‘Prescription-event monitoring’ (PEM) is one of two national systems of post-marketing surveillance in operation in Britain. It identified 22 065 patients who had received NHS prescriptions for alprazolam, and data available on 10 895 of these were analysed. The main reasons for treatment with alprazolam were anxiety and depression. The patients provided 3360 patient-years of treatment and 7540 patient