Search

SummaryThis paper is something of a patchwork, incorporating many issues that have intrigued me during 34 years of research. I have included the importance of maintaining a solid base in clinical work, alongside research activities, and being alert to the possibility of a somatic condition contributing to psychiatric symptoms. I stress the value of careful observation of patients, their response to treatments and reasons for dropping out. In addition, I have included 14 more lessons, learned from my experience of research, which I hope will be of use to those readers who aspire to become researchers.

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in family members is a robust predictor of relapse. Not surprisingly, family interventions are remarkably effective and thus recommended in current treatment guidelines. Their key elements seem to be common therapeutic factors, followed by education and coping skills training. However, few studies have explored these key elements and the process of the intervention itself. We conducted a qualitative and quantitative analysis of the records from a pioneering family intervention trial addressing expressed emotion, published by Leff and colleagues four decades ago. Records were analyzed into categories and data explored using descriptive statistics. This was complemented by a narrative evaluation using an inductive approach based on emotional markers and markers of change. The most used strategies in the intervention were addressing needs, followed by coping skills enhancement, advice, and emotional support. Dealing with overinvolvement and reframing were the next most frequent. Single-family home sessions seemed to augment the therapeutic work conducted in family groups. Overall the intervention seemed to promote cognitive and emotional change in the participants, and therapists were sensitive to the emotional trajectory of each subject. On the basis of our findings, we developed a longitudinal framework for better understanding the process of this treatment approach.

Transcultural observations offer an opportunity to study attitude to mental illness in different societies and family structures. The disparity between industrialised and lower-income societies reflects greater tolerance due to the ability of extended families to compensate for the patient's limitations.

BackgroundOne in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control.AimsTo develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the therapist is able to control so that the avatar progressively yields control to the patient.MethodAvatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS).ResultsThe control group showed no change over time in their scores on the three assessments, whereasthe novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 (P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 (P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU withthe period ofavatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8.ConclusionsAvatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.

The AVATAR therapy is a computer-based intervention which aims to reduce the frequency and severity of voices. The approach is based on computer technology which enables each patient to create an avatar of the entity (human or non-human) that they believe is talking to them. The therapist promotes a dialogue between the patient and the avatar in which the avatar progressively comes under the patient's control. Using real-time voice conversion delivery software, the therapist can modify the relationship between the patient and his/her voice. The innovation of this new intervention is discussed in the present paper as well as the advantages of using a computer based system. The subjective view of the technology from a participant's point of view is also presented.

Background: There is concern about the level of satisfaction with mental healthcare among minority ethnic patients in the UK, particularly as black patients have more compulsory admissions to hospital. Aims: To determine and compare levels of satisfaction with mental healthcare between patients from different ethnic groups in a three-centre study of first-onset psychosis. Method: Data were collected from 216 patients with first-episode psychosis and 101 caregivers from South London, Nottingham and Bristol, using the Acute Services Study Questionnaire (Patient and Relative Version) and measures of sociodemographic variables and insight. Results: No differences were found between ethnic groups in most domains of satisfaction tested individually, including items relating to treatment by ward staff and number of domains rated as satisfactory. However, logistic regression modelling (adjusting for age, gender, social class, diagnostic category and compulsion) showed that black Caribbean patients did not believe that they were receiving the right treatment and were less satisfied with medication than white patients. Black African patients were less satisfied with non-pharmacological treatments than white patients. These findings were not explained by lack of insight or compulsory treatment. Conclusions: The study found that black patients were less satisfied with specific aspects of treatment, particularly medication, but were equally satisfied with nursing and social care. Understanding the reasons behind this may improve the acceptability of psychiatric care to black minority ethnic groups.

Background: Previous epidemiological studies have shown a high incidence of schizophrenia in African-Caribbeans in the UK, but not in Asians. Aims: We investigated the hypothesis that cultural adherence might protect the Asians against the stress of living in a majority white culture. Methods: The Culture and Identity Schedule (CANDID) was given to patients with a diagnosis of schizophrenia making their first contact with psychiatric services, and to a matched group of controls randomly selected from the general population. Results: While the Asian patients displayed no drift away from the traditional values as espoused by their controls, the African-Caribbean patients were less traditional than their controls. Conclusions: The fact that a movement away from their traditional culture distinguishes African-Caribbean patients with a severe psychiatric illness, schizophrenia, from their mentally healthy controls strongly favours marginalization over biculturalism as an interpretation of this shift.

