had an equivalently elevated mean level. Considered apart from unipolar or bipolar diagnosis, the depressive syndrome was strongly associated with increased CSF protein in men (p = 0.004); again, there was no difference across type of illness (depression versus mania) among women. Elevated CSF protein content seems to be associated with illness syndrome rather than diagnosis, and may represent an important finding among men with depression.

Gender and mortality in schizophrenia: do women act like men?

The effect of gender on mortality was explored for a sample of DSM-III diagnosed schizophrenics followed for up to 42 years. The data for 332 cases and 304 matched normal controls were from the retrospective cohort family studies, the Iowa 500 and non-500. Survival analysis and Cox regression models were used to test the effects of gender, illness status and their interaction on the risks for natural and unnatural deaths. The control men experienced significantly more unnatural deaths than the control women, which was not found for schizophrenic men and women. The unnatural death rate among schizophrenic women was similar to the rate for schizophrenic and control men, and significantly higher than for control women during the early phase of the illness. Findings suggest that some factors that predict suicide may be similar for schizophrenic women and men.

Schizophrenia--falling incidence and better outcome?

It has been suggested that schizophrenia is a disappearing disease. The evidence for this assertion is reviewed, and also for a parallel theory advanced in recent years that the disorder may be undergoing a benign metamorphosis in its course and outcome. It is concluded that the evidence is presently unconvincing given the methodological problems inherent in most follow-up studies; changes have taken place in clinicians' assumptions, in treatments, and in the quality of follow-up studies, rather than in the disorder itself. Nevertheless, possible time trends in the incidence and outcome of schizophrenia call for further scientific investigation.

Gender and the familial risk for schizophrenia. Disentangling confounding factors

Recent studies of the effect of gender on the familial risk for schizophrenia have shown that relatives of females have a higher risk for schizophrenia than relatives of males. This study attempts to explain the effect by examining factors found to differentiate schizophrenic men and women and found to be related to the familial risk for schizophrenia. Cox proportional hazard regression model was used to examine the simultaneous effects of age at onset, season of birth, and premorbid history, controlled for symptoms that have been found to differ by gender (dysphoria, paranoia, and flat affect). Results showed that the effect of gender on the transmission of schizophrenia could not be explained by gender differences in age at onset, symptom expression, premorbid history, and winter birth. However, premorbid history had an effect on familial risk independent of gender, indicating that probands with a poor premorbid history had a lower familial risk for schizophrenia than those with a good premorbid history. Implications of the findings are discussed.

Morbidity risks of schizophrenia and affective disorders among first-degree relatives of patients with schizoaffective disorders

Of 510 patients consecutively admitted and diagnosed as schizophrenic, 310 who failed to meet research criteria for schizophrenia were labelled as having 'atypical psychosis'. This heterogeneous group of patients was then subtyped into more homogeneous subgroupings according to their clinical characteristics, independent of their family data. One subgroup resembled schizophrenia, one resembled affective disorders and a third (n = 57), which did not resemble either schizophrenia or affective disorder, was defined as 'schizoaffective'. Comparing the morbidity risks for schizophrenic and affective disorders in the relatives of this schizoaffective group with those of the relatives of 'typical' groups of schizophrenia and affective disorder, showed that this group was different from those with schizophrenic and affective disorders.

Sex differences in the familial transmission of schizophrenia

The hypothesis that schizophrenic men have a lower familial risk for schizophrenia than schizophrenic women was tested using the DSM-III-diagnosed samples of the Iowa 500 and non-500 family studies. Survival analyses were used to test for differences in the risk for schizophrenia and spectrum disorders, for sex of proband and sex of relative, controlled for fertility effects and ascertainment bias. Male and female relatives of schizophrenic men had a significantly lower risk for schizophrenia, schizophreniform, and schizoaffective disorders than relatives of schizophrenic women. However, the effect was not significant for the full spectrum nor when analysed by sex of relative. Sex differences in the risk for other psychiatric disorders among relatives of schizophrenic probands were not significant.

