In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness.

A systematic review was undertaken of relevant articles on medline, ClinPsych and Excerpta Medica Psychiatry.

Sixty-eight articles were used in the review.

Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.

The proliferation of psychotherapies has been balanced by an equal and opposite tendency towards integration. Integrative approaches are particularly relevant to psychotherapy in psychiatric settings.

Medline and manual literature searches yielded over 250 articles on psychotherapy integration, which are reviewed in the light of the authors' experience in a district psychotherapy service.

Psychotherapy integration is an umbrella term covering a wide range of meanings: rapprochement between different theoretical positions; convergence of ideas and techniques; eclectic selection from many different methods; and integration proper in specifically integrative therapies. Many effective psychotherapeutic treatments for psychiatric disorders are integrative, including those for depression, schizophrenia, bulimia nervosa and borderline personality disorder.

Integration at the level of practice is common and desirable. At the level of theory, clarification and creative conflict are essential. Different therapeutic approaches should work closely together but retain their separate identities.

Eye movement desensitisation and reprocessing (EMDR) has attracted controversy and has led to publications covering a wide range of psychological problems treated by EMDR, in particular, post-traumatic stress disorder (PTSD). There is growing clinical evidence of the effectiveness of EMDR, but a lack of a convincing theoretical basis to explain its rapid effect.

This paper argues that a combination of Pavlovian and Darwinian theory provide a theoretical explanation for the therapeutic effectiveness of EMDR.

We suggest that the investigatory component of the orienting reflex is an evolutionary development enabling organisms to assess their environment for both opportunities and threats. We propose that EMDR is rapidly effective because it is a clinical method of Pavlovian conditioning by which the positive visceral element of the investigatory reflex can be paired with clinically-induced noxious memories to remove their negative affect.

Compared with established forms of treatment for PTSD, EMDR is rapid, with resulting clinical and economic benefits. Our suggested theoretical basis for EMDR has implications for further explanatory research and for developments in EMDR treatment.

This paper describes the 13 year course of illness in an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

In a 13-year follow-up study of 67 patients with ICD–9 schizophrenia, identified in Nottingham in 1978–80, the course of illness (symptoms, disability and hospitalisation) was assessed using standardised instruments, applied at onset 1, 2, and 13 years. Time to first relapse and first readmission were calculated and plotted as survival curves and patients were assigned to the course types described by Ciompi.

The survival curves show that first relapses and first readmissions occur during the first five years. The amount of time spent in psychotic episodes and in hospital is greatest in the first year of follow-up, but stable thereafter. Social adjustment improves from entry to the study to the first follow-up year, but there is a small deterioration in social adjustment between 2 and 13 years.

The findings reported suggest that after the initial episode the course of schizophrenia is relatively stable. The data support neither concepts of progressive deterioration nor progressive amelioration. There was no evidence of a ‘late recovery’.

Incidence rates of schizophrenia among UK African–Caribbeans have been reported as high. Various explanations including selective migration and genetic vulnerability have been proposed.

In one calendar year, all new cases of psychosis presenting to various psychiatric services in two clearly defined geographical catchment areas in Trinidad – one in the rural south and the other an urban area – were studied. Standardised diagnostic instruments were applied and information collected using WHO screening and measurement instruments.

A total of 56 cases were collected, giving an incidence rate of 2.2/1000 of broad schizophrenia with a rate of 1.6 for S+ schizophrenia.

These rates are similar to those from the WHO study in Honolulu and Aarhus, and much lower than the rates for African–Caribbeans in London. The cases were followed up for one year and the poor outcome rate for schizophrenia was 19%. The findings are discussed in a cross-cultural context and suggestions for future research made.

The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.

Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.

Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v. 56% of the control group, showed moderate or severe residual symptoms.

CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed.

A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and ‘low level’ psychotic thinking which were not directly targeted.

Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.

CT was associated with a 25–50% reduction in recovery time depending on the definition used.

The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and ‘low level’ psychotic thinking. Nevertheless this kind of ‘clinical’ recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed.

It has been proposed that schizophrenia is associated with underactivity of brain glutamatergic neurotransmission, especially at the level of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptor. Glycine potentiates NMDA receptor-mediated neurotransmission, indicating that it may serve as an effective therapeutic agent in the treatment of schizophrenia.

