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Recent epidemiological and family genetic studies in different countries using standardized diagnostic interviews for mental disorders have rather consistently demonstrated considerably lower current (e.g. ECA Study: 0.9%) and lifetime (1.4%) prevalence estimates of Major Depression in the elderly (older than 65 years of age) as compared to younger age groups (e.g. 30-44 years: 1 year, 3.9%; lifetime, 7.5%). Some investigators have questioned the validity of these data and suggested alternative interpretations. One possibility is that the complex standardized symptoms and clinical probe questions, and the required judgmental process inherent in diagnostic interviews exceed the cognitive capacity of older adults. This may result in systematic response bias. This paper examines the degree to which the lower prevalence estimates of depression in the elderly are biased due to specific characteristics of the assessment strategy. Analyses of epidemiologic data from the Munich Follow-up Study (MFS), based on the Diagnostic Interview Schedule, demonstrate that (1) older respondents report lifetime depressive symptoms with the same frequency as younger respondents. The additional probe questions designed to identify the degree to which symptoms were caused by factors other than psychological revealed that (2) the elderly more often attribute such symptoms to physical illnesses or conditions. This results in (3) the exclusion of the reported symptoms as a basis for diagnosing depression. A laboratory study demonstrated that "working memory capacity" was a good predictor of this response behavior, indicating that the complexity of the formalized questions exceeds the cognitive capacity of the elderly. Attributing symptoms to a physical illness or condition might be a heuristic strategy to simplify complex recall and judgment processes; the resulting answer is plausible but incorrect. We recommend that the symptom and probe questions of standardized diagnostic interviews be simplified, especially for use with the elderly.

Background: This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States., Methods: The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview., Results: Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status., Conclusions: The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.

This paper reviews reliability and validity studies of the WHO - Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The instrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders, it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-retest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa coefficients for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CIDI was judged to be acceptable for most subjects and was found to be appropriate for use in different kinds of settings and countries. There is however still a need for reliability studies in general population samples, the area the CIDI was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CIDI with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly, cognitive probes to improve recall of episodes and their timing, as well as the role of order effects in the presentation of diagnostic sections.

The effect of comorbidity on rates of suicidal ideation and suicide attempts from an adult general population of former West Germany is investigated. The assessment instrument is a modified German version of the Diagnostic Interview Schedule (DIS), a fully standardized interview for the assessment of selected DSM-III lifetime diagnoses as well as suicidal ideation and suicide attempts. Of the general population 4.1% (2.2% male and 4.1% female) made suicide attempts during their lifetime. Only 2 of 18 people who attempted suicide did not meet criteria for a DSM-III-R diagnosis. Cases with pure major depression did not have an odds ratio for suicide attempts significantly higher than subjects with no DSM-III diagnosis. However, cases with both a major depression and a lifetime-anxiety-disorder diagnosis showed significantly elevated odds ratios. Therefore, it is suggested that comorbidity of anxiety and depression, and not depression itself, seems to be a risk factor for suicide attempts.

This article describes a large longitudinal multicenter collaborative study that investigated the form, frequency, course, and outcome of psychological problems that were seen in primary health care settings in 15 different sites around the world. The research employed a two-stage sampling design in which the 12-item General Health Questionnaire was administered to 26,422 persons aged 18 to 65 years who were consulting health care services. Of these persons, 5604 were selected for detailed examinations using standardized instruments and were followed up at 3 months and 1 year to provide information on course and outcome. All assessment instruments have been translated into 13 different languages. The project has produced a database that allows for the exploration of the nature of psychological disorders experienced by patients in general medical care and their association with physical illness, illness behavior, and disability over time.

Rates of depression are compared by sex in epidemiologic surveys conducted in the United States, Canada, Germany and New Zealand. These surveys used similar sampling and diagnostic techniques and the data were standardized to the age and sex distribution of the USA to facilitate comparisons. Data show that the rates of major depression and dysthymia are higher in females than in males and are approximately equal for bipolar disorder across all four countries. The mean age of onset of major depression did not differ by sex across the four countries. The rates of major depression for males seem to be rising and for females stabilizing for birth cohorts born after 1945 (World War II). New data from the National Comorbidity Survey which has younger birth cohorts can directly examine this issue.