Comparison of major depressive patients with a predominantly sad versus anxious mood

One hundred and seventy-seven patients with major depressive disorder (MDD) experienced a mood disturbance that could be characterized as predominantly sad (55%), anxious (31%) or mixed (14%). Patients that had a predominantly sad mood were more likely to be hypersomnic, anhedonic, younger and seen in an outpatient setting. Predominantly anxious MDD patients were more likely to have been hospitalized, agitated, psychotic, incapacitated, insomnic, and to have had higher post-dexamethasone cortisol levels.

Gender and schizophrenia: implications for understanding the heterogeneity of the illness

This study begins to test the hypothesis that schizophrenic men and women may be at risk for experiencing different subtypes of the illness. Given past research, hypotheses predict that schizophrenic men will have an earlier age of onset, poorer premorbid history, lower family morbid risk, and poorer course. Data consist of 332 schizophrenic patients diagnosed according to DSM-III and 713 of their first-degree relatives from the double-blind Iowa 500 and non-500 family studies. Survival analysis was used to estimate age of onset, and Strömgren's abridged method for age correction was used to estimate family morbidity risks. Findings support our hypotheses and suggest that men may be at risk for experiencing a more severe form of schizophrenia.

The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy

The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy (ECT) was studied using a naturalistic/archival study design. A sample of 125 patients who received no somatic treatment were compared with 128 patients who all received a course of ECT with at least four treatments. Patients were separated according to age at admission. Treated patients, aged 40 or older, who were clearly remitters showed no differences in previous episodes, subsequent episodes, subsequent hospitalizations, or likelihood of experiencing a period of full recovery when compared with a similar group of untreated patients. Hospitalization greater than 1 year and chronicity were significantly more common in the untreated older subjects. Treated patients aged 39 or younger, who also were clearly remitters, showed significant increases in subsequent episodes and subsequent hospitalizations when compared with a group of depressed patients of similar age who received no somatic treatment. Hospitalization greater than 1 year was also more common in the untreated younger patients. ECT clearly reduces the rate of chronicity in older patients but may be associated with an increase in episodes after treatment in the younger population.

An archival study of depression before and after age 55

In this archival study, 58 patients with unipolar depression who were 55 years of age or older were compared to 155 depressed control patients age 54 years or less. The older patients with unipolar depression had a significantly worse outcome, with only 51.7% experiencing a period of full remission during follow-up. Medical disorders were common, and older depressed patients showed a clear excess of cardiovascular disorders. Clinical symptoms did not separate the two groups, with the exception of psychomotor retardation and agitation. Electroconvulsive therapy was associated with less continuous hospitalization and an overall superior outcome.

Outcome of schizophrenia in India using various diagnostic systems

A group of 112 patients diagnosed to be suffering from schizophrenia according to ICD-9 concept of this disorder were followed-up for a period of 18-30 months. Five diagnostic systems for schizophrenia: CATEGO, Research Diagnostic Criteria, Feighner's Criteria, DSM-III and Schneider's First Rank Symptoms were also applied to the study group at the beginning of the investigation. The outcome was assessed in the areas of clinical improvement, course, severity of illness and work. The course of the disorder and outcome in various definitions did not reveal significant variability though patients diagnosed to be schizophrenics according to DSM-III tended to display more psychopathology and impaired work efficiency at the time of follow-up.

A century of delusions in south west Scotland

Two groups of patients admitted to psychiatric hospital in Dumfries were studied, drawn from the periods 1880-1889 and 1970-1979. Feighner criteria were applied to make three diagnostic categories - depression, mania and schizophrenia - and the occurrence and content of delusions were noted for each. A significant decline in the prevalence of delusional depressive illness was found between the two periods, and a similar trend was noted for delusional manic illness. In contrast, the prevalence of delusional schizophrenic illness was stable. This decline is taken to reflect a change in the phenomenology of affective illness since last century in South West Scotland. The content of delusions is also discussed.