BackgroundStudies demonstrating an association between childhood trauma and psychosis in adulthood have not systematically explored gender differences.AimsTo investigate gender differences in the prevalence of childhood sexual and physical abuse among people with psychosis in comparison with healthy controls.MethodThe Childhood Experiences of Care and Abuse Questionnaire was completed to elicit experiences of sexual and physical abuse during childhood in first-episode psychosis cases and population-based controls.ResultsAmong women, those in the cases group were twice as likely to report either physical or sexual abuse compared with controls following adjustment for all confounders. In particular, the effect of physical abuse in women was stronger and more robust than that for sexual abuse. A similar trend was found for psychotic-like experiences in the female control group. No association was found in men.ConclusionsReports of severe childhood physical or sexual abuse were associated with psychosis in women but not in men.

We sought to investigate the prevalence and social correlates of psychotic-like experiences in a general population sample of Black and White British subjects. Data were collected from randomly selected community control subjects, recruited as part of the SOP study, a three-centre population based study of first-episode psychosis. The proportion of subjects reporting one or more psychotic-like experience was 19% (n = 72/372). These were more common in Black Caribbean (OR 2.08) and Black African subjects (OR 4.59), compared with White British. In addition, a number of indicators of childhood and adult disadvantage were associated with psychotic-like experiences. When these variables were simultaneously entered into a regression model, Black African ethnicity, concentrated adult disadvantage, and separation from parents retained a significant effect. The higher prevalence of psychotic-like experiences in the Black Caribbean, but not Black African, group was explained by high levels of social disadvantage over the life course.

BackgroundNumerous studies have reported high rates of psychosis in the Black Caribbean population in the UK. Recent speculation about the reasons for these high rates has focused on social factors. However, there have been few empirical studies. We sought to compare the prevalence of specific indicators of social disadvantage and isolation, and variations by ethnicity, in subjects with a first episode of psychosis and a series of healthy controls.MethodAll cases with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were recruited over a 3-year period. Data relating to clinical and social variables were collected from cases and controls.ResultsOn all indicators, cases were more socially disadvantaged and isolated than controls, after controlling for potential confounders. These associations held when the sample was restricted to those with an affective diagnosis and to those with a short prodrome and short duration of untreated psychosis. There was a clear linear relationship between concentrated disadvantage and odds of psychosis. Similar patterns were evident in the two main ethnic groups, White British and Black Caribbean. However, indicators of social disadvantage and isolation were more common in Black Caribbean subjects than White British subjects.ConclusionsWe found strong associations between indicators of disadvantage and psychosis. If these variables index exposure to factors that increase risk of psychosis, their greater prevalence in the Black Caribbean population may contribute to the reported high rates of psychosis in this population.

BackgroundIt remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis.AimsTo investigate whether an excess of neurological soft signs is independent of diagnosis (schizophreniav.affective psychosis) and cognitive ability (IQ).MethodEvaluation of types of neurological soft signs in a prospective cohort of all individuals presenting with psychoses over 2 years (n=310), and in a control group from the general population (n=239).ResultsPrimary (PPPConclusionsHigher rates of primary and motor coordination signs are not associated with lower cognitive ability, and are specific to the presence of psychosis.

Introduction In this study, we aimed to establish: (1) whether social isolation modifies the effect of unemployment on first episode psychosis and duration of untreated psychosis (DUP); and (2) whether the gap between high employment expectations and perceived poor employment achievement is associated with first-episode psychosis; and (3) whether the relationship of this achievement-expectation gap and first-episode psychosis is strongest in the African-Caribbean population. Method All patients with a first episode of psychosis presenting to specialist mental health services within tightly defined catchment areas in south-east London and Nottingham over a 2-year period were included in the study. A random sample of healthy participants living within the same catchment areas was also recruited. Data were collected on socio-demographic and clinical characteristics, DUP, social contacts, and perceived levels of employment achievement and expectation. Analysis was conducted on data of 546 participants (224 cases, 322 controls) from the SOP study. Results The relationship between unemployment and risk of non-affective psychosis was moderated by social contacts (unemployed/low social contacts, OR 7.52, 95% CI 2.97-19.08; unemployed/medium social contacts, OR 3.27, 95% CI 1.66-6.47; unemployed/high social contacts, OR 1.36, 95% CI 0.47-3.93). Unemployed patients experienced a longer DUP when having reported lower levels of social contacts. Participants whose employment achievement was lower than their expectations were more likely to be cases than those in whom achievement matched or exceeded expectations (adjusted OR 1.84, 95% CI 1.13-3.02). This applied equally to both African-Caribbean and White British participants (the Mantel-Haenszel test for homogeneity of odds ratios, chi(2) = 0.96, P = 0.33). Conclusions This study suggests that unemployment, social isolation, employment achievement and expectations are important environmental factors associated with risk of psychosis. More attention needs to be focused on interactions between environmental factors as well as subjective experience of those factors in future research on the aetiology of psychosis.