Recent epidemiologic studies (i.e., studies conducted since 1980) have consistently demonstrated, on the basis of standardized diagnostic assessments, that there is a substantial overlap between different types of anxiety and depressive disorders. The current literature, however, discusses this issue primarily within the concept of comorbidity and there are some controversies about the existence of a separate disorder of mixed anxiety-depression (MAD). MAD can be defined by the presence of mixed symptoms of depression and anxiety that are below the diagnostic threshold for either one of these diagnoses. Since MAD has not been included in any of the current official classification systems, its prevalence, risk factors, course, and outcome have not been studied specifically in any of the recent epidemiologic studies even though MAD is thought to be very important, especially in primary care settings. This paper reviews recent epidemiologic studies and presents data from the Munich Follow-Up Study, which has found a prevalence of about 1% for MAD as defined by the ICD-10. Despite the lack of clear diagnostic criteria for MAD, there are some indications that: (1) this disorder might be frequent in primary care settings, and (2) patients with MAD frequently demonstrate subjective suffering, show impairment in personal and occupational functioning, and have high health service utilization rates. Current empirical evidence is still insufficient for deciding a suitable classificatory solution for this problem.

Recent epidemiological studies have consistently shown that panic disorder, according to DSM-III, occurs in adults with a lifetime prevalence of about 2% and a 6-month prevalence of about 1.2%. Panic attacks are relatively common, with a lifetime rate of about 9%. Being female and divorced and separated is associated with higher prevalence of panic disorder. The hazard rates for panic disorder were highest between the ages of 25 and 34 years for females and between the ages of 30 and 44 years for males. Panic disorder frequently co-occurs with other anxiety disorders as well as with a wide range of mental disorders such as depression and substance use disorder. Based on few epidemiological studies, panic disorder has been found to have a chronic course with rare complete remission. Subjects with panic disorder were at an increased risk of social impairment, not getting along with their partners, as well as being financially dependent, and were likely to report fair or poor global physical health, and emotional health. Cases with panic disorder had the most severe psychosocial impairment and the worst outcome as compared to other anxiety disorders. Moreover, they are high users of all types of medical services, including mental health and general medical providers. Although recent epidemiological data, with its improved methodology, have considerably increased our knowledge concerning panic attack, panic disorder and agoraphobia, there are still major questions concerning the etiology, natural history, prevention, or control of panic disorder that need to be answered. Furthermore, since panic disorder has been considered as developing in stages, our current epidemiological knowledge cannot tell us in sufficient detail about the specific role of suggested risk factors in the development of panic disorder through its various stages.

This paper reports lifetime and 6-month prevalence rates of alcohol abuse and dependence in West Germany. Assessment instruments are a modified German version of the Diagnostic Interview Schedule (DIS), a fully standardized interview for the assessment of selected DSM-III diagnoses and the Munich Alcoholism Test (MALT). According to the DIS/DSM-III criteria, 13.0% of the adult general population (aged 25-64 years) were found to fulfill the lifetime criteria for alcohol abuse, alcohol dependence, or both; however, only 1.3% of all men and 0.9% of the women interviewed received a current DSM-III diagnosis of alcohol abuse or dependence. There was good consensus between current DSM-III diagnoses with current clinical ICD-diagnoses, but poor concordance with lifetime diagnoses. Symptoms of alcoholism, onset and severity, comorbidity with other DIS/DSM-III disorders as well as some selected risk factors are reported. The results are primarily compared with the results of the US-Epidemiological Catchment Area Program (ECA).