Childhood head trauma and psychosis

The medical histories of 200 schizophrenic patients were compared to those of 203 depressed patients, 122 manic patients, and 134 surgical controls. All subjects were hospital inpatients. Charts were specifically examined to record any head injury before age 10 that had required medical attention or caused loss of consciousness. Schizophrenics had a significantly greater history of head trauma than the manics, depressives, and surgical controls. There were no significant differences between manics and depressives or between affective disorders as a group and surgical controls. Childhood trauma may be a contributing factor to the development of psychosis in some individuals.

From unipolar depression to bipolar illness: 29 who changed

We studied 29 patients who were admitted to a psychiatric hospital for depression, never had had a previous mania, and developed the mania in follow-up. When compared to patients who were stable unipolars, the potential bipolars had a history of more episodes prior to their onset of mania, more hospital admissions, more marked self-reproach and guilt; in follow-up, they had more hospitalizations.

Duration criteria and long-term outcome in affective disorder and schizophrenia

This paper attempts to see whether the shorter duration criteria for affective disorders may naturally result in selecting patients who would show a better long-term outcome than that of schizophrenic patients. Follow-up of 298 patients with mania or depression revealed that those with 6 months or more of symptoms still had a better outcome than the outcome of schizophrenics. Furthermore, their outcome was similar to that of manics and depressives with less than 6 months of symptoms. Therefore, factors other than the shorter duration criterion for affective disorders should be sought to explain their better outcome than that of schizophrenics.

Familial transmission of major affective disorders. Is there evidence supporting the distinction between unipolar and bipolar disorders?

The two-threshold multifactorial polygenic (MFP) model was applied to blind family study data, collected in a long-term follow-up and family study of major affective disorders. This model tested whether bipolar and unipolar disorders are manifestations of the same underlying factors or if they are independently caused disorders. The hypothesis that bipolar and unipolar disorders are, respectively, severe and mild forms of the same disorder was supported. There was little evidence for different familial aetiologies for bipolar and unipolar disorders in our sample.

Transmission of affective disorders: an application of segregation analysis to blind family study data

The single major locus (SML) model of Bucher and Elston (1981) was applied to data collected in a long-term follow-up and family study of major effective disorders. Pedigree segregation analysis was used to test the hypothesis that bipolar and unipolar disorders are phenotypic variants of the same genotype at a SML. The particular SML model examined did not adequately describe the familial pattern of these disorders in families of bipolar and unipolar probands. Although other SML models may be superior, it is likely that the existence of a SML will be obscured by genetic heterogeneity.

Psychosis in bipolar and unipolar affective illness with special reference to schizo-affective disorder

Bipolar and unipolar patients respectively were separated into psychotic and non-psychotic sub-types. The bipolar psychotic patients were more likely to have certain severe symptoms, such as hallucinations and motor abnormalities, than were the unipolar patients, but the family histories of the four sub-groups were identical. The psychotic sub-groups had a different course of illness, in that they were less likely to have had a history of multiple episodes on admission and were more likely to show chronicity for a period of time on discharge. The data are interpreted as being opposed to the concept of a continuum of vulnerability in the affective disorders, and as not favouring either psychotic unipolar or psychotic bipolar illnesses or schizo-affective disorder being considered autonomous. One possible interpretation of the findings is that a trait or propensity to psychosis is transmitted totally independently of the major affective illness, and that this propensity is silent or not observed when the patient is in remission.