Eleven treatment-resistant patients with chronic schizophrenia completed a double-blind placebo-controlled, six-week, randomly assigned, crossover treatment trial of 0.8 g/kg body weight/day of glycine, added to their prior antipsychotic treatment.

Glycine was well tolerated, resulted in significantly increased serum glycine levels and induced a mean 36 (7%) reduction in negative symptoms (P < 0.0001). Significant improvments were also induced in depressive and cognitive symptoms. The greatest reduction in negative symptoms was registered in the patients who had the lowest baseline serum glycine levels.

These results extend previous findings and suggest an additional approach to the pharmacotherapy of negative symptoms and cognitive deficits in schizophrenia.

Stability of neuroleptic medication has been associated with optimal clinical effect and minimal side-effects. Depot administration is assumed to yield better stability.

Thirty patients on depot neuroleptic treatment were followed during three years with repeated measurements of plasma level and concurrent ratings of clinical symptoms and side-effects.

Of 120 blood samples 35 (29%) measurements were outside ± 2 s.d. measurement error (expected 5%). Perphenazine levels were more variable (46%) than haloperidol (25%) and flupenthixol (12.5%). No relationship was found between side-effect ratings and fluctuations of plasma levels.

Depot neuroleptic medication does not eliminate a clinically unwanted and sometimes marked variation in plasma level.

Parental emotional overinvolvement (EOI) may entail a worse outcome in schizophrenia. In the present study we examined demographic and clinical predictors of EOI.

The predictors were examined in a Norwegian sample of 41 recently admitted patients (schizophrenia or schizophreniform disorder) and 66 parents. Parents' expressed emotion was assessed by the Camberwell Family Interview.

Regression analyses showed that higher EOI was significantly related, on the part of the parent to being a mother, single, spending more time with the patient; and, on the part of the patient, to no substance misuse, more anxiety–depression, and less uncritical and aggressive behaviour. EOI was not linked to previous hospital admissions.

Our analyses indicate that characteristics of the parent and of the parent–patient dyad seem to be the most important determinants of EOI. EOI is probably not linked to psychotic relapse, but rather to affective disturbances in the patient.

The objective of this project was to test whether there are differences in the size of the caudate nucleus in schizophrenic in-patients with and without tardive dyskinesia.

The study was cross-sectional in design, examining group differences between institutionalised schizophrenic patients with and without tardive dyskinesia, using non-enhanced computerised tomography scans of the brain. The group comprised 15 schizophrenic patients with persistent tardive dyskinesia and 21 in-patient schizophrenic controls who were group-matched for demographic variables.

The dyskinetic subjects had a significantly larger left caudate nucleus and tended to have a larger right caudate nucleus than the controls. There were no differences between the groups on any of the measures of cerebral atrophy.

The findings can be understood within the context of models of neostriatal function. It is possible that a larger caudate nucleus could be used to identify patients at risk of developing tardive dyskinesia.

Maternal stress during pregnancy has been suggested as a risk factor for schizophrenia We tested the hypothesis that being the child of an unwanted pregnancy would be associated with later schizophrenia.

Data were collected prospectively in the Northern Finland 1966 Birth Cohort of 11 017 individuals. In the sixth or seventh month of pregnancy mothers were asked whether the pregnancy was wanted, mistimed but wanted or unwanted. Schizophrenia diagnoses in the cohort members were obtained from the Finnish Hospital Discharge Register.

Seventy-six cases of DSM–III–R schizophrenia were identified in the whole cohort between the ages of 16 and 28 years; a cumulative incidence of 0.7%, compared with 1.5% for those bom from unwanted pregnancies. The risk of later schizophrenia among unwanted children was raised compared with wanted or mistimed children, even after adjustment for confounding by sociodemographic, pregnancy and perinatal variables (OR 2.4; 95% CI 1.2–4.8).

The results suggest that unwantedness may operate either directly as a psychosocial stress during development making children more liable to schizophrenia or it may be a marker for behaviours associated with risk in either the mother or the child.

In patients with bipolar disorder, admissions for manic and depressive episodes frequently display a seasonal pattern. We examined this variation and compared the patterns with the seasonal admission rates for schizophrenia.