The Lifetime and 6 month DSM-III prevalence rates of mental disorders from an adult general population sample of former West Germany are reported. The most frequent mental disorders (lifetime) from the Munich Follow-up Study were anxiety disorders (13.87%), followed by substance (13.51%) and affective (12.90%) disorders. Within anxiety disorders, simple and social phobia (8.01%) were the most common, followed by agoraphobia (5.47%) and panic disorder (2.39%). Females had about twice the rates of males for affective (18.68% versus 6.42%), anxiety (18.13% versus 9.07%), and somatization disorders (1.60% versus 0.00%); males had about three times the rates of substance disorders (21.23% versus 6.11%) of females. Being widowed and separated/divorced was associated with high rates of major depression. Most disordered subjects had at least two diagnoses (69%). The most frequent comorbidity pattern was anxiety and affective disorders. Simple and social phobia began mostly in childhood or early adolescence, whereas agoraphobia and panic disorder had a later average age of onset. The majority of the cases with both anxiety and depression had depression clearly after the occurrence of anxiety. The DIS-DSM-III findings of our study have been compared with both ICD-9 diagnoses assigned by clinicians independently as well as other epidemiological studies conducted with a comparable methodology.

The CIDI is a fully standardised, structured interview for the assessment of psychiatric disorders according to DSM-III-R and proposed ICD-10 criteria. The development of this interview has been the collaborative effort of researchers from 18 sites around the world. In a field trial to test the cross-cultural acceptability and reliability of the questions, there was found to be high acceptance and excellent reliability for the substance use questions, problems with the lengthy alcohol section, and difficulties translating relevant substance use concepts into different languages. There is therefore room for further improvement in the substance-related questions. There proved to be differences between ICD-10 and DSM-III-R regarding substance abuse and dependence disorders.

The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-10 and DSM-III-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.

The similarities and differences of comorbidity in treated and untreated samples with anxiety disorders were examined using data from the Munich Follow-up Study: 133 subjects with anxiety and depressive disorders and 101 former in-patients at the Max Planck Institute for Psychiatry. Diagnoses were based on the DIS, not using the optional DSM-III exclusion rules. In these epidemiological and clinical samples, 69% and 95% respectively had at least two diagnoses. The epidemiological sample was clearly differentiated from the clinical sample by age of onset. The development of both depressive episodes and substance disorders in the two samples was mostly secondary to the development of anxiety problems. The outcome for subjects with both anxiety and depressive disorders tended to be worse than that for those with anxiety alone, regardless of whether a depressive episode was present at the time of the follow-up investigation. The usefulness is underlined of the comorbidity concept based on operationalised diagnosis without the exclusion rules offered by DSM-III and DSM-III-R.

In this paper a combination of individual- and group-training with unassertive children is described with strongly deprived children from a daily pedagogical institute. Instead of systematic parent's consulting other supportive elements like consulting with educators and teachers, intensive in-vivo-practices, weekly letters with homework etc. were used. Single case design and evaluating on the basis of a A-B-A-C design and a follow-up after eight weeks with three social disadvantaged children at the age of nine to eleven years were used to evaluate the effectiveness of the program. Goal-attainment-scaling was used for each of the five to seven behavioral outcome measures in the individual- and group-training by video. The administration of this program proved to be effective and efficient. The improvements were above the expectations of the training's aims and were stable over a follow-up period.

This study was conducted in order to test the hypothesis derived from the International Pilot Study of Schizophrenia (IPSS) that the existence of extended families in developing countries contributes to the more favorable course and outcome of schizophrenia in these countries in comparison with industrial countries. For this purpose, we compared data from the 5- and 10-year follow-up obtained within the IPSS at Cali, Colombia with data from two 5- to 8-year follow-up studies of former schizophrenic inpatients of the Max Planck Institute of Psychiatry (MPIP) in Munich, FRG. Although, in Cali, schizophrenics are hospitalized and treated with drugs only during acute episodes of the psychosis and no facilities exist for long-term treatment, the psychopathological outcome was, on the whole, not worse than in Munich. Furthermore, the duration of hospitalization during the follow-up period was much lower at Cali and a significantly lower number of Colombian than of German patients was not separated from their families. However, contrary to the hypothesis, family size did not predict course and outcome at both centers.