BackgroundFirst-episode psychosis is typically preceded by a prodrome in which there is deterioration in global and social functioningAimsTo examine whether the duration of the prodromal phase influences grey and white matter volumes at the onset of psychosisMethodsEighty-two people were scanned using magnetic resonance imaging when they developed a first episode of psychosis. The duration of the prodromal phase was estimated from detailed interviews and medical records. Voxel-based morphometry was used to assess neuroanatomical abnormalitiesResultsA long prodromal phase was associated with smaller grey matter volumes in the cingulate, frontal and left insular cortex, and with less white matter volume bilaterally in the superior longitudinal and uncinate fasciculi and the cingulumConclusionsThe severity of volumetric abnormalities in first-episode psychosis was greater in those with a long prodrome

BackgroundGrey matter and other structural brain abnormalities are consistently reported in first-onset schizophrenia, but less is known about the extent of neuroanatomical changes in first-onset affective psychosisAimsTo determine which brain abnormalities are specific to (a) schizophrenia and (b) affective psychosisMethodWe obtained dual-echo (proton density/T2-weighted) magnetic resonance images and carried out voxel-based analysis on the images of 73 patients with first-episode psychosis (schizophrenian=44, affective psychosisn=29) and 58 healthy controlsResultsBoth patients with schizophrenia and patients with affective psychosis had enlarged lateral and third ventricle volumes. Regional cortical grey matter reductions (including bilateral anterior cingulate gyrus, left insula and left fusiform gyrus) were evident in affective psychosis but not in schizophrenia, although patients with schizophrenia displayed decreased hippocampal grey matter and increased striatal grey matter at a more liberal statistical thresholdConclusionsBoth schizophrenia and affective psychosis are associated with volumetric abnormalities at the onset of frank psychosis, with some of these evident in common brain areas

The evidence regarding effectiveness of family interventions for psychosis (FIP) is strong and consistent. However, there is a gap in the research on the process of these interventions, and little is known about their active ingredients. This review aims to identify the active ingredients of FIP. We conducted a systematic literature review, focusing on qualitative research, and analyzed 22 papers in total. We found a single study comprehensively exploring the process of FIP. All other studies focused on particular aspects of process-related variables. The key elements of FIP seem to be the so-called "common therapeutic factors", followed by education about the illness and coping skills training. This review supports the value of a stepped model of intervention according to the needs of the families. However, the evidence reviewed also reveals a gap in the research findings based on the limited research available. FIP are complex, psychosocial interventions with multiple components, and more intensive, qualitative research is needed to establish linkages between process and outcome.

The progress achieved in transforming a psychiatric-hospital-based service to one based in the community is reviewed, comparing the United States with the United Kingdom. The situation in low- and middle-income (LAMI) countries is considered in terms of the history of psychiatric services, including the role of colonialism. Statutory psychiatric resources in a number of LAMI countries are enumerated. Innovative examples of the provision of psychiatric care in the community in countries with scanty resources are described, augmented by the author's investigative visits to many of them. The lessons to be learned from these experiences are summarized in an overview.

The spread of asylums throughout Europe and North America is charted and the use of asylums to contain the rejects of society described. Figures are given showing the peak bed occupancy in various countries and the fall in beds thereafter. The turnaround is ascribed to the effects of World War II on military psychiatrists, the introduction of antipsychotic medication, public scandals around the abuse of patients, and sociological critiques of institutions. Political backing for the transition to community psychiatry is discussed with particular reference to the situations in Italy and the UK. Community services developed for the long-stay patients are described and the results of some long-term follow-ups presented. Attention is drawn to the barriers to social integration of patients in the community, and to the lack of job opportunities. The costs of hospital and community care are presented from two studies and the need for cost-benefit analyses stressed. Critiques of deinstitutionalization from professionals, the media, and the public are discussed, with a focus on issues of violence by patients, imprisonment, and homelessness. The distinction is drawn between services for the long-stay and for the acutely ill, and the need for a comprehensive service is emphasized.

