Aims. Little is known about how the rates and characteristics of mental health service users in unpaid work, training and study compare with those in paid employment. Methods. From staff report and patient records, 1353 mental health service users of seven Community Mental Health Teams in two London boroughs were categorized as in paid work, unpaid vocational activity or no vocational activity. Types of work were described using Standard Occupational Classifications. The characteristics of each group were reported and associations with vocational status were explored. Results. Of the sample, 5.5% were in paid work and 12.7% were in unpaid vocational activity, (including 5.3% in voluntary work and 8.1% in study or training). People in paid work were engaged in a broader range of occupations than those in voluntary work and most in paid work (58.5%) worked part-time. Younger age and high educational attainment characterized both groups. Having sustained previous employment was most strongly associated with being in paid work. Conclusions. Rates of vocational activity were very low. Results did not suggest a clear clinical distinction between those in paid and unpaid activity. The motivations for and functions of unpaid work need further research.

BACKGROUND:Although dementia and elder abuse prevention are political priorities, there are no evidence-based interventions to reduce abuse by family carers. We have limited understanding of why some family carers, but not others in similar circumstances, behave abusively. We aimed to test our hypothesis, that more anxious dementia carers report more abusive behaviours, and dysfunctional coping strategies and carer burden mediate this relationship. METHOD:We interviewed 220 family/friend dementia carers from Essex and London Community Mental Health Teams. We used the revised Modified Conflict Tactics Scale to measure abuse. RESULTS:More anxious and depressed carers reported more abuse; this relationship was mediated by using dysfunctional coping strategies and higher burden. Abuse was predicted by: spending more hours caring, experiencing more abusive behaviour from care recipients and higher burden. LIMITATIONS:This was a cross-sectional study so we cannot confirm directions of causality. While many carers were willing to report abusive actions, some may not have been and our numbers may be an underestimate. CONCLUSION:Anxious and depressed carers are particularly likely to report abusive behaviour when asked. Testing interventions directed at reducing carer anxiety, depression or changing unhelpful coping strategies, and/or reducing care recipient aggression where possible, is a logical and urgent next step.

Objective To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses. Design Non-blind randomised controlled trial. Setting Two inner London boroughs. Participants 251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services. Interventions Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants). Main outcome measures Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services. Results No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval −16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4). Conclusions Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

Background: Provision of palliative care for patients with non-cancer conditions is hindered by the difficulty of predicting when people will die and fear of causing distress by raising end-of-life issues. Objectives: To compare patients’ and professionals’ (1) estimations of prognosis; (2) perceptions of the seriousness of the illness and needs for supportive care; and (3) acceptability of this sensitive research, in end-stage cancer and non-cancer diseases. Design: Prospective cohort study. Setting: A teaching hospital and a Marie Curie hospice in London. Subjects: Twenty patients with advanced non-malignant disease (heart failure, chronic obstructive pulmonary disease and renal failure) and 20 patients with advanced cancer, and their physicians in charge. Method: A feasibility study using vignettes to aid patients and doctors estimate of prognoses. Main outcome measures were (1) patients’ and physicians’ estimates of health status, care needs and prognosis; and (2) patient survival. Results: Patients were willing and able to estimate their own life expectancy and cancer patients correctly estimated that they had a poorer prognosis than non-cancer patients. Non-cancer patients perceived that they had similar needs for supportive care as cancer patients. Physicians made little distinction in palliative care needs between patients with and without cancer, but tended to make more pessimistic estimates of prognosis in non-cancer patients. Conclusions: Patients are able to judge their health status and life expectancy and do not object to questions about end-of-life care. Cancer and non-cancer patients have similar needs for supportive care. We need further evidence on the value of self-rated prognosis and how to provide palliative and supportive care for all patients who are near death.

Background: Cancer patients who receive care from specialist palliative care services in the UK are younger than those who do not receive this care. This may be explained by agerelated differences in attitudes to end-of-life care. Objective: To determine the relationship between age and i) attitudes to death and preparation for death; and ii) knowledge about, and attitudes to, cancer and palliative care. Design: Interviews with older people, using a novel questionnaire developed using nominal groups. Main comparisons were made between people aged 55-74 with those aged 75 years and over. Setting: General practices in London. Subjects: 129 people aged 55-74 and 127 people aged 75 years or over on the lists of general practitioners. Methods: A cross-sectional survey to determine knowledge and experience of hospice care; preparation for end-of-life; and attitudes to end-of-life issues. Results: Participants were knowledgeable about specialist palliative care and almost half had some indirect contact with a hospice. People aged <74 were less likely than younger participants to want their doctor to end their life in a terminal illness. Although they believed death was easier to face for older people, they did not believe that younger people deserved more consideration than older people when dying, or that they should have priority for hospice care. Education, social class, hospice knowledge and anxiety about death had little influence on overall attitudes. Conclusions: The relative under-utilization of hospice and specialist palliative care services by older people with cancer in the UK cannot be explained by their attitudes to end-of-life issues and palliative care.

BackgroundLittle is known about the mental health of gay men and lesbians living in Europe.AimsTo compare psychological status, quality of life and use of mental health services by lesbians and gay men with heterosexual people.MethodCross-sectional study in England and Wales using ‘snowball’ sampling.ResultsParticipants: 656 gay men, 505 heterosexual men, 430 lesbians and 588 heterosexual women. Gay men were more likely than heterosexual men to score above threshold on the Clinical Interview Schedule, indicating greater levels of psychological distress (RR 1.24, 95% Cl 1.07–1.43), as were lesbians compared with heterosexual women (RR 1.30, 95% Cl 1.11-1.52). Gay men and lesbians were more likely than heterosexuals to have consulted a mental health professional in the past, deliberately harmed themselves and used recreational drugs. Lesbians were more likely to have experienced verbal and physical intimidation and to consume more alcohol than heterosexual women.ConclusionsAwareness of mental health issues for gay men and lesbians should become a standard part of training for mental health professionals, who need to be aware of the potential for substance misuse and self-harm in this group and of the discrimination experienced by many lesbians.

Objective To explore the relation between spiritual beliefs and resolution of bereavement.Design Prospective cohort study of people about to be bereaved with follow up continuing for 14 months after the death.Setting A Marie Curie centre for specialist palliative care in London.Participants 135 relatives and close friends of patients admitted to the centre with terminal illness.Main outcome measure Core bereavement items, a standardised measure of grief, measured 1, 9, and 14 months after the patients' death.Results People reporting no spiritual belief had not resolved their grief by 14 months after the death. Participants with strong spiritual beliefs resolved their grief progressively over the same period. People with low levels of belief showed little change in die first nine months but thereafter resolved their grief. These differences approached significance in a repeated measures analysis of variance (F=2.42, P=0.058). Strength of spiritual belief remained an important predictor after the explanatory power of relevant confounding variables was controlled for. At 14 months the difference between the group with no beliefs and the combined low and high belief groups was 7.30 (95% confidence interval 0.86 to 13.73) points on the core bereavement items scale. Adjusting for confounders in the final model reduced this difference to 4.64 (1.04 to 10.32) points.Conclusion People who profess stronger spiritual beliefs seem to resolve their grief more rapidly and completely after the death of a close person dian do people with no spiritual beliefs.

Background Disturbance of sleep is common in individuals with dementia where there may be reversal of the sleep-wake cycle. People with dementia of the Alzheimer's type have melatonin secretion rhythm disorders. There is some evidence that treatment with exogenous melatonin is an effective treatment for sleep disturbance associated with dementia: A randomised double blind placebo controlled cross over trial was undertaken to test the hypothesis that slow release exogenous melatonin 6 mg improves sleep for people with dementia.Methods Forty-four participants with DSM-IV diagnoses of dementia-with sleep disturbance were selected for a seven week randomised double blind cross over trial of slow release melatonin 6 mg versus placebo. Sleep parameters were objectively measured using wrist actigraphy:Results Twenty-five out of 44 completed the trial. Sleep was significantly disturbed in the sample population. Melatonin. had no effect on median total time asleep (n = 25, z = 1.35, p = 0.18), number of awakenings (n = 25, z = 0.32, p = 0.75) or sleep efficiency (n = 25, z = 0.17, p = 0.24). Nor were there any carry over effects from melatonin.Conclusions Contrary to previous findings, we found no evidence that two weeks of exogenous melatonin is effective in improving sleep in people with dementia, although possible benefits of melatonin following longer periods of administration cannot be discounted. Copyright (C) 2002 John Wiley Sons, Ltd.

Background. Psychiatrists are asked to give opinions as to fitness to plead, a legal concept. There is a dearth of research into fitness to plead in the UK, with no prospective studies and no studies involving the comparison of fit and unfit subjects. In particular, there have been no investigations into the meaning of 'unfit to plead' in terms of psychiatric symptomatology, or as to the relative importance of each legal fitness criterion in psychiatrists' conclusions as to fitness.Method. The study comprised a prospective evaluation of 479 consecutive referrals to psychiatrists at court. Individual legal fitness criteria were examined as predictors of unfitness. Associations of unfitness, and of individual legal fitness criteria, were examined with Brief Psychiatric Rating Scale (BPRS) symptom scores.Results. The two most important of the legal criteria in clinical decisions as to unfitness were whether the person could follow the proceedings of the trial or give adequate instructions to their solicitor. The legal criteria concerning trial were more predictive of unfitness than those concerning plea. Unfitness was significantly associated with the presence of positive psychotic symptomatology, in particular conceptual disorganization and delusional thinking, but not with symptoms of anxiety, depression or withdrawal.Conclusion. Unfitness is most significantly associated with symptoms affecting comprehension and communication. The fitness criteria could be simplified without loss of power. These results, predominantly concerned with mental illness, may not generalize to the mentally impaired.

BACKGROUND:The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics.METHODS:Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale.RESULTS:The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%).CONCLUSIONS:These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.

OBJECTIVE:To determine the prevalence rate of personality disorder among a consecutive sample of UK primary care attenders. Associations between a diagnosis of personality disorder, sociodemographic background and common mental disorder were examined.METHOD:Three hundred and three consecutive primary care attenders were examined for the presence of ICD-10 and DSM-4 personality disorders using an informant-based interview.RESULTS:Personality disorder was diagnosed in 24% (95% CI: 19-29) of the sample. Personality-disordered subjects were more likely to have psychiatric morbidity as indicated by GHQ-12, to report previous psychological morbidity, to be single and to attend the surgery on an emergency basis. 'Cluster B' personality disorders were particularly associated with psychiatric morbidity.CONCLUSION:There is a high prevalence rate of personality disorders among primary care attenders. These disorders are associated with the presence of common mental disorder and unplanned surgery attendance. Personality disorders may represent a significant source of burden in primary care.

Objective. To investigate the response of residential homes to four specific health problems of residents and the relationship between the quality of this response and the prevalence of depression.

BACKGROUND:Few formalized shared care schemes exist within psychiatry and the evidence base for sharing psychiatric care is weak.AIMS:To evaluate the utility of patient-held shared care records for individuals with long-term mental illness.METHOD:Cluster-randomised controlled parallel-group 12-month trial involving 90 patients with long-term mental illness drawn from 28 general practices.RESULTS:Carrying a shared care record had no significant effect on mental state or satisfaction with psychiatric services. Compared with controls, patients in the shared care group were no more likely to be admitted (relative risk 1.2, 95% CI 0.86-1.67) and attend clinic (relative risk 0.96, 95% CI 0.67-1.36) over the study period. Uptake of the shared care scheme was low by patients and professionals alike. Subjects with psychotic illness were significantly less likely to use their records (relative risk 0.51, 95% CI 0.27-0.99).CONCLUSIONS:Patient-held records may not be helpful for patients with long-term mental illness.

BackgroundAn excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.AimsTo compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.MethodA five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.ResultsAge-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.ConclusionsThe nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

BACKGROUNDThe diagnosis and treatment of depression constitutes a significant component of a general practitioner's workload. A pilot study has suggested that the practice nurse may have an important contribution to make in the care of patients with depression.AIMTo evaluate an extended role for practice nurses in improving the outcome of depression through two specially-designed interviews running in parallel.METHODTwo naturalistic, random allocation studies took place concurrently over four months. Study 1 evaluated the effectiveness of standardized psychiatric assessment by a practice nurse and feedback of information to the general practitioner (GP). Study 2 evaluated the above assessment and feedback combined with nurse-assisted follow-up care. Twenty general practices participating in the Medical Research Council General Practice Research Framework took part in the study. Subjects included general practice attenders identified as depressed by their GP. The main outcome measures were a change in Beck Depression Inventory (BDI) scores and in the proportion of patients fulfilling DSM-III criteria for major depression.RESULTSA total of 577 patients were recruited; 516 [89% (95% CI = 86-92%)] were rated as depressed on the BDI and 474 [82% (95% CI = 79-85%)] met criteria for DSM-III major depression. Altogether, 524 (91%) patients completed follow-up at four months. All groups of patients showed improvement, but no difference in the rate of improvement was shown for the nurse intervention groups. BDI mean scores fell from 18.54 (95% CI = 17.53-20.06) to 11.53 (95% CI = 10.02-13.04) in Study 1, and from 21.01 (95% = CI 20.26-21.86) to 10.62 (95% CI = 9.73-11.51) in Study 2. The proportion of patients fulfilling criteria for DSM-III major depression in Study 1 fell from 80% (95% CI = 73-87%) to 30% (95% CI = 22-38%), and in Study 2 from 80% (95% CI = 76-84%) to 27% (95% CI = 23-31%). Prescription rates of antidepressant medication were higher than expected, ranging between 63% and 76% in the two studies.CONCLUSIONThere was an increase in the rate of antidepressant prescription, but no additional benefit could be adduced for patients who received a nurse intervention.

Synopsis This study aims to describe factors associated with cognitive decline among 2584 subjects, aged 65–74, who were followed up for 54 months in the Medical Research Council Elderly Hypertension Trial (1982–1989). The subjects completed a cognitive test, the Paired Associate Learning Test (PALT), five times over this period. Decline on the PALT was associated with advanced age, male sex, rural residence, depression and low intelligence. These effects were modified by gender and level of pre-morbid intelligence. Advanced age, rural residence and number of cigarettes smoked daily were only associated with PALT decline among women of below median intelligence. The association between depression and PALT decline was only apparent in women of below median intelligence and men of above median intelligence. While these findings are consistent with other research into cognitive decline, they differ in some ways from reported risk factors for dementia, suggesting aetiological separateness. That women were more vulnerable than men to the effects of age and smoking raises the question of the impact on cognition of accelerated atherosclerosis after the menopause.

# Effect is not proved {#article-title-2} EDITOR,—On the basis of the results of two cognitive tests Martin J Prince and colleagues conclude that hypertensive drug regimens in elderly people impair cognition no more than does a placebo.1 This may lead to the changes suggested by the key message “Concerns about damaging cognition should not deter doctors from treating hypertension in older patients.” We have concerns about the study's design: the nature of the outcome measures used, the lack of any run in period before treatment to minimise practice …