The main aim of the present study was to examine whether the well-established association between depression and social dysfunction still remains when effects of a coexistent anxiety disorder are eliminated from the data. As these effects strongly depend on the proportion of depressed subjects suffering simultaneously from an anxiety disorder, we first examined the frequency of mixed and pure depressive disorders and that of pure anxiety disorders (control subjects) in a community sample (n = 483). Using DIS/DSM-III criteria (reference period 6 months), pure anxiety disorders were most frequent (6%), followed by pure depressive disorders (3%) and the coexistence of anxiety and depression (2%). Cases suffering from both disorders were most severely afflicted in terms of psychopathology (persistence of symptoms, comorbidity regarding other mental disorders). At the diagnostic level, the association between depression and social dysfunction was only slightly influenced by effects resulting from comorbidity; at the level of actual symptoms, however, we found that cases suffering simultaneously from severe depression and severe anxiety were significantly more handicapped in their social lives than depressive subjects with only mild anxiety symptoms.

Risk of rehospitalization was investigated in 100 former psychiatric inpatients with ICD-9 diagnoses of schizophrenia, schizoaffective and affective psychosis in a 6- to 7-year interval following discharge. Subtype of disorder, aftercare characteristics, previous course of illness and specific sociodemographic factors were hypothesized to predict the probability of readmissions to a hospital. For time-related statistical analyses the survival approach and proportional hazards model were used. The risk of rehospitalization varies considerably between the diagnostic subgroups studied, depending on the length of the observation period chosen. Schizophrenics had the highest risk (after 3 years 66%, 6 years 80%), followed by schizoaffective patients (58 and 65%) and affective psychosis patients (41 and 58%). Aftercare in a short defined period after discharge from the hospital reduced significantly the risk of readmission for patients with an affective psychosis and patients who were married. Former rehospitalization increases the risk of a readmission. Severity of psychopathological features had only minor predictive value.

The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version. The field test is being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and the general populace in different cultures and to provide data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will allow investigators reliably to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.

The reliability of DSM-III diagnoses using an expanded version of the Diagnostic Interview Schedule (DIS), called the Composite International Diagnostic Interview (CIDI), was evaluated by examining 60 psychiatric inpatients on a test-retest basis. Acceptable agreement coefficients of (kappa) 0.5 or above were found for all but two disorders: dysthymic disorder and generalized anxiety disorder. The subclassification of DSM-III affective disorders also revealed some discrepancies between the test and the retest interviews. When compared with results from earlier versions of the DIS, diagnostic reliability was found to have improved for the DSM-III anxiety disorders in particular. These improvements can possibly be attributed to some changes in the wording of the respective items of this section. Several reasons for lowered test-retest reliability are discussed.

The present study is based on a complete institutional and personal coverage of psychosocial care institutions in nine local regions within the Federal Republic of Germany. The study was carried out by means of a short structured questionnaire and was supported by local psychosocial working groups. The following questions were considered on the basis of a sociodemographic differentiation, in urband and rural districts: 1. To what extent do differences appear between urban and rural districts with regard to outpatient-, inpatient- and complementary treatment facilities? 2. To what extent do differences appear in regard to the quantity and quality of specialized professional personel operating there? 3. In what way, and to what extent, compensatory care mechanism do exist? The results show important and systematic differences with regard to the outpatient, inpatient and complementary treatment facilities. Rural districts are characterised by an emphasis on inpatient facilities, including homes, as well as by a marked lack of outpatient facilties, especially of a psychotherapeutic nature. Psychosocial professions with high qualifications, especially in psychotherapeutic respect, are mainly found in regions characterised as urban, while they are nearly completely absent in rural districts. In addition the results point at a underprivileged treatment structure of rural district. However there are indications of compensatory care mechanisms. This means that persons without any specialized training are often engaged in treatment jobs requiring specialisation. This applies in particular to the complementary field of patient care. The article discusses overlapping problems of proper geographic distribution of psychosocial treatment facilities in accordance with actual requirements. Furthermore political conclusions resulting from this aiming at improvementsof the care structure for mentally ill persons are discussed.