BackgroundMinor physical anomalies are more prevalent among people with psychosis. This supports a neurodevelopmental aetiology for psychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association.AimsTo examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis.MethodSixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients.ResultsThe total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus.ConclusionsMinor physical anomalies in a sample of patients with first-episode psychosis are associated with regional grey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

It is of clinical importance to identify the contribution of the individual components in a composite intervention, but this is difficult in practice. The aim of this study was to differentiate the effects of pharmacological and psychosocial interventions in improving the symptoms of patients with schizophrenia undergoing an intensive rehabilitation programme. The Krawiecka Goldberg Vaughn scale was used to record the symptoms of 19 long-stay inpatients in the rehabilitation programme. Ratings were made every 2 weeks for periods of between 1 year and 20 months. Analysis of the time course of symptoms showed that substitution of a single novel antipsychotic for conventional antipsychotic regimes was followed by a significant reduction in delusions but no improvement in hallucinations or negative symptoms. However, hallucinations and negative symptoms reduced significantly over the whole period of the observations, indicating an effect of the composite psychosocial interventions in the programme. For patients with persistent psychotic symptoms, changing from conventional to novel antipsychotic medication is likely to reduce delusions, whereas hallucinations and negative symptoms may be more responsive to a combination of psychosocial interventions.

Purpose A long duration of untreated psychosis (DUP) is associated with relatively poor clinical and social outcomes. In order to identify whether an anatomically mediated mechanism may give rise to poorer outcomes, it is important to identify whether a long DUP is associated with greater brain structural abnormalities. Method 81 patients with first-episode psychosis (schizophrenia, affective, and other psychoses) were scanned using high resolution Magnetic Resonance Imaging. DUP was defined as the number of days between first onset of psychotic symptoms and first contact with mental health services. High-resolution MRI images and voxel-based methods of image analysis were used to investigate brain structure in these patients. Results Longer DUP was associated with gray matter reductions in left middle and inferior temporal, left occipital and left fusiform cortices, and with gray matter excess of the left basal ganglia. All findings remained significant when co-varying for exposure to antipsychotic treatment. Conclusions Temporal gray matter reductions are more marked in patients with a long DUP. This could reflect a progressive pathological process that is active prior to treatment. Alternatively, these abnormalities could be associated with a more insidious onset of illness and a later presentation to services.

It has yet to be established whether neurological soft signs (NSS), which include poor motor coordination, sensory perceptual difficulties and difficulties in sequencing of complex motor tasks, result from specific or diffuse brain structural abnormalities. Studying the neuroanatomical basis of NSS in healthy individuals may help to identify which brain areas are specifically associated with these signs, while excluding the potential confounding effects of psychiatric and neurological disorders. We investigated the relationship between brain structure and NSS in 43 healthy individuals, using the Neurological Evaluation Scale for neurological assessment, and high resolution MRI and voxel-based methods of image analysis to investigate brain structure. Higher rates of NSS were associated with a reduction of inferior frontal gyrus, middle and superior temporal gyrus, and anterior cingulate gyrus. It is of note that in a previous study of patients with psychosis we found that an excess of NSS was associated with a reduction of similar cortical areas. Therefore, we suggest that these cortical brain structural changes represent a common neuroanatomical substrate of NSS, across healthy individuals and patients with psychosis.

BackgroundPrevious research has found that African–Caribbean and Black African patients are likely to come into contact with mental health services via more negative routes, when compared with White patients. We sought to investigate pathways to mental health care and ethnicity in a sample of patients with a first episode of psychosis drawn from two UK centres.MethodWe included all White British, other White, African–Caribbean and Black African patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.ResultsCompared with White British patients, general practitioner referral was less frequent for both African–Caribbean and Black African patients and referral by a criminal justice agency was more common. With the exception of criminal justice referrals for Black African patients, these findings remained significant after adjusting for potential confounders.ConclusionsThese findings suggest that factors are operating during a first episode of psychosis to increase the risk that the pathway to care for Black patients will involve non-health professionals.