Leukocyte regulation in depression and schizophrenia

The distribution of leukocytes in the blood stream is affected by levels of circulatory glucocorticoids. Elevated concentrations of cortisol are usually associated with an increase in the number of neutrophils and a decrease in the number of lymphocytes. Since primary depressive illness is often associated with hypercortisolemia, we hypothesized that similar changes in the blood stream of depressive patients may occur. To test this hypothesis, we retrospectively compared leukocyte counts in 177 untreated depressive patients and 178 untreated schizophrenic controls. We found a significant increase in the absolute and relative numbers of neutrophils and a significant decrease in the absolute and relative numbers of lymphocytes in the depressive group. Furthermore, when compared to normative values from the general population, depressed patients showed higher frequencies of both neutrophilia and lymphopenia than the schizophrenic group. These results indicate differences in the regulation of leukocytes in depression and schizophrenia consistent with the effects of higher levels of plasma cortisol in the depressive group.

A search for 'schizophrenia spectrum disorders'. An application of a multiple threshold model to blind family study data

Family data from schizophrenic and control probands were analyzed using a descriptive analysis and multiple threshold models to determine whether a given group of diagnoses made in accordance with ICD-9 was aetiologically related to schizophrenia. The proportion of relatives receiving any psychiatric diagnosis, other than schizophrenia and affective disorder, was essentially the same between the two study groups. Furthermore, the data did not fit the multiple threshold model tested. Thus, the hypothesis that schizophrenia and a spectrum of disorders defined according to ICD-9 have a common familial aetiology was not accepted.

The evolution of symptoms in institutionalized hebephrenic/catatonic schizophrenics

The charts of 52 hebephrenic/catatonic schizophrenics requiring long-term institutionalization were selected from the Iowa 500 study and reviewed. The presence or absence of 28 different symptoms was noted on a year by year basis over a span of 35 years. Symptoms usually classified as positive symptoms of schizophrenia, such as hallucinations and delusions, were found to have earlier onset and greater tendency to resolve over time than symptoms usually classified as negative such as flat affect, decreased social interaction and sensorium defects.

Psychotic features in major depression. Is mood congruence important?

We studied outcome and family history in 203 patients with psychotic depression. Patients whose psychotic features were mood-incongruent were significantly younger and had a slightly poorer outcome. Morbid risks for affective disorder and schizophrenia among relatives distinguished these mood-incongruent patients from patients with non-psychotic depression but not from patients with schizophrenia. In contrast, depressive probands with mood-congruent psychotic features resembled probands with non-psychotic depression and differed significantly from schizophrenia probands in terms of family history. While depressed patients with mood-congruent psychotic features experienced poorer short-term outcome relative to non-psychotic depressed patients, a 40-year follow-up has shown that these differences disappear over time. Moreover, these two groups are quite similar according to family history data. Both family history and short-term outcome data suggest that major depression with mood-incongruent psychotic features cannot be classified altogether with either affective disorders or schizophrenia. More definite conclusions must await the results of long-term outcome and family studies of these patients presently underway.

Testing the monogenic theory of schizophrenia: An application of segregation analysis to blind family study data

Segregation analysis was applied to blind family data concerning schizophrenia to decide if the transmission of schizophrenia could be explained by a single major gene. Our results showed that the Mendelian model was unacceptable. Therefore, the monogenic hypothesis could not account for the transmission of schizophrenia. Since the hypothesis of no parent-child transmission was also not accepted, there was an indication that some form of vertical transmission existed which could be psychosocial, or an interaction between genetic and psychosocial factors. Our results suggest genetic heterogeneity in schizophrenia. Currently available clinical criteria for defining subgroups must be improved in conjunction with detection of biological indicators so that segregation analysis of family data could be effectively used in determining modes of transmission in schizophrenia.

Memory deficit and long-term outcome in schizophrenia: a preliminary study

Twenty-two schizophrenic patients who presented memory deficit at admission were followed up over a 30- to 40-year period along with 178 schizophrenic patients without memory deficit. Memory deficit at admission predicted poor outcome in marital, occupational, and psychiatric outcome categories. The symptoms and signs of memory deficit were assessed without knowledge of the patient's status at admission. A significantly higher proportion of the memory deficit group continued to show both symptoms and signs of memory deficit at followup. Thus, the presence of memory deficit in schizophrenics was a highly stable variable across a 30- to 40-year period. Implications of the preliminary results of this study are discussed, had future studies are suggested.

