Evidence favours the population approach over high-risk approaches to suicide prevention, but methodological problems may have obscured the contribution of the latter. This editorial uses the findings of a recent evaluation of a high-risk approach used in England to consider the role of high-risk interventions in national suicide prevention strategies.

Changes in sympathetic nervous system responses have been noted to accompany changes in psychological states during psychiatric treatment. Funkenstein, Greenblatt and Solomon, observing the blood pressure response to epinephrine and methacholine, have reported a change in blood pressure patterns on the part of patients who benefited from electric shock treatment (1). Gellhorn has presented evidence that improvement in the psychoses is associated with heightened sympathetic reactivity (2).

When the diagnosis of epilepsy is made, the patient must first of all be investigated to make sure that the epilepsy is not symptomatic of a disease that will need some special line of treatment. For example, epilepsy starting at any age may be the first indication of a cerebral tumour, although this will obviously be more likely among the older patients. The nature and extent of these investigations will depend on such factors as the age of onset, the type of seizure and the associated positive physical signs. However, even in the cases where there is no evidence whatsoever that the epilepsy is symptomatic, an electroencephalogram may help in differentiating the type of epilepsy from which any particular patient is suffering, and so aid in deciding on the form of treatment most likely to be beneficial. When any necessary investigations have been carried out and the form that treatment is to take has been settled, the social implication of this diagnosis has then to be faced. This often resolves itself into a discussion of the patient's employment.

Benda (1947) has reported values falling within the normal range for the serum calcium, phosphate and alkaline phosphatase in mongolism. More recently however Sobel et al. (1956) have stated that, while the inorganic phosphate and phosphatase are normal, the serum calcium is low in mongolism. The data on which this report was based do not appear to have been published to date. Further information on this point therefore seemed desirable.

The development of the concepts underlying the terms mental deficiency and psychosis with mental deficiency, may be arbitrarily divided into four periods, which to a considerable degree, overlap. The first period is concerned with the separation of the two principal groups, mental deficiency and mental disorder. Even before the time of Hippocrates some differentiation had been made between the idiot, who was feeble-minded from birth and the dement, who had deteriorated from a previously normal status. Pinel (1), however, as late as 1806 used the term idiocy loosely, and included many cases of terminal dementia and other deteriorated states. The end of the first period is marked by the definitive separation by Esquirol (2), in 1828, of mental defect and mental disorder, but it was not till 1886, in England, that a legal differentiation was made been insanity and feeble-mindedness.

I. Males.

(i) Object of the Inquiry.

This paper gives some first results of an investigation into types of physique and into the alleged relation between physique and temperament. The problem here is to try to discover a method of measuring the tendencies to a particular bodily build that may be present in certain individuals.

The accompanying illustration represents what is believed to be a hitherto undescribed abnormality of the scalp. The condition was discovered accidentally. I observed an attendant cutting a lad's hair, and remarked that he was not doing it very well, as there appeared to be numerous scissor-marks. It was explained that the marks were due to the arrangement of the hair. This led to careful examination of the whole scalp. Its condition is very well represented in the illustration. On each side there are five deep furrows, passing from behind forwards. Those nearest the middle line are straight; the others slightly curved, and they are the more curved the further they are removed from the middle line, and at the same time they diminish in length. When the hair is of ordinary length the condition of the scalp would not be suspected; it is only when the hair is very short that the furrows become evident. For the purpose of preparing the accompanying illustration the hair was cut as short as possible, but the hair growing in the furrows was necessarily left somewhat longer than elsewhere, with the result of indicating with great clearness the course and arrangement of the depressions. The furrowing of the forehead is not abnormal, but is produced by the patient whenever he is annoyed, as he was when the photograph was taken.