Patients with schizophrenia and related psychoses have an excess of minor neurological abnormalities (neurological soft signs) of unclear neuropathological origin. These include poor motor coordination, sensory perceptual difficulties and difficulties in sequencing complex motor tasks. Neurological soft signs seem not to reflect primary tract or nuclear pathology. It still has to be established whether neurological soft signs result from specific or diffuse brain structural abnormalities. Studying their anatomical correlates can provide not only a better understanding of the aetiopathogenesis of soft signs, but also of the pathophysiology of schizophrenia. Surprisingly few studies have investigated the brain correlates of neurological soft signs. In the present study, we investigated the relationship between brain structure and neurological soft signs in an epidemiologically based sample of 77 first-episode psychosis patients. We used the Neurological Evaluation Scale for neurological assessment and high-resolution MRI and voxel-based methods of image analysis to investigate brain structure. Higher rates of soft neurological signs (both motor and sensory) were associated with a reduction of grey matter volume of subcortical structures (putamen, globus pallidus and thalamus). Signs of sensory integration deficits were additionally associated with volume reduction in the cerebral cortex, including the precentral, superior and middle temporal, and lingual gyri. Neurological soft signs and their associated brain changes were independent of antipsychotic exposure. We conclude that neurological soft signs are associated with regional grey matter volume changes and that they may represent a clinical sign of the perturbed cortical-subcortical connectivity that putatively underlies psychotic disorders.

The role of relatives expressed emotion (EE) in mediating the efficacy of family interventions has been studied in randomized controlled trials (RCTs) involving people with schizophrenia and depression. Reanalysis ot two RCTs (n = 48) by Leff (1989) indicated that lowering relatives' EE and/or reducing social contact between the patient, and family members accounted for the efficacy of the intervention for schizophrenia. However this relationship has not been investigated previously with regard to depression, and this paper presents the results of a recent RCT which included measurement of EE and other possible mediating variables. In this study, amelioration of the critical attitude of the partner did not account for the superiority of couples therapy over antidepressant medication, since the same change occurred in the drug group. However, reducing the patient's exposure to the partner's hostility partially explained the efficacy of couples therapy. Further research on the process of change in families undergoing therapy is indicated to identify the variables that account for the efficacy of therapy.

Background. Working with people with mental illness is very challenging and mental health workers can have a significant impact on the mental status of their patients. Few studies have been published that describe training programmes for this staff group. Aim. This paper aims to describe and evaluate a training programme for generic mental health workers used in the context of a residential unit for ‘difficult to place’ mentally ill patients. Method. The staff training programme was adapted from a previous programme showing good efficacy. It was conducted over 10 sessions and addressed a wide range of issues relating to the management of mentally ill patients, with the use of a variety of teaching methods. Twenty-nine generic mental health workers participated in the programme. The impact of the programme was examined using a knowledge questionnaire and a semi-structured questionnaire exploring the range and use of management strategies by staff members. Results. Comparison of pre- and post-training measures indicated that the training programme increased staff knowledge of schizophrenia and the use of certain management skills, in particular, systematic strategies to effect change. This included increased use of structured programmes with patients. Conclusion. The training programme was effective in increasing knowledge and skills of staff and could be used with a variety of psychiatric staff. There are numerous limitations to this study, in particular the poor attendance rates which are likely to have decreased the impact of the programme.

Background: The aim of this study was to explore the characteristics and efficacy of psychoeducational family intervention for persons with schizophrenia in rural China. Methods: A cluster randomised controlled trial of psychoeducational family intervention for families experiencing schizophrenia (three groups, 326 cases) was conducted in Xinjin County, Chengdu. Treatment groups consisted of family intervention and medication, medication alone, and a control. Results: The results showed a gain in knowledge, a change in the relatives' caring attitudes towards the patients, and an increase in treatment compliance in the psychoeducational family intervention group (p < 0.05, 0.001). Most importantly, the relapse rate over 9 months in this group (16.3 %) was half that of the drug-only group (37.8 %), and just over one-quarter of that of the control group (61.5 %) (p < 0.05). Antipsychotic drug treatment and families' attitudes towards patients after the 9-month follow-up were significantly associated with clinical outcome (p < 0.05). Conclusions: In rural China, family intervention should focus on improving the relatives' recognition of illness, the caring attitude towards the patients, treatment compliance, relapse prevention, and the training of the patients' social functioning. This trial, one of the largest in the literature, has shown that psychoeducational family intervention is effective and suitable for psychiatric rehabilitation in Chinese rural communities.