Two problems concerning the IMPS are revealed. First, the importance of an appropriate reliability measure is demonstrated in a sample of 124 inpatients. Widely divergent results are found using three different intraclass correlation coefficients. The one producing the highest results was used by Klett and McNair (1966) and by Behrends et al. (1971). However, the results from this measure only apply to certain types of investigation. A measure more applicable to most investigations in psychiatric research (the intraclass correlation coefficient of individual ratings with between-rater variance included) produced results that were clearly lower, although still acceptable, with an average correlation of 0.72 between the 12 scales. Secondly, the multiplication of item scores by 2 or 8 when forming the scale scores is shown to lead to unusual and undesirable scale distributions in a sample of 1932 inpatients. The resulting implications for assessing change scores on some of the IMPS scales are discussed.

Forty-six patients with the ICD diagnosis of schizophrenic or similar paranoid psychosis, 35 patients with the ICD diagnosis of affective psychosis, 22 patients with the ICD diagnosis of schizoaffective psychosis, and a large sample of control probands from the general population were followed up using standardized assessment procedures 5-8 years after index hospital treatment. A comparison of respective psychopathological or social outcome measures among the diagnostic groups and between patients and matched non-patients from the general population survey confirms the hypothesis that patients with the diagnosis of schizophrenia have, as a group, the poorest degree of psychopathological disturbances and social maladjustment. However, there is a large subgroup with a favourable outcome. Some predictors for poor outcome, described in the literature and in a former follow-up study of ours, could be confirmed. Under the aspect of invariance under different sample conditions, the predictive power of some prognostic scales, such as the Stephens Scale, the Vaillant Scale, and the Strauss-Carpenter Scale, was substantiated.

Psychopathological status and psychosocial functioning of 40 former inpatients suffering from an anxiety neurosis (ICD 300.0) or phobia (ICD 300.2) were followed up over a period of 6-8 years using standardized instruments. In addition, the course of illness, the utilization of medical services and the periods of work disabilities were assessed. With regard to psychopathology, in more than half of the patients course and outcome could be regarded as chronic and severe; only one third of the patients were free of marked or severe psychopathological symptoms during the 12 months preceding the reexamination. Although on the psychosocial outcome level 67% of the 40 former inpatients showed marked or severe difficulties in most social role areas, especially in the field of personal interaction, the great majority of these patients seemed to have adapted somehow to their life situations. Only 13% could be regarded as severely impaired and in continuous need of supervision and guidance. Coping difficulties with everyday demands and dissatisfaction with their social functioning and their anxiety-related restrictions were most prominent in all anxious patients. In contrast to some other long-term follow-up studies, most of which were carried out on outpatients, the results suggest a rather unfavourable course and outcome of anxiety disorders.

DSM-III lifetime diagnoses were assessed in 52 patients with a lifetime history of anorexia nervosa or bulimia by means of a standardised diagnostic interview. It was found that 44.2% had a lifetime diagnosis of DSM-III major affective disorder, with abstaining anorectics having a lower rate of depression than those with bulimic symptoms. In the great majority of cases, the onset of affective disorder post-dated the onset of the eating disorder by at least one year. In patients whose eating disorder was in remission, the rate of depressive symptoms was lower than in those in the acute stage of their illness. These findings, combined with recent studies on biological changes in eating disorders, and psychological theories of depression, suggest that in most cases in which the two conditions are associated, the depression is secondary to the eating disorder.

In the context of a seven-year follow-up study, 171 former psychiatric inpatients and 158 subjects from the general population were interviewed twice, first with the German version of the Diagnostic Interview Schedule (DIS) (version 2), and second with a clinical interview using the Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie (AMDP) checklist to assign a clinical International Classification of Diseases (eighth revision) (ICD-8) diagnosis, independent of the DIS. With the clinicians' ICD-8 diagnosis as a measure of the quality of the DIS, the results indicate a sufficiently high overall specificity and sensitivity of the DIS as a case-finding instrument in a general population survey, and a surprisingly high concordance of most DIS diagnostic classes with comparable ICD diagnoses. Only for panic disorders (possibly due to different symptom and time criteria) and schizophrenia (possibly due to the strict probe system, the dependence on self-reports, and time criteria) was low sensitivity found. Because there is no DIS diagnostic category comparable with ICD-8 unipolar affective psychosis, a meaningful comparison of this ICD category with Research Diagnostic Criteria and DSM-III was not possible.