Patients with bipolar disorder or schizophrenia were identified from the Finnish Hospital Discharge Register of in-patient admissions to all psychiatric hospitals during the years 1969–91. They were included in the analysis if the first admission had occurred before 30 years of age. A total of 295 bipolar patients were found and a sample of 295 schizophrenic patients was randomly selected for comparison.

There was no seasonal variation among all hospital admissions for bipolar disorder or schizophrenia However, the first admission for a depressive compared with a manic episode of bipolar disorder occurred significantly more often in the autumn (33% v. 21% respectively). The peak difference occurred during the week after the autumnal equinox in September.

Our findings suggest that there is no seasonal variation in bipolar disorder, although in some patients the clinical course might be influenced by the autumn, as far as the likelihood of a first admission for depression is concerned.

Non-institutionalised patients treated with antidepressants have been shown to have indicators of a generalised vulnerability, such as high rates of health service use and excessive prescription drug use. Therefore, mortality in this patient group is of interest.

All first-incidence antidepressant users in a defined population during a five-year period were identified. Their total mortality during a nine-year follow-up was analysed. Cox proportional hazards regression was used to analyse total mortality, and mortality in cardiovascular disease, controlling for baseline chronic medical disease.

Antidepressant treatment at the index date was a statistically significant predictor for increased long-term mortality in the over-65s, even when controlling for pre-existing chronic medical disease. Baseline ischaemic heart disease and concurrent antidepressant treatment significantly predicted mortality from cardiovascular causes.

Prescribed antidepressant treatment identifies patients who are at risk of increased mortality. For the physician in ambulatory care, knowledge of a patient's antidepressant treatment history may be a valuable tool in managing patient care.

Very little is known about the adequacy and safety of maternal parenting behaviour in the context of severe postpartum psychiatric illness, about specific difficulties in relation to different types of mental illness, or about the potential for improvement over the course of an episode of illness. The Bethlem Mother–Infant Interaction Scale (BMIS) was thus developed as an aid to assessment on a specialist psychiatric Mother and Baby Unit.

Nurses' ratings of the quality of mother–infant interaction using the BMIS were collected throughout the consecutive admissions of 78 in-patient pairs. The ratings from three points during the admissions were examined according to the mothers' RDC diagnoses and also according to the eventual outcome of the admission.

The nature of the mother's illness was associated with the quality of her infant care-taking using the BMIS ratings. The nurses' ratings during the second week of admission together with maternal psychiatric diagnosis, were strongly predictive of the eventual outcome of the admission. The majority of women who were separated from their infants on discharge or who required formal supervision belonged to the schizophrenic group.

The results suggest that the BMIS can be used in this in-patient setting to aid clinical decisions about the safety of parenting by individual mothers with severe mental illness in the postpartum period.

The aim of this study was to investigate the validity of the Arabic versions of the GHQ–30 and GHQ–12 in a sample of primary health care (PHC) patients in Al Ain, United Arab Emirates.

A randomly selected sample (n=157) of patients attending a PHC centre in Al Ain was screened using the Arabic version of the GHQ–30, the first 12 items of which constitute the GHQ–12. Then a standardised clinical interview using the Clinical Interview Schedule (CIS) was conducted with all screened patients. The receiver operating characteristic analyses of the Arabic versions of both GHQ–30 and GHQ–12 were compared and their correlation coefficients with the weighted total score of the CIS and the overall severity rate were estimated. Discriminant functional analysis was also performed to assess the discriminatory powers of both the GHQ–30 and GHQ–12.

Using the simple Likert scoring method, the best cut-off point of the GHQ–30, that balances between sensitivity and specificity, was 31/32 with a sensitivity of 0.83 and specificity of 0.83, and that of the GHQ–12 was 12/13 with a sensitivity of 0.83 and specificity 0.80. The total discriminatory powers of the GHQ–30 and GHQ–12 were approximately 93 and 86%, respectively. Both versions of the GHQ were found to have a significant concurrent validity.

The Arabic versions of both GHQ–30 and GHQ–12 are valid psychiatric screening instruments, with almost similar performance, for Arabic-speaking PHC patients.