Background: Difficult-to-place patients are left at the end of programmes of psychiatric hospital closure and need specialised services, the nature of which is still under debate. The aim of this study was to evaluate a rehabilitation programme specially designed for difficult-to-place patients in a psychiatric hospital undergoing closure. Method: Twenty-two difficult-to-place patients were identified and underwent a customised rehabilitation programme. Their outcome after 1 year was compared with that of a similar group of 64 patients from another psychiatric hospital who had not received the main components of the rehabilitation programme. Results: Compared with the control patients, the experimental patients showed a significant reduction in severe problems of social behaviour (p < 0.005) and a borderline significant increase in domestic skills (p < 0.06). Conclusions: The results support the value of individually planned behavioural programmes for difficult-to-place patients, combined with training programmes for the staff and rationalisation of medication regimes.

The past 50 years have seen a revolution in psychiatric care that is resulting in the demise of psychiatric hospitals. The process of replacing the diverse functions of the old asylums with community-based services has occurred unevenly throughout the world. Here, we use international case studies to consider how far this change has been beneficial to its main subjects — the patients.

Background: Childhood abuse is considered one of the main environmental risk factors for the development of psychotic symptoms and disorders. However, this association could be due to genetic factors influencing exposure to such risky environments or increasing sensitivity to the detrimental impact of abuse. Therefore, using a large epidemiological case-control sample, we explored the interplay between a specific form of childhood abuse and family psychiatric history (a proxy for genetic risk) in the onset of psychosis. Methods: Data were available on 172 first presentation psychosis cases and 246 geographically matched controls from the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study. Information on childhood abuse was obtained retrospectively using the Childhood Experience of Care and Abuse Questionnaire and occurrence of psychotic and affective disorders in first degree relatives with the Family Interview for Genetic Studies. Results: Parental psychosis was more common among psychosis cases than unaffected controls (adjusted OR = 5.96, 95% CI: 2.09-17.01, P = .001). Parental psychosis was also associated with physical abuse from mothers in both cases (OR = 3.64, 95% CI: 1.06-12.51, P = .040) and controls (OR = 10.93, 95% CI: 1.03-115.90, P = .047), indicative of a gene-environment correlation. Nevertheless, adjusting for parental psychosis did not measurably impact on the abuse-psychosis association (adjusted OR = 3.31, 95% CI: 1.22-8.95, P = .018). No interactions were found between familial liability and maternal physical abuse in determining psychosis caseness. Conclusions: This study found no evidence that familial risk accounts for associations between childhood physical abuse and psychotic disorder nor that it substantially increases the odds of psychosis among individuals reporting abuse.

The relationship between stressors and the onset of psychosis is well described in the literature. However, for minority ethnic groups in the UK the impact of racism and racial life events has not been studied to the same extent. In this paper we describe the development of a semi-structured interview – Racial Life Events Schedule (RALES) – in order to measure racial life events as well as continuing difficulties attributable to racial discrimination. The interview was piloted on 12 African-Caribbean and eight Asian patients presenting with first onset schizophrenia. The interview was useful in eliciting racial events but overall there were no differences between patients and community controls. We believe that this schedule is useful for understanding racial events in the individual's personal and cultural context. The development and the schedule are described in this paper. Copyright © 2001 Whurr Publishers Ltd.

Objectives: Many developed countries, having invested massively in psychiatric hospitals in the past 150 years, are in the process of dismantling them. The central question is whether this change in the location of care from the psychiatric hospital to district-based services has benefited the patients. The objectives of this review are to examine the evidence on which an answer to the above question might be based. Method: Much of the relevant research comes from the 13-year programme of the Team for the Assessment of Psychiatric Services conducted in London, but other research will be reviewed as appropriate. Results and conclusions: Long-stay, non-demented patients, including the elderly, enjoy a better quality of life in the community homes compared with the psychiatric hospitals. Public attitudes constitute an obstacle to social integration into the healthy community, but can be ameliorated with local educational programmes. The provision of work has been unsatisfactory, but the development of social firms holds some promise. Patients with dementia receive better care in community nursing homes compared with hospital wards, according to their relatives' opinions, backed up by observational studies. The part of the service which is most unsatisfactory is the admission facilities. This is due to a variety of causes, including a failure to plan for the admission needs of discharged long-stay patients, the virtual absence of rehabilitation units in the community and an inadequate provision of a range of sheltered accommodation. However, these problems could be resolved with adequate investment in innovative facilities.

