Assessing young people who deliberately harm themselves.

BACKGROUND: Many young people who harm themselves have chronic mental health or social problems or are at risk of future self-harm or even suicide. The accident and emergency (A&E) clinic is an important gateway to treatment. AIMS: To describe the psychosocial assessment of 12- to 24-year-old patients attending A&E clinics following deliberate self-harm (DSH) and to identify features of service management and provision which maximise specialist assessment. METHOD: A postal questionnaire was sent to a sample of one in three A&E departments in England. In a representative sample of 18 of these hospitals, staff were interviewed and 50 case notes per hospital were examined. RESULTS: Psychosocial assessment by non-specialist doctors in A&E departments tended to be of variable quality, focused on short-term risk. Around 43% of patients aged 12-24 were assessed by a specialist; specialist assessment was associated with high admission rates and the presence of on-site psychiatric departments and DSH teams. CONCLUSIONS: Young DSH patients at risk often go unidentified; as a result their psychological problems may not be treated. Hospitals are frequently unaware of the proportion of patients discharged without adequate assessment.

Links between infant crying and sleep-waking at six weeks of age.

Infant crying, and parental concern about unexplained crying, peak when infants are around 6 weeks of age. Diary measures of amounts of time infants spent crying, sleeping, waking-settled and feeding at 6 weeks were obtained in three samples: a group of moderate criers (N = 45), a group with an evening crying peak (N = 33) and a group whose fuss/crying exceeded 3 h per day (persistent criers, N = 54). Substantial negative correlations between amounts of fuss/crying and sleeping, but few associations between fuss/crying and waking or feeding, were found. The persistent criers slept an average of 77 min per 24 h less than the moderate criers. The clearest group differences were in the daytime and all three groups showed evidence of a diurnal organisation in their behaviour. Persistent crying at 6 weeks is associated with a sleeping deficit.

Supplementary carrying compared with advice to increase responsive parenting as interventions to prevent persistent infant crying.

OBJECTIVE: To compare two interventions (supplementary carrying, increased parental responsiveness) introduced from birth for their effectiveness in reducing the amounts of crying in general community infants at 2, 6, and 12 weeks age. DESIGN AND PARTICIPANTS: Mothers and infants in newborn wards of maternity hospitals were assigned to carrying intervention, responsiveness intervention, or control groups. Follow-up measures were used to confirm that the interventions were implemented and to determine their effects on infant crying. SETTING AND MEASUREMENTS: Diary measurements completed in the home were employed to measure the aspects of parental behavior targeted by the interventions. Audio recordings, diaries, and questionnaires assessed the amounts the infants cried and the impact of the crying on their mothers and the health services. Sample sizes at 6 weeks of age were 59 (carrying intervention), 57 (responsiveness intervention), and 94 infants (control group). RESULTS: The carrying intervention successfully increased the amounts the infants were carried, particularly while settled, to the target levels. The responsiveness intervention led to more limited increases in carrying and to a modest increase in feeding frequency, but did not affect measures of parental interactiveness and play. No differences in amounts of crying and fussing were found between the three groups of infants on any of the measures. Subsidiary analyses confirmed that the dependent variable (infant fuss/crying) and main independent variable (carrying while settled) were not significantly correlated. CONCLUSION: It is not, at present, possible to recommend either supplementary carrying or increased parental responsiveness as primary, preventative interventions to reduce infant crying.

Objective confirmation of crying durations in infants referred for excessive crying.

Parents commonly seek clinicians' help for infant crying that they judge to be excessive. To date there is no independent evidence whether such babies actually cry more than average. To assess this, maternal diary and 24 hour audiotape recordings of the crying periods of 16 infants referred for excessive crying were compared with equivalent measures of a normative sample. The overall amounts of crying measured by the two methods were similar. The referred infants cried substantially more over 24 hours and in the afternoon and evening. The difference approached significance in the morning but was insignificant at night time. Some qualifications to the findings are indicated.

The Camberwell Community Survey: a summary of results.

