Psychosis Incident Cohort Outcome Study (PICOS). A multisite study of clinical, social and biological characteristics, patterns of care and predictors of outcome in first-episode psychosis. Background, methodology and overview of the patient sample.

AIMS: This paper aims at providing an overview of the background, design and initial findings of Psychosis Incident Cohort Outcome Study (PICOS). METHODS: PICOS is a large multi-site population-based study on first-episode psychosis (FEP) patients attending public mental health services in the Veneto region (Italy) over a 3-year period. PICOS has a naturalistic longitudinal design and it includes three different modules addressing, respectively, clinical and social variables, genetics and brain imaging. Its primary aims are to characterize FEP patients in terms of clinical, psychological and social presentation, and to investigate the relative weight of clinical, environmental and biological factors (i.e. genetics and brain structure/functioning) in predicting the outcome of FEP. RESULTS: An in-depth description of the research methodology is given first. Details on recruitment phase and baseline and follow-up evaluations are then provided. Initial findings relating to patients' baseline assessments are also presented. Future planned analyses are outlined. CONCLUSIONS: Both strengths and limitations of PICOS are discussed in the light of issues not addressed in the current literature on FEP. This study aims at making a substantial contribution to research on FEP patients. It is hoped that the research strategies adopted in PICOS will enhance the convergence of methodologies in ongoing and future studies on FEP.

Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.

OBJECTIVE: To determine the properties of the alcohol use disorders identification test in screening primary care attenders for alcohol problems. DESIGN: A validity study among consecutive primary care attenders aged 18-65 years. Every third subject completed the alcohol use disorders identification test (a 10 item self report questionnaire on alcohol intake and related problems) and was interviewed by an investigator with the composite international diagnostic interview alcohol use module (a standardised interview for the independent assessment of alcohol intake and related disorders). SETTING: 10 primary care clinics in Verona, north eastern Italy. PATIENTS: 500 subjects were approached and 482 (96.4%) completed evaluation. RESULTS: When the alcohol use disorders identification test was used to detect subjects with alcohol problems the area under the receiver operating characteristic curve was 0.95. The cut off score of 5 was associated with a sensitivity of 0.84, a specificity of 0.90, and a positive predictive value of 0.60. The screening ability of the total score derived from summing the responses to the five items minimising the probability of misclassification between subjects with and without alcohol problems provided an area under the receiver operating characteristic curve of 0.93. A score of 5 or more on the five items was associated with a sensitivity of 0.79, a specificity of 0.95, and a positive predictive value of 0.73. CONCLUSIONS: The alcohol use disorders identification test performs well in detecting subjects with formal alcohol disorders and those with hazardous alcohol intake. Using five of the 10 items on the questionnaire gives reasonable accuracy, and these are recommended as questions of choice to screen patients for alcohol problems.

Validation of a screening questionnaire for alcoholism (MAST) in an Italian sample.

One hundred fifty subjects (75 index cases and 75 controls) completed the Italian version of the Michigan Alcoholism Screening Test (MAST). Using Relative Operating Characteristic (ROC) analysis, the 5/6 cut-off point was found to be the best as for discriminating between "cases" and "non-cases" in terms of balance between sensitivity (96%) and specificity (89%). The positive predictive value, the negative predictive value, and the overall misclassification rate were 90%, 95%, and 7% respectively. Using item by item assessment of discriminating capacity, we developed a brief ten item Italian version (2/3 cut-off point). This discriminated between alcoholics and non-alcoholics as well as the longer version, and is thus superior in situations where a brief evaluation is necessary.

South Verona's psychiatric service: an integrated system of community care.

Italy's mental health law of 1978 mandated the closing of state mental hospitals to new and former patients and the creation of comprehensive community-based service systems. The authors describe the organization, facilities and services, and treatment principles of one system created in accordance with the law--the South Verona Community Psychiatric Service, which serves a population of 75,000. Case register data for South Verona for the years 1978 to 1984 reflect the changes mandated by the law. They also indicate that despite an increase in admissions to the psychiatric ward in the general hospital following the closing of the state hospital, there was a substantial overall decrease in the number of hospital beds occupied per day by South Verona residents after passage of the law, and that a substantial proportion of patients with functional psychosis were able to be treated as outpatients.