The purpose of the study was to evaluate whether community psychiatric nurses trained in family work skills could effectively alter the emotional environment in families caring for a person with schizophrenia, and what the cost implications were. Thirty families entered the trial and were randomised to the complete package of family work (16 subjects) or to a control group (14 subjects) receiving education alone. All relatives scored highly on Expressed Emotion (EE) initially. Of the 12 experimental relatives followed up, seven changed to low EE, compared with only two of the 11 control relatives (Fishers exact p =0.053). The relapse rates for the patients over one year were 25% in the experimental group and 36% in the control group, a non-significant difference. However, two other control patients spent the whole year in hospital. The cost of the training and of working with one family was more than covered by the savings in hospital costs.

Objective: To review the evidence for the efficacy, efficiency and effectiveness of family work for schizophrenia. Method: The review is based on the relevant literature but is not intended to be exhaustive, except in the area of practical application. Results: The effectiveness of family work has been established by a series of randomized controlled trials. Relatives groups are efficient in terms of staff time, and multiple family groups may be more efficacious than sessions with single families. However, a substantial proportion of relatives refuse to attend a group and need sessions in the home. Family work skills can be acquired by clinicians working in ordinary settings, although few studies have addressed this question. Problems have been encountered regularly by trained community workers trying to practise their newly acquired skills. Conclusion: Difficulties in implementation may be remedied by adopting a systemic approach and including the managers of the service in the initial training sessions.

The Team for the Assessment of Psychiatric Services (TAPS) was established in May 1985 with the explicit purpose of evaluating the national policy of replacing psychiatric hospitals with district based services. TAPS' remit was to mount the evaluation with respect to the closure of Friern and Claybury Hospitals in north London. Funding was provided by the Department of Health and North-East Thames Regional Health Authority (latterly North Thames Regional Health Authority) with supplements from the King's Fund and the Sainsbury Family Trusts. During 13 years of research TAPS has employed more than 50 members of staff and associated researchers. A full listing is given in Leff (1997). This summary of the research is organised by topics. However, there was very close integration of the various projects.

BackgroundThere have been no large-scale prospective studies evaluating the transfer of care from psychiatric hospitals to district-based services.AimsWe aimed to compare the quality of life of patients in two north London hospitals scheduled for closure with that in the community homes to which they were discharged.MethodThe total long-stay population of Friern Hospital and several hundred long-stay patients in Claybury Hospital were assessed with a batch of eight schedules while in hospital. They were followed up after one year in the community and then at five years.ResultsOf the 670 discharged patients, 126 died before the five-year follow-up. Data were obtained on 523 (97%) of the survivors. There was no change in the patients' clinical state or in their problems of social behaviour. However, they gained domestic and community living skills. They also acquired friends and confidants. They were living in much freer conditions and the great majority wanted to remain in their current homes.ConclusionsCommunity care has enhanced the quality of life of this group of patients, involved in a well-planned and adequately resourced reprovision programme.

Objective: Sociodemographic factors play an important role in the genesis of mental disorders. High rates of unemployment and other social factors have been reported previously among African-Caribbeans with schizophrenia in London. The aim of the present study was to compare these factors in Trinidad with London African-Caribbeans. Method: Using internationally defined criteria, patients with first-onset schizophrenia were recruited in both countries, and information on the onset of symptoms, help-seeking, pathways into care, premorbid personality and educational and employment status were collected. These two samples are compared on a number of these factors. A total of 56 cases of first onset of psychosis coming into contact with psychiatric services in Trinidad were studied. Of these, 46 cases were diagnosed as having schizophrenia using the CATEGO program. Over a period of 2 years, 38 African-Caribbean patients with schizophrenia were recruited in London. Results: African-Caribbean patients with schizophrenia in London were more likely to be admitted for perceived threat to others and to have shown loss of interest and serious neglect and to have assaulted others. A lower proportion were admitted via a psychiatrist and a higher proportion by the police. The unemployment rate among the London sample of African-Caribbeans was much higher than that in the general population, whereas this was not the case for the Trinidad patients. Conclusion: These findings are discussed in the context of culture and aetiology of schizophrenia, and suggestions with regard to future research are made.