This study addresses the issue of need for and provision of psychotherapy care in urban and rural areas. In the first part, prevalence of mental disorders based on epidemiological field studies in the county of Traunstein and the city of Mannheim are discussed. Among patients of general practitioners the prevalence of mental disorders was slightly higher in Mannheim than in Traunstein. Concerning the provision of care, results of a questionnaire survey of a random sample of 1542 nonmedical counsellors or psychotherapists in Traunstein, Mannheim and the metropolitan area of West Berlin are presented. The rate of nonmedical therapists/100,000 inhabitants was the same for Traunstein and Mannheim. A more detailed analysis of their service capacity revealed that it was by 17% to 20% higher for Mannheim than for Traunstein; the prevalence of mental disorders in patients of general practitioners was shown to be about 10% higher in Mannheim than in Traunstein. Under the assumption that there is a linear relationship between prevalence and need for care, there appears to be a slight, but not marked undersupply of services by doctors and nonmedical counsellors or psychotherapists in Traunstein as compared to Mannheim. In comparison, the districts of West Berlin were classified into those with high and those with a low percentage of blue collar workers. The rate of nonmedical counsellors or psychotherapists in the "upper class" districts in West Berlin was almost four times higher than that for the "lower class" districts of West Berlin, in Mannheim and Traunstein. The rate/100,000 for the service capacity of nonmedical counsellors or psychotherapists in the "upper class" districts of West Berlin was much higher, and in the "lower class" districts of West Berlin much lower, than in Traunstein or Mannheim. Our data show that there are some discrepancies in the provision of care between rural and urban areas, which however are not large when Traunstein is compared with Mannheim; there were however, substantial discrepancies in the provision of care between cities (Mannheim and West Berlin) and between districts within the same city (West Berlin).

The study examines to what degree well-documented present and life-time psychotic symptoms in a group of former psychiatric inpatients are ascertained when using the Diagnostic Interview Schedule (DIS). The Inpatient Multidimensional Psychiatric Scale (IMPS) and the Manual for the Assessment and Documentation of Psychopathology/Diagnostische Sichtlochkartei (AMDP/DiaSika) Interview-Checklist approach were used for the "clinical" evaluations of symptoms. The results indicate fair concordance between the two clinical approaches and the DIS with regard to the presence of any delusional or hallucination symptoms. Low to poor agreement was found in the assessment of many of the rather specific hallucinations and delusions. Generally, the concordance found was higher when compared to the more clinical AMDP/DiaSiKa approach than to the IMPS. More detailed comparisons with diagnostic subgroups of schizophrenic and schizoaffective patients substantiated the findings in the overall sample. Overall it was reconfirmed that the DIS approach is limited to those patients who are cooperative and at least partly remitted.

The study compares in a randomized clinical control-group design with a waiting list-and acupuncture therapy control-group the short term (three months) effectiveness of a newly developed psychological biobehavioral treatment program in 30 chronic migraine patients. The results show a significant reduction of vascular and tension related headache-frequency and intensity (primary outcome criteria) in both the acupuncture and psychological treatment condition. The waiting list control-group remained almost unchanged over the whole observation period. The improvement in both treatment conditions remained stable throughout the post therapy period to the three months follow-up, but only the psychological treatment condition revealed a highly significant reduction in the use of all kinds of medication in comparison to the pre-treatment period. Single case analyses showed a slight superiority of the psychological treatment condition over the acupuncture therapy due to a more generalized improvement in all secondary outcome variables (psychological restrictions in every day life, medication, duration of headache). The effect of specific components of the psychological treatment program are examined and possible general implication for a treatment of severely disturbed chronic migraine patients are discussed.