Bringing into action the psychiatric reform in South-Verona. A five year experience.

The organization of psychiatric care in Verona prior to the new Italian Mental Health Act, and the organization of the new South-Verona Community Psychiatric Service (CPS) implemented in 1978 after the approval of the new law, are described. Case-register data for the period 1979-1983 are also reported. To compare in-patient care provided in South-Verona after the Reform with that of the previous year, data on hospital admissions during 1977 were collected retrospectively. From 1977 to 1983 compulsory admissions have decreased by 67%, the average number of occupied beds per day and the average length of in-patient stay have decreased by 34%, while the total rates of admission have increased by 4%. The long-stay in-patient rate, which was already considerably low in 1977 (48/100,000), is still decreasing slightly and no "new" long-stay patients have accumulated in psychiatric institutions during the past three years. In South-Verona most of the patients are treated outside the hospital and the same staff is responsible for in- as well as for out-patient care (which includes domiciliary visits and day care), to ensure therapeutic continuity. Although it lacks some complementary facilities the South-Verona CPS in its five years of experience has been able to bring into action the psychiatric reform as indicated by the new Law.

Predictive scales for parasuicide repetition. Further results.

A six-item predictive scale for parasuicide repetition was retested on a second sample of Italian parasuicides. All the patients firstever admitted after a deliberate self-harm to the psychiatric department of a general hospital during the period April 1973-March 1976 were interviewed and followed-up after an interval of 1 year. The scale showed the same predictive power found in the first sample (1970-73) and gave a range of probability of repetition within 1 year of 15% at a score of 0 up to 44.8% at the scores 3, 4, 5, and 6. Moreover it discriminated between repeaters and non-repeaters at a significant level. Only two items (diagnosis of sociopathy and change of domicile in the last year) of the five items which discriminated repeaters from non-repeaters in the first study were still significantly associated with repetition, while four additional items (previous in-patient psychiatric treatment; previous parasuicide resulting in hospital admission; unemployment; criminal record) appeared as new discriminating factors. In spite of these changes the rate of repetition remained constant over the years at around 26%.

Aspects of suicide and parsuicide.

Five aspects of suicidal behaviour in Edinburgh from 1968 to 1974 were examined. The data referred to 478 suicidal deaths and to parasuicide (attempted suicide) admissions to the Regional Poisoning Treatment Centre (R.P.T.C.). Firstly: 28% of suicides were found to have had a parasuicide admission and there was some evidence of a slight excess of deaths in the years immediately following parasuicide. Secondly: among suicides preceded by parasuicide, those with a recent episode (within 2 years of death) were found to be essentially similar to those with a longer interval. Thirdly: a history of previous parasuicide at any time was found to be important in delineating two groups of suicide. Suicides with prior parasuicide died more often from poisoning with drugs and were more likely to have a history of psychiatric treatment; suicides without prior parasuicide died more often from poisoning with domestic gas or violent means, were older, of higher social class and less often married. Fourthly: parasuicides who killed themselves within 2 years of admission to the R.P.T.C. were compared with a group of (broadly nonsuicidal) parasuicides. And lastly: a scale predictive of repetition of parasuicidal behaviour was used in an attempt to distinguish parasuicides who killed themselves from those who did not. The scale did not discriminate between the two groups.

A fatal case of pancytopenia due to levomepromazine.

A fatal pancytopenia occurred in a patient with an history of depression with hypomanic rebounds, admitted for a manic episode and treated with levomepromazine, diazepam and lithium carbonate.

Cross-validation of a predictive scale for subsequent suicidal behaviour in an Italian sample.

A six-point prodictive scale for parasuicide repetition developed by Buglass and Horton (1974a) was tested on a group of patients admitted for parasuicide to a psychiatric ward of one of the city hospitals of Verona. The scale gave a range of probability of repetition within 12 months of 15 per cent at a score of o up to 45-5 per cent at the scores 3, 4, 5 and 6. Moreover the scale discriminated significantly between repeaters and non-repeaters. Items significantly associated with repetition in the Italian sample, which are not represented by the six-point scale were: previous parasuicide not admitted to hospital, violence received, alcohol taken at time of act, less than one year at the present address.