The phenomenon to which Lasègue and Falret in 1873 applied the term “folie à deux”, had many times previously been recognized and described. William Harvey (1651) noted a case, and his contemporary, Sir Kenelm Digby (1658) not only recorded an excellent clinical description but suggested a psychopathology (Greenberg et al., 1956). For Lasègue and Falret, folie à deux was a social rather than a psychiatric phenomenon: the second “passive” subject, they believed, was not truly psychotic but simply “absurdly credulous”. As they saw it, the more authoritative and intelligent “active” partner created the delusions and imposed them on the “passive” subject. This was more likely to occur in a setting of prolonged and isolated intimacy. The delusions were more likely to be accepted if they were plausible and played on the hopes and fears of the second subject. Heredity, they pointed out, offered no overall explanation, for this process frequently involved unrelated individuals. The second subject often accepted the first's delusions only after a fruitless and exhausting struggle to restore his sanity: “the indifferent escape both this useless travail and its consequences.” They held the prognosis for the “passive” subject to be invariably good, providing that the pair were separated. As early as 1563 Wier, writing on the cure of nuns afflicted en masse by demoniacal possession, had advised this course.

The addiction and conviction status of 60 male patients who presented to a London drug clinic in 1970 was re-examined 10 years later. Eleven of the patients had died. Three-quarters of the survivors had been abstinent for five years and one quarter were still addicted in this time. Ninety-seven per cent had received a court conviction by 1981 and 83 per cent were convicted during follow-up. Neither hospital treatment receipt of a clinic prescription nor imprisonment was associated with eventual abstinence. Poor outcome, in combined terms of continued addiction and re-conviction, related to early parental loss, poor academic achievement, conviction before drug use, longer imprisonment and a high conviction rate. Criminality emerges as the predominant and continuing expression of deviancy in these drug clinic patients.

The problem of treating the “back ward” chronic schizophrenic is likely to remain for some years to come, and with it the problem of establishing the genuine effectiveness of particular treatments. Disentangling effective from non-effective therapeutic techniques in “total-push” programmes is particularly complicated. What precisely is responsible for the minimal improvements observed: some subtle change in “ward climate”, the altered medication or the new music therapist? Writers who view mental illness primarily as a breakdown in normal interactional relationships with other persons have stressed the therapeutic importance of certain types of social milieu (e.g. Martin, 1962). Others (e.g. Greenblatt et al., 1955) have suggested that the success of even the physical treatments can be explained in terms of the optimism and enthusiasm with which they are carried out. However, there are few systematic research attempts to disentangle the physiological from the psychological variables.

High mortality rates among schizophrenic patients from infectious diseases, particularly tuberculosis, pneumonia and gastro-enteritis, reported for periods up to the 1940s were shown not to be specific for schizophrenia, but were characteristic of the mental hospital population as a whole (Alstrom, 1942). Studies covering more recent times confirm the decline and virtual disappearance of mortality from tuberculosis (Baldwin, 1979), but an extensive literature continues to emphasise the relatively high mortality of the mentally ill, including those defined as schizophrenic (Innes & Millar, 1970; Tsuang & Woolson, 1977), and more recent record linkage studies (Herrman et al, 1983; Allebeck & Wistedt, 1986) have continued to show an excess of both natural and unnatural deaths. Long follow-up studies of reasonably large groups of well documented cases are relatively uncommon in this area and therefore the 532 cases in the Harrow study were carefully followed up from the point of view of the occurrence and cause of death.

This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.

Evidence-based mental healthcare is evolving rapidly. There is a need for well-tested and effective interventions that are suited to culturally diverse populations. This editorial considers the findings from the SITARA study. There are a substantial number of implications for research, policy and practice.

A non-psychotic adult attempted surgically to reconstruct a foreskin for himself. The patient's membership of an organisation which lobbies against circumcision was contributory.

Depression and borderline personality disorder (BPD) are both thought to be accompanied by alterations in the subjective experience of environmental rewards. We evaluated responses in women to sweet, bitter and neutral tastes (juice, quinine and water): 29 with depression, 17 with BPD and 27 healthy controls. The BPD group gave lower pleasantness and higher disgust ratings for quinine and juice compared with the control group; the depression group did not differ significantly from the control group. Juice disgust ratings were related to self-disgust in BPD, suggesting close links between abnormal sensory processing and self-identity in BPD.

The clinical features of a fatal case of the neuroleptic malignant syndrome are presented. The fatal episode was a recurrence of the syndrome after a milder episode 3 months earlier. Prescription of neuroleptics was continued unchanged following the latter, as a correct diagnosis was not made at the time. The case emphasises the importance of early recognition of the syndrome and the possibility of spontaneous remission of symptoms despite continued neuroleptic treatment.