This issue contains a review of studies of the effectiveness of compulsory interventions in the community. Other sets of papers report findings from twin studies and population surveys, and six individual papers examine a variety of topics.

Background. There is limited randomized controlled trial (RCT) evidence for compulsory community treatment. Other study methods may clarify their effectiveness. We reviewed RCT and non-RCT evidence for the effect of compulsory community treatment on hospital admissions, bed-days, compliance and out-patient contacts.

Method. A systematic review of RCTs, controlled before-and-after (CBA) studies, and interrupted time series (ITS) analyses. Meta-analysis of RCTs.

Results. Eight papers covering five studies (two RCTs and three CBAs) met inclusion criteria (total n=1108). There was no statistical difference in 12-month admission rates between subjects on involuntary out-patient treatment and controls. Survival analyses of time to admission were equivocal. All five studies reported decreases in the number of bed-days following involuntary out-patient treatment but this only reached statistical significance in one situation; patients receiving the intervention were less likely to have admissions of over 100 days. There was no difference in treatment adherence between the intervention and control groups in either RCT or two of the CBA studies. However, the third CBA study reported a statistically significant increase of nearly five visits in the mean number of overall contacts in the involuntary out-patient treatment group.

Conclusions. The evidence for involuntary out-patient treatment in reducing either admissions or bed-days is very limited. It therefore cannot be seen as a less restrictive alternative to admission. Other effects are uncertain. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

Background. Both psychopathic personality traits and antisocial behavior are influenced by genetic as well as environmental factors. However, little is known about how genetic and environmental factors contribute to the associations between the psychopathic personality traits and antisocial behavior.

Method. Data were drawn from a longitudinal population-based twin sample including all 1480 twin pairs born in Sweden between May 1985 and December 1986. The twins responded to mailed self-report questionnaires at two occasions: 1999 (twins 13–14 years old), and 2002 (twins 16–17 years old).

Results. A common genetic factor loaded substantially on both psychopathic personality traits and antisocial behavior, whereas a common shared environmental factor loaded exclusively on antisocial behavior.

Conclusions. The genetic overlap between psychopathic personality traits and antisocial behavior may reflect a genetic vulnerability to externalizing psychopathology. The finding of shared environmental influences only in antisocial behavior suggests an etiological distinction between psychopathic personality dimensions and antisocial behavior. Knowledge about temperamental correlates to antisocial behavior is important for identification of susceptibility genes, as well as for possible prevention through identification of at-risk children early in life.

Background. Although adult antisocial personality disorder is generally preceded by a pattern of childhood/adolescent conduct problems, only a subset of those who manifest these developmental precursors go on exhibit significant antisocial behavior in adulthood. To date, however, researchers have yet to resolve the origins of either stability or change in antisocial behavior from childhood/adolescence to adulthood.

Method. The present study sought to fill this gap in the literature, making use of a sample of 626 twin pairs from the ongoing Minnesota Twin Family Study (MTFS). Participants were assessed three times between late adolescence and early adulthood. We made use of biometric Cholesky decomposition and latent growth curve modeling techniques, which allow researchers to disambiguate processes of stability and change and evaluate their respective etiologies (i.e. genetic or environmental).

Results. Our results revealed that genetic forces were largely responsible for the stability of adult symptoms of antisocial behavior (AAB) from late adolescence through mid-adulthood, while non-shared environmental influences were primarily responsible for change. Importantly, however, although some of the latter represented systematic and long-lasting influence, much of this non-shared environmental variance appeared transient and idiosyncratic.

Conclusions. Such findings highlight the enduring impact of genetic influences on AAB, and offer insights into the nature of non-shared environmental influences on development.

Background. Previous reports of genetic influences on obsessive–compulsive disorder (OCD) symptoms have suggested moderate heritability. Family history studies of co-morbidity have found familial aggregation with tics, especially for early-onset OCD, and familial aggregation with anxiety disorders.

Method. Heritability of OCD and familial aggregation of OCD, tics and anxiety disorders were investigated in a community sample of 6-year-old twins using a two-phase design in which 4662 twin pairs were sampled and 854 pairs were assessed in the second phase by maternal-informant diagnostic interview using DSM-IV criteria.

Results. In the multivariate model combined additive genetic and common environmental effects were estimated as 47% for sub-threshold OCD, and the model was unable to distinguish these sources of familial aggregation. There were strong familial aggregations between sub-threshold OCD and tics and between sub-threshold OCD and other anxiety disorders (80% and 97% respectively), although again specific sources could not be distinguished.

Conclusions. The findings are consistent with the hypothesis of a tic-related early-onset OCD phenotype, but also with the hypothesis of an anxiety-related early-onset OCD phenotype.

Background. The use of cannabis and other illicit drugs (OIDs) and their co-morbid misuse are frequently reported in the literature. Correlated vulnerabilities and causal or gateway influences have been implicated in this association. We investigated the source of this co-morbidity between cannabis use (experimentation, early and repeated use, and problems) and OID experimentation and problems using genetic models proposed by Neale and Kendler (American Journal of Human Genetics 1995, 57, 935–953).

Method. In a sample of 4152 same-sex male and female adult Australian twin individuals, we fit 13 genetically informative models of co-morbidity to data on experimentation, early use, repeated use of cannabis and co-morbid OID experimentation, and to abuse/dependence (A/D) problems with cannabis and OIDs.

Results. Model-fitting results suggest that common genetic, shared and unique environmental factors are responsible for the association between cannabis experimentation, early use, repeated use and A/D problems and OID experimentation or problems. The liability causation model, which is a reduced form of the correlated vulnerabilities model, also fit very well. In women, we found evidence for high-risk cannabis experimenters and repeated users to be at increased risk for OID experimentation, despite being below the risk threshold on the liability distribution for OID experimentation (extreme multiformity).

Conclusions. Co-morbid cannabis and OID use and misuse are due partly to a common predisposition to substance use disorders. Putative causal effects could not be ruled out. These models warrant further research, so that features of the correlated vulnerabilities model and the gateway models can be studied jointly in a single series of adaptive nested models.

Background. This is the first study to examine variation across cohorts in lifetime risk of DSM-IV mental disorders in metropolitan China.

Method. Face-to-face household interviews of 2633 adults in Beijing and 2568 adults in Shanghai were conducted from November 2001 to February 2002 using a multi-stage household probability sampling method. The Chinese World Mental Health (WMH) Survey Initiative version of the WHO Composite International Diagnostic Interview (WMH-CIDI) was used for assessment.

Results. Lifetime prevalence of any disorder was 13·2%. Alcohol abuse (4·7%), major depressive disorder (3·5%), and specific phobia (2·6%) were the most common disorders. The median age of onset was later for mood (43 years) than anxiety (17 years) and substance use (25 years) disorders. Compared to observed lifetime prevalence, the projected lifetime risk as of age 75 years increased by 106% for major depressive disorder (7·2%), and was uniformly higher for all disorders. Relative odds of any lifetime disorder were 4·7 in the most recent cohorts (ages 18–34) compared to the eldest cohorts (ages [ges ]65).

Conclusions. The findings of this cross-sectional study tally with the view that rapid socioeconomic changes may bring about increasing incidence of mental disorders in China. However, prospective longitudinal studies are needed to confirm if the increase is real. Because of the huge size of the Chinese population, any increase in projected lifetime risk of mental disorders represents an enormous increase in the number of affected individuals.

Background.Many patients with psychological or physical problems are interested in non-medical approaches. The reasons for the growing popularity of complementary and alternative medicine (CAM) are not well understood considering that evidence of the effectiveness of conventional therapies is greater than ever before. We have examined data from the Zurich Study to determine trends and predictors of CAM use in Switzerland.

Method.The Zurich Study is a longitudinal community study that was started in 1979 with a sample of 591 participants born in 1958 and 1959. In 1999, the last of six interview waves with face-to-face interviews was conducted. CAM use was analyzed with data from interviews in 1993 and 1999. Polytomous logistic regression analysis focused on the personal, demographic and sociocultural background of CAM users.

Results.CAM use in the last 12 months was reported by 21·9% of the participants in 1993 and by 29·5% in 1999. CAM use among those exhibiting either physical or psychological problems was in the ratio of two to one. There was a trend from alternative variants of CAM (homeopathy) to complementary ones (massage, osteopathy, acupuncture). The vast majority of CAM use was in addition to conventional therapies. Predictors of CAM use were, among others, attribution of physical complaints to stress and other psychological variables, very low education level in parents, and lacking political interest.

Conclusions.Besides the sociocultural background, characteristics such as the psychological attribution style play an important role in CAM use. CAM use in Switzerland is mainly of a complementary rather than an alternative nature.

Background. No instrument has been developed specifically for assessing the clinician–patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction.

Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction, test–retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden.

Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test–retest reliability was r=0·76 for STAR-P and r=0·68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit.

Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care.

Background. Identify a group of adults with ‘undiagnosed’ attention deficit hyperactivity disorder (ADHD) and compare their personal and family medical histories, psychosocial profiles, functional impairment and quality of life with non-ADHD controls. Additionally, compare adults with undiagnosed and diagnosed ADHD to investigate possible reasons why the undiagnosed avoid clinical detection.

Method. ICD-9 codes for ADHD in administrative claims records and responses to a telephone-administered adult ADHD screener [the Adult ADHD Self-Report Scale (ASRS)] were used to classify approximately 21000 members of two large managed health-care plans as ‘undiagnosed’ (no coded diagnosis; ASRS positive) or ‘non-ADHD’ controls (no coded diagnosis; ASRS negative). Patients identified as ‘undiagnosed’ ADHD were compared with samples of non-ADHD controls and ‘diagnosed’ ADHD patients (ICD-9 coded ADHD diagnoses) on the basis of demographics, socio-economic status, past and present mental health conditions, and self-reported functional and psychosocial impairment and quality of life.

Results. A total of 752 ‘undiagnosed’ ADHD subjects, 199 ‘non-ADHD’ controls and 198 ‘diagnosed’ ADHD subjects completed a telephone interview. Overall, the ‘undiagnosed’ ADHD cohort demonstrated higher rates of co-morbid illness and greater functional impairment than ‘non-ADHD’ controls, including significantly higher rates of current depression, and problem drinking, lower educational attainment, and greater emotional and interpersonal difficulties. ‘Undiagnosed’ ADHD subjects reported a different racial composition and lower educational attainment than ‘diagnosed’ ADHD subjects.

Conclusion. Individuals with ‘undiagnosed’ ADHD manifest significantly greater functional and psychosocial impairment than those screening negative for the disorder, suggesting that ADHD poses a serious burden to adults even when clinically unrecognized.

Background. Previous studies have suggested that men and women process emotional stimuli differently. In this study, we used event-related functional magnetic resonance imaging (fMRI) to investigate gender differences in regional cerebral activity during the perception of positive or negative emotions.

Method. The experiment comprised two emotional conditions (positively/negatively valenced words) during which fMRI data were acquired.

Results. Thirty-eight healthy volunteers (19 males, 19 females) were investigated. A direct comparison of brain activation between men and women revealed differential activation in the right putamen, the right superior temporal gyrus, and the left supramarginal gyrus during processing of positively valenced words versus non-words for women versus men. By contrast, during processing of negatively valenced words versus non-words, relatively greater activation was seen in the left perirhinal cortex and hippocampus for women versus men, and in the right supramarginal gyrus for men versus women.

Conclusions. Our findings suggest gender-related neural responses to emotional stimuli and could contribute to the understanding of mechanisms underlying the gender disparity of neuropsychiatric diseases such as mood disorders.

Background. No study to date has examined the effects of mood stabilizer alone and the combination of mood stabilizer and atypical antipsychotic, quetiapine, on hippocampal neurochemical markers of bipolar disordered patients concurrently. We therefore undertook a proton magnetic resonance spectroscopy (1H MRS) study of drug-free patients with bipolar disorder (drug-free group), patients undergoing valproate treatment (valproate group), patients administered valproate+quetiapine (valprote+quetiapine group) and healthy controls, focusing on the in vivo neuroanatomy of the hippocampus.

Method. Thirty patients from the Firat University School of Medicine Department of Psychiatry and 10 healthy controls gave written informed consent to participate in the study. The patients and controls underwent proton magnetic resonance spectroscopic imaging (1H MRSI), and measures of N-acetylaspartate (NAA), choline-containing compounds (CHO), and creatine+phosphocreatine (CRE) in hippocampal regions were obtained.

Results. The drug-free patients had significantly lower NAA/CRE and NAA/CHO ratios compared with the valproate and valproate+quetiapine groups and the healthy controls. The lower NAA/CRE and NAA/CHO ratios remained statistically significant even after covarying for age or whole brain volume compared with the valproate and valproate+quetiapine groups and healthy controls. In post hoc comparisons, a significant difference was found between the valproate+quetiapine group and the valproate group only with regard to NAA/CHO.

Conclusion. Our findings suggest that valproate has a neuroprotective effect. In post hoc comparisons, a significant difference was found between the valproate+quetiapine and the valproate group with regard to NAA/CHO, indicating that the addition of quetiapine further increases the level of NAA and provides an additional neuroprotective effect.

Background. Symptom fluctuation in bulimia nervosa (BN) is related to menstrual cycle phase. However, the relationship between bulimic symptoms and ovarian hormones (estrogens and progesterone) has not been examined directly in women with BN.

Method. Regularly menstruating women with DSM-IV BN (n=9) and regularly menstruating controls (n=8) collected hormone samples and recorded mood and bulimic symptoms daily for 35 consecutive days. Estradiol and progesterone were measured by radioimmunoassay. Within-subject analyses examined prospective longitudinal associations between changes in ovarian hormones and changes in binge frequency in women with BN. Analyses controlled for the possible influence of negative affect on binge frequency as well as the influence of progesterone when examining estradiol associations and the influence of estradiol when examining progesterone associations. Between-subject analyses examined whether women with BN were more likely to have disrupted hormonal profiles than controls.

Results. Increases in binge eating were significantly associated with both decreases in estradiol and increases in progesterone in BN women with intact menstrual cycles. Although BN women were more likely to have disrupted hormone profiles than controls, this difference did not reach statistical significance, and mean estradiol and progesterone levels did not differ between bulimic and control groups.

Conclusions. The results are consistent with those from experimental animal studies and suggest that decreases in estradiol and increases in progesterone may contribute to increases in binge eating. Ovarian hormone function represents a promising candidate for unraveling the neurobiological mechanisms of binge eating.

Background. No accurate means of determining which individuals will develop post-traumatic stress disorder (PTSD) following a traumatic event has yet been identified. This study aimed to determine the validity of the Trauma Screening Questionnaire (TSQ) in predicting the development of PTSD following assault.

Method. Five hundred and sixty-two individuals who presented to an emergency unit following assault completed the TSQ between 1 and 3 weeks later. The Davidson Trauma Scale (DTS) was completed by the same individuals at 1 month and 6 months following assault to determine the presence of PTSD. The predictive power of the TSQ was determined by statistical tests.

Results. The TSQ was an effective means of predicting future PTSD, with a sensitivity of 0·85, specificity 0·89, negative predictive value (NPV) 0·98 and efficiency 0·90. The positive predictive value (PPV) was lower (0·48), probably as a result of the relatively low prevalence of PTSD at 1 month (11%) and 6 months (8%) following the assault.

Conclusions. This study suggests that the TSQ can be used between 1 and 3 weeks after assault to help identify individuals who will develop PTSD.