The advent of more explicit diagnostic criteria and the growing interest in "lifetime" rates of mental disorders has made imperative an accurate determination of time-related diagnostic criteria. We used data from two independent test-retest studies of the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI) to study the reliability of different time-related questions in these fully standardized diagnostic interviews. With two exceptions (anxiety disorders and alcohol-related questions), the test-retest reliability of most time-related questions in both interviews was judged to be satisfactorily high. Furthermore, the validity of time-related questions in the DIS (age at symptom onset, duration and frequency of illness episodes) was examined by comparing them with detailed "consensus" ratings done independently by different clinicians for 207 former psychiatric inpatients. A surprisingly high concordance was found for former psychotic patients except for those still severely disturbed at the follow-up investigation. Some severe restrictions were also found for nonpsychotic disorders with regard to judgment of the age at onset of phobias, panic attacks, and depression. For a more valid assessment of time-related symptom information, the use of specific memory aids is suggested.

A sample of 48 former nonpsychotic inpatients was studied with respect to the overlap of depression and anxiety. Particular emphasis was placed on social dysfunctions associated with anxiety disorder as both a pure and a mixed condition. Furthermore, another question examined was whether social dysfunctions represent a risk factor for the development of a severe depression. Almost 40% of patients with a DSM-III anxiety disorder (during the last 4 weeks before follow-up) simultaneously fulfilled the criteria of a depressive disorder, mainly those of a major depression. While the course of symptomatology for both the pure anxiety and the mixed group had been rather similar over a long period of time, social dysfunctions before index admission had been generally more pronounced in patients who later developed a severe secondary depression. Social dysfunctions of patients with both disorders are not exclusively explainable by a higher severity of symptoms or the presence of particular personality features.

The results of a 7-year follow-up study of 50 former psychiatric inpatients with a diagnosis of depressive neurosis (ICD 300.4) who met the RDC criteria for Major Depression are reported. The follow-up assessment of the patients included the use of standardized social, psychological and psychopathological instruments. In addition, the course of illness as well as the utilization of medical services and periods of working disability were evaluated. The results indicate a rather unfavourable course and outcome in terms of symptoms for approximately 40% of the sample, including six patients who had committed suicide after index discharge. Almost 40% of the sample showed mild chronic symptoms with persistent impairments in social functioning especially in the area of social interaction, whereas only 20% of the sample were classified as satisfactorily improved or completely remitted.

This paper presents the findings of two independent studies which examined the test-retest reliability and the fall-off effects of the Munich Life Event List (MEL). The MEL is a three-step interview procedure for assessing life incidents which focuses on recognition processes rather than free recall. In a reliability study, test-retest coefficients of the MEL, based on a sample of 42 subjects, were quite stable over a 6-week interval. Stability for severe incidents appeared to be higher than for the less severe ones. In the fall-off study, a total rate of 30% fall-off was noted for all incidents reported retrospectively over an 8-year period. A more detailed analysis revealed average monthly fall-off effects of 0.36%. The size of fall-off effects was higher for non-severe and positive incidents than for severe incidents. This was particularly evident for the symptomatic groups. Non-symptomatic males reported a higher overall number of life incidents than females. This was partly due to more frequent reporting of severe incidents. The findings of the fall-off study do not support the common belief that the reliability of life incident report is much worse when the assessment period is extended over a period of several years as compared to the traditional 6-month period.

One hundred and eighty-three patients suffering from functional psychoses were diagnosed according to ICD-8, RDC, and DSM-III criteria, and the concordance rates for the diagnoses compared. The heterogeneity of the diagnosis 'schizoaffective psychosis' as defined by these systems became clear. With respect to prognosis, the DSM-III diagnosis of schizophrenia was most closely related to poor outcome. Affective psychoses and schizoaffective psychoses, as well as DSM-III 'schizophreniform disorders', demonstrated a favourable prognosis.