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A letter to the editor is presented in response to the article "Psychiatric in-patient care and suicide in England, 1997 to 2008 : a longitudinal study," by N. Kapur and colleagues published online in the 17th May 2012 issue.

Objective: To determine the aetiology of forearm pain. In particular to determine the relative contribution of (a) psychological factors, features of somatisation, and health anxiety and behaviour, (b) work related mechanical factors, and (c) work related psychosocial factors in the onset of forearm pain., Design: 2 year prospective population based cohort study, with retrospective assessment of exposures at work., Setting: Altrincham, Greater Manchester., Participants: 1953 individuals aged 18-65 years., Outcome Measures: Forearm pain of new onset., Results: At follow up, 105 (8.3%) participants reported forearm pain of new onset lasting at least one day in the past month. Among these, 67% also reported shoulder pain, 65% back pain, and 45% chronic widespread pain. Increased risks of onset were associated with high levels of psychological distress (relative risk 2.4, 95% confidence interval 1.5 to 3.8), reporting at least two other somatic symptoms (1.7, 0.95 to 3.0), and high scores on the illness behaviour subscale of the illness attitude scales. The two work related mechanical exposures associated with the highest risk of forearm pain in the future were repetitive movements of the arm (4.1, 1.7 to 10) or wrists (3.4, 1.3 to 8.7), whereas the strongest work related psychosocial risk was dissatisfaction with support from colleagues or supervisors (4.7, 2. 2 to 10)., Conclusions: Psychological distress, aspects of illness behaviour, and other somatic symptoms are important predictors of onset of forearm pain in addition to work related psychosocial and mechanical factors. Misleading terms such as "cumulative trauma disorder" or "repetitive strain injury," implying a single uniform aetiology, should be avoided.

Objective: We examine the descriptive epidemiology of chronic widespread pain using the 'Manchester' definition [CWP(M)] and assess psychosocial and other features which characterize subjects with such pain according to these more stringent criteria., Methods: A population postal survey of 3004 subjects was conducted in the Greater Manchester area of the UK., Results: The point prevalence of Manchester-defined chronic widespread pain was 4.7%. CWP(M) was associated with psychological disturbance [risk ratio (RR) = 2.2, 95% confidence interval (CI) (1.4-3.5)], fatigue [RR = 3.8, 95% CI (2.3-6.1)], low levels of self-care [RR = 2.2, 95% CI (1.4-3.6)] and with the reporting of other somatic symptoms [RR = 2.0, 95% CI (1.3-3.1)]. Hypochondriacal beliefs and a preoccupation with bodily symptoms were also associated with the presence of CWP(M)., Conclusion: This definition of chronic widespread pain is more precise in identifying subjects with truly widespread pain and its associated adverse psychosocial factors. Clear associations with other 'non-pain' somatic symptoms were identified, which further supports the hypothesis that chronic widespread pain is one feature of somatization.

Objective: To determine whether psychological symptoms and mental disorder are an intrinsic part of the chronic widespread pain syndrome or whether they have been observed in clinic attenders primarily because of their influence on the decision to seek a medical consultation., Methods: A population survey of 1953 subjects was conducted in the Greater Manchester area of the United Kingdom. The survey included a postal questionnaire, and in a subgroup of respondents with high levels of distress, the presence of mental disorder was assessed by a semistructured standardized interview. Subjects with chronic widespread pain were classified according to whether they had sought a medical consultation for the reported pain ("consulters") or not ("nonconsulters")., Results: In all, 252 subjects (13%) satisfied American College of Rheumatology criteria for chronic widespread pain, and of these 72% reported having consulted a general practitioner about this pain. There was a clear difference in levels of psychological distress, measured by the General Health Questionnaire (GHQ), between consulters, nonconsulters, and those with no pain. Consulters did not differ from nonconsulters in terms of levels of fatigue, social dysfunction, or number of somatic symptoms reported. Although consulters (among whom one in 4 had a mental disorder) were more likely to have a mental disorder than subjects without pain [OR = 4.9, 95% CI (2.6, 9.5)] the increase in risk comparing consulters to nonconsulters [OR = 2.1, 95% CI (0.7, 5.9)] and nonconsulters to subjects without pain [OR = 1.4, 95% CI (0.7, 2.6)] was not significant., Conclusion: The results suggest that psychological distress is associated with chronic widespread pain in addition to any effect on whether consultation is sought for symptoms. The finding that one-quarter of consulters to primary care with chronic widespread pain have a mental disorder should alert primary care physicians and rheumatologists to screen for mental disorder in this group.

Objective: To determine the natural history of shoulder pain in the population, and predictors of outcome on the basis of clinical and individual factors. In addition, to determine whether outcome is influenced by the definition of shoulder pain used., Methods: A prospective cohort study, over a 3 year period, of subjects recruited from a cross sectional population screening study of shoulder pain, conducted in the Greater Manchester area of the UK., Results: Of 92 subjects classified as having shoulder pain in the cross sectional study, 50 (54%) reported shoulder pain at followup about 3 years later. In 90% of cases this was accompanied by some disability specifically relating to the symptoms. Baseline factors that predicted symptoms at followup were: pain (indicated on a manikin) within a more narrowly defined shoulder region, shoulder pain related disability, pain on the day of examination, symptoms lasting more than one year, and a high score on the General Health Questionnaire, a measure of psychological distress., Conclusion: Shoulder pain in the population is a longterm disabling symptom, although many subjects do not seek early medical consultation. Disability (independent of whether there was restriction of movement on examination) is a strong predictor of continuing symptoms. The outcome observed in epidemiological studies of shoulder pain will be influenced by the initial definition of symptoms.