Background: Previous studies have shown that manifestations of symptoms and premorbid personality of patients with schizophrenia differ across cultures. However, these have only been demonstrated in cultural settings apart from each other. Method: We set out to compare these across different ethnic groups from a catchment area in west London. The Asian and the white group had similar inception rates of schizophrenia and we therefore decided to compare these two groups to ascertain similarities in social, demographic and personality factors and pathways into care. First-onset cases of schizophrenia were studied on a number of parameters using previously validated instruments. Results: There were more similarities than differences between the two groups. When compared with the findings of a previous multicentre study in India, London Asians, like their counterparts in India, were more likely than the London white sample to present with loss of appetite, become more religious and behave as if hearing voices. However, compared to their Indian counterparts, the onset of symptoms was more likely to be insidious and alternative sources of healing were less likely to be approached. Conclusions: These findings are discussed in relation to the findings for white patients and recommendations made for future research.

Objective: To examine the outcome of a population of long stay psychiatric patients resettled in the community. Design: Prospective study with 5 year follow up. Setting: Over 140 residential settings in north London. Subjects: 670 long stay patients from two London hospitals (Friern and Claybury) discharged to the community from 1985 to 1993. Main outcome measures: Continuity and quality of residential care, readmission to hospital, mortality, crime, and vagrancy. Results: Of the 523 patients who survived the 5 year follow up period, 469 (89.6%) were living in the community by the end of follow up, 310 (59.2%) in their original community placement. A third (210) of all patients were readmitted at least once. Crime and homelessness presented few problems. Standardised mortality ratios for the group were comparable with those reported for similar populations. Conclusions: When carefully planned and adequately resourced, community care for long stay psychiatric patients is beneficial to most individuals and has minimal detrimental effects on society. Key messages Replacing a psychiatric hospital with full residential facilities in the community has worked well for most long stay psychiatric patients Recurrent and sporadic readmissions to hospital are inevitable for high risk patients regardless of their living conditions Fears are unfounded that former hospital inmates are destined to neglect, high mortality, and homelessness, or that they pose a threat to the public

BackgroundThe incidence rate for broad schizophrenia among second-generation African–Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors.AimsTo determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997)MethodA12-month study of all persons in the 18–54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using World Health Organization screening and measurement instruments.ResultsOn an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10 000 (95% CI 1.97–3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10 000 (95% CI 2.3–4.1), which is significantly lower than the comparable rate for London's African–Caribbeans of 6.6/10000 (95% CI 4.5–8.7)ConclusionsThe very high rate for broad schizophrenia among African–Caribbean people in the UK is probably due to environmental factors.

Background. African-Caribbean patients have less desirable routes of entry into the psychiatric services than other ethnic groups in Britain but this may not apply to the first contact with services.Methods. Patients' pathways to care, type of admission or referral and sectioning details were recorded for all first contact patients presenting to south London psychiatric services over a 2-year period. We also conducted a retrospective analysis of data from the Camberwell Register, comparing rates of compulsory admission between ‘Whites’ and ‘African-Caribbeans’ for first and readmissions, over a 20-year period.Results. Our first contact sample comprised 38 White, 38 African-Caribbean and 24 Asian patients with CATEGO defined broad schizophrenia. GP referral was found to be the most common mode of contact and there were no significant differences between the ethnic groups with regard to compulsory admission. Similarly, data from the Camberwell Register showed no significant difference in rates of compulsory admission between first admission White and African-Caribbean patients. However, when all readmissions were examined, African-Caribbeans were more likely to be admitted involuntarily.Conclusions. Our findings suggest that reports of less desirable routes of entry for African-Caribbean patients into the psychiatric service do not apply to their first admission but are likely to develop over time and repeated contact with the services.

Cultural identity is an integral part of an individual's self and it may affect social and individual functioning of individuals leading to mental distress.The present paper describes the key conce...

Several studies in the UK have observed that the inception rates of schizophrenia among the African-Caribbeans are well elevated when compared withWhite populations.However, on the basis of available data on biological factors it appears that social factors play a more important role in the aetiology of schizophrenia in this group. Reviewing the current state of literature on self-esteem and social factors it is proposed that lack of early attachments and prolonged separation from one or both parents may well play a significant role in the genesis of schizophrenia in this group. It is proposed that some of these factors mediate through low self-esteem and the clinicians and researchers alike are urged to explore further the role of self-esteem in genesis and maintenance of symptoms of schizophrenia.