The Camberwell Community Survey was carried out during 1978 and 1979 on a random sample of the population of Camberwell in south London. This is an inner city area with high deprivation indices. 800 members of the community and a random sample of 74 out-patients with affective symptoms were interviewed using the Present State Examination (PSE) and Life Events and Difficulties Schedule (LEDS) of Brown and Harris. The survey has resulted in many publications. The present paper summarises its aims, methods and results.

Adversity in groups with an increased risk of minor affective disorder.

The hypothesis that the sociodemographic distribution of minor affective disorder can be explained by high-risk groups experiencing more psychosocial stress, defined in terms of life events and chronic difficulties, was tested. Linear logistic analysis of data from 275 subjects identified in a community psychiatric survey provided little support for this. Although high-risk groups uniformly experienced more psychosocial adversity, and adversity was strongly associated with disorder, this did not provide an adequate explanation for the increased risk of disorder. This must therefore be explained in other ways.

Gender, parity and the prevalence of minor affective disorder.

Data from a two-stage survey of the general population were used to test the proposition that the over-representation of minor affective disorders among women was restricted to those who had had children, independently of current involvement in childcare. Initial analyses supported this proposition strongly. Subsequent linear logistic analyses were largely in favour of an effect of marriage rather than of parity, but it remains possible that part of the gender differences in rates of depression arises because of the effect of parity in raising female prevalence. If substantiated, the parity effect could operate through social or biological mechanisms; although its nature is unclear, it merits further investigation.

Counselling the relatives of the long-term adult mentally ill. I. Evaluation of the impact on relatives and patients.

The efficacy of implementing a clinically feasible psychosocial intervention which addresses the needs of carers of the long-term mentally ill is reported. All the relatives of patients in continuous high contact with one clinical team in a local day-care facility were offered the intervention. An interactive education session at home was followed by a monthly relatives group which aimed to reduce components of expressed emotion and to alleviate burden. Patients and relatives were assessed. The controls were the patients in contact with the other teams in the day-care facility, and their relatives. The intervention was effective at reducing EE and improving family relationships. Offering this kind of support to people who are providing long-term care for the severely mentally ill can contribute significantly to the quality of life of both supporters and patients.

Counselling the relatives of the long-term adult mentally ill. II. A low-cost supportive model.

A psychosocial intervention is described geared to the needs of carers of the long-term mentally ill, which is feasible for a busy clinical team to implement: relatives were not selected for the group by patient diagnosis or motivation and little extra staff input was required. An interactive education session at home was followed by a monthly relatives group which aimed to reduce components of expressed emotion (EE) and to alleviate burden. The group facilitators adopted a directive but non-judgemental style, and constructive coping efforts were encouraged. The intervention was effective at reducing EE and improving family relationships. The study offers a realistic model of how to offer support to people providing long-term care for the severely mentally ill.

The risk of minor depression before age 65: results from a community survey.

Data from a general population survey of psychiatric disorder in Camberwell were used to calculate the risk of a CATEGO-defined depressive episode before the age of 65, using a modification of Strömgren's method. Current depression was defined as cases within the relevant categories of the CATEGO program and at threshold level or above on the Index of Definition (Wing et al. 1978). A past history of depression was elicited using key symptoms such as persistent tearfulness and depressed mood, already enquired after in the course of the PSE, to identify potential episodes, followed by questions to determine accessory symptoms, duration, and degree of social impairment. Clinical judgement was then used to decide whether the disturbance constituted a significant depressive episode. Risk under one set of assumptions was 46% for men and 72% for women. Using another method based on (untenably) conservative assumptions, it became 16% and 30% respectively. The status and implications of these high values are discussed, particularly for genetic studies.

Adversity and the symptoms of depression.

Data from a community survey were used to test the proposition that pathological guilt and vegetative symptoms of depression were less likely to be associated with stressful life events and difficulties than non-specific symptoms like tension and worry. Two types of analysis were carried out: the first took only cases, defined as ID5+ on the Index of Definition program, the second was based on all subjects. Only the second analysis provided support for our predictions.

Psychiatric symptoms, social disablement and illness behaviour.