Morbidity risks of schizophrenia and affective disorders among first degree relatives of patients with schizophrenia, mania, depression and surgical conditions

One thousand five hundred and seventy eight first degree relatives of schizophrenics, manics, depressives and controls were personally interviewed using the Iowa Structured Psychiatric Interview Form without knowledge of the probands' diagnoses. Our data, based on blind diagnostic assessment of the relatives, support the distinction between schizophrenia and affective disorders, although the distinction between schizophrenia and mania was not clear-cut. Our data could not support familial subtyping of paranoid and non-paranoid schizophrenia, and unipolar and bipolar affective disorders. Future studies attempting to develop research criteria for subtyping schizophrenia and effective disorders should utilize not only clinical and familial data but also biological markers and other non-familial variables.

Causes of death in schizophrenia and manic-depression

Causes of death were studied in a cohort of 200 schizophrenic, 100 manic, and 225 depressive patients who were followed in a historical prospective study. These patients were admitted between 1934 and 1944 and were studied 30 to 40 years later. Five cause of death categories were considered in this analysis: (1) unnatural deaths, (2) neoplasms, (3) diseases of the circulatory system, (4) infective and parasitic diseases, and (5) other causes. For each cause of death, the expected number of deaths was calculated from vital statistics for the State of Iowa for the time period of follow-up. Observed numbers of deaths were contrasted with expected numbers of deaths to assess statistical significance for each diagnostic group. There was a significant excess of unnatural deaths in all diagnostic groups in both sexes, with the exception of female manics. This group, however, did show a significant excess of circulatory system deaths. Both male and female schizophrenics showed a substantial excess of infective disorder deaths.

Should 'non-Feighner schizophrenia' be classified with affective disorder?

Narrow definitions of schizophrenia increase homogeneity at the expense of leaving unclassified many patients with shizophrenic symptoms. Family history and follow-up studies indicate that many such patients ought to be classified with those having affective disorders. This study determines morbid risks for affective disorder and schizophrenia in first degree relatives of patients with chart but not research diagnoses of schizophrenia. Comparisons with morbid risk figures for relatives of individuals satisfying research criteria for depression, mania or schizophrenia indicate that the 'non-Feighner schizophrenia' group is probably too heterogenous to be classified entirely as affective disorder or as schizophrenia.

Qualitative differences in human figure drawings according to schizophrenic subtype

Human figure drawings were obtained from 136 adult schizophrenics, of whom 63 were mentally retarded. The protocols were evaluated independently by three jduges for presence of 15 defined features that stressed the quality rather than specific content of the drawings. Adequate reliability and frequency were established for seven of the parameters, which were then compared for prevalence among subgroups classified by diagnosis, preognosis, chronicity, and level of retardation. Significant differences appeared for all comparisons and each of the analyzed features. The differences among non-retarded schizophrenic subgroups seemed to reflect phenomenological distinctions, while differences associated with intellectual retardation seemed to represent developmental limitations. These data supported the validity of the figure drawing technique for distinguishing among schizophrenic subtypes and underscored the importance of suitable methodology in evaluating projective measures.

Kraepelin-oriented research-diagnosable schizophrenia, mania, and depression in Schneider-negative schizophrenics

The rigorous neo-Kraepelinean research criteria of the St. Louis/Iowa and Taylor groups were applied to case record data of 116 first admissions of Schneider-negative schizophrenics--that is, those without first-rank symptoms (FRSs)--hospitalized in a strongly Schneider-oriented German University Psychiatric Clinic from 1962 to 1971. This sample had a total of 45.7% (53 cases) of psychiatric illness diagnosable by research methods. Indeed, only 31% (36 cases) of Schneider-negative schizophrenics turned out to have research-positive Kraepelin-oriented schizophrenia; and of these, 21 fulfilled both sets of research criteria for schizophrenia. It is important that 14.6% (17 cases) of Schneider-negative schizophrenia consisted of research-diagnosable affective disorder, with mania making up 5.2% and depression 9.4% of this figure. The findings suggest that a sample of Schneider-oriented schizophrenia without FRSs as routinely diagnosed in Germany does not seem to represent a clear-cut homogeneous and 'uncontaminated' group of schizophrenics.

Acute confabulatory psychosis: a rare form of unipolar mania?

Emil Kraepelin's paper on false memories (Erinnerungsfälschungen) was probably the most extensive and incisive analysis of these phenomena ever made. Using his views as a starting point, the concept of confabulation is then defined in a Kraepelin-oriented manner, making it also applicable to the phantastic false memories found in some rarer forms of functional psychotic illness. Kraepelin and Leonhard have been preeminent in their concern with such clinical states; thus, Leonhard's confabulatory euphoria and confabulatory paraphrenia can be symptomatically and syndromally linked up with points of view on paranoid mania and confabulatory paraphrenia held by Kraepelin. An "ideally typical" case is also presented to highlight some of the difficulties involved in trying to distinguish mania from schizophrenia when the clinical picture is dominated by phantastic "functional" confabulations.

Delusional depressions: natural history and response to treatment

A review of the abundant literature concerning the distinction between delusional and non-delusional depressions, especially of the work of Aubrey Lewis, reveals that before the introduction of specific therapies most in-patients with major depressive illness eventually recovered; the small percentage who did not almost all came from the delusional group. The dichotomy lost its clinical significance after the introduction of ECT, as both groups were equally responsive. However, accumulating evidence indicates that unipolar delusional depressives are significantly less responsive to tricyclic anti-depressant therapy than non-delusional depressives. The presence or absence of delusional thinking should be considered as a significant criterion in the classification of depressive disorders, and the presence or absence of delusional thinking should influence the choice of treatment for severely depressed patients.

Mortality in patients with schizophrenia, mania, depression and surgical conditions. A comparison with general population mortality

Mortality data are presented from a four-decade follow-up study of 200 schizophrenic, 100 manic, 225 depressive patients, and 160 surgical controls (80 appendicectomy; 80 herniorrhaphy). Data for this analysis were available on 648 (95 per cent) members of the study population. Using sex-age standardized mortality ratios (SMR), the mortality experience of the study population was compared with that of the state of Iowa, the geographical area served by the admitting medical facility for the study group. Results are presented for a four-decade period beginning 1935-44, and ending 1965-74. All three psychiatric groups had a significant increase in mortality risk. This was most pronounced in the first decade following admission, although schizophrenic patients, especially females, continued to show a significant excess of deaths throughout the entire four decades of the follow-up period. During no decade of the follow-up period did the mortality of the surgical controls differ significantly from that of the Iowa population.

The Iowa 500: field work in a 35-year follow-up of depression, mania, and schizophrenia

This paper reports a follow-up and family study being carried out at the University of Iowa College of Medicine on primary affective disorders and schizophrenia in patients hospitalized thirty-five years ago. The purpose of this project is to obtain objective data to shed light on our understanding of these two major functional psychoses -- their diagnostic validity, clinical features, course and outcome, heterogeneity, life histories, related illnesses and characteristics of familial association. This research started with 525 patients selected from inpatients consecutively admitted to the Iowa Psychopathic Hospital between 1934 and 1944, and with a stratified random sample of 160 surgical patients admitted to the University General Hospital during the same period. A specially designed structured interview form -- the Iowa Structured Psychiatric Interview (ISPI) -- is used to follow up all living index patients, and as many of their living first-degree relatives as possible. At this time, over one-third of the estimated total study population of three thousand patients and relatives have been personally interviewed, and the preliminary findings are reported here.