In this paper we investigate the relationship between social performance and the use of medical services, and to what extent this is independent of clinical disorder. In a sample of adults living in Camberwell, South London, social disability and clinical disorder were both predictive of service use. Those subjects who were admitted to psychiatric day-patient or inpatient facilities were found to show the highest levels of both types of impairment, followed by psychiatric outpatients. People who had seen their general practitioner because of their 'nerves' were less impaired than those in touch with the specialist psychiatric services but had significantly poorer social performance and a higher level of clinical disorder than people not in contact with medical services at all. When the severity of clinical disorder was controlled, however, levels of social performance no longer discriminated between the different groups of service users, except that psychiatric outpatients remained significantly more socially disabled than the general practice group.

Adversity and working class vulnerability to minor affective disorder.

In this paper, we examine the proposition that members of lower social classes are more likely than those from higher classes to develop minor affective disorders in the face of adverse experiences. This was examined using data from a psychiatric survey of the general population of Camberwell, S.E. London, U.K. Working class subjects experienced significantly more adversity than their middle class counterparts. However, the relationship between life events and psychiatric disorder was consistent and considerable in the working class group. It was attenuated or non-existent in middle class subjects, depending on the particular categorisation of the data. Log-linear analyses suggested that the basis of this finding was unclear. Both the results and the underlying reasons for them merit further investigation.

The List of Threatening Experiences: a subset of 12 life event categories with considerable long-term contextual threat.

In a survey of a random sample of the general population recent life events, collected and rated for long-term contextual threat according to the methods of Brown & Harris (1978), were also recorded where possible on an inventory of life event categories (Tennant & Andrews, 1977). Of the 82.5% of all events collected which were covered by the inventory, 12 of the 67 event categories accounted for 77% of life events with an aetiologicaly significant rating of marked or moderate long-term threat. Where practical and economic constraints oblige research workers to choose the inventory method, a brief list of event categories, such as the List of Threatening Experiences, is recommended in preference to much longer lists.

Misfortune and resilience: a community study of women.

A community survey of psychiatric disorder carried out in South London enabled the authors to investigate the 'vulnerability model' proposed by Brown & Harris (1978). In the current study none of the 'vulnerability factors' proposed by Brown & Harris fulfilled the requirements of the model. It was, however, found that working class women with children seemed particularly prone to develop minor psychiatric disorder in response to adversity. A similar result is apparent in the analyses of the earlier authors. A number of studies now published give some support to the vulnerability model using what are broadly measures of social support, but there is little corroboration using the other variables proposed by Brown & Harris.

The domain of life events: a comparison of two techniques of description.

This paper compares the coverage of potential life events by the inventory developed by Tennant & Andrews (1976) and the post hoc designation originated by Brown (1974). It was found that the rubric of the inventory failed to describe 5% of 'marked' events and 21% of 'moderate' events. The relative risk of minor psychiatric disorder in response to events was 3.1 for those defined by the Brown technique and 1.4 for those using the inventory. The results suggests that the post hoc designation is superior. This superiority must be weighed against its undoubted costliness.

The relation of childhood separation experiences to adult depressive and anxiety states.

The relation of childhood separation experiences to adult depression, anxiety and 'general psychological morbidity' was assessed in a random population survey. Four causes of separation were examined in each of three age groups: childhood illness, parental illness, parental marital discord and wartime evacuation. Childhood separations occurring up to five years of age bore no relation to depression, anxiety nor to incidence of morbidity generally. From five to ten years of age, separations caused by parental illness and marital discord were related to morbidity, and in the latter instance were more likely to cause depression than anxiety. From 11 to 15 years, only separations due to parental illness were related to morbidity generally.

Female vulnerability to neurosis: the influence of social roles.

Studies of prevalence of neurotic disorders show women to be far more vulnerable than men. Biological factors cannot account for this marked sex difference; social factors are clearly implicated. Findings from a community study in London show that social roles, especially those relating to marriage, are implicated. It appeared that lack of employment outside the home was deleterious for both sexes, while a poor marital relationship was deleterious for women alone. Although care of young children was associated with neurosis in women, it did so by virtue of depriving women of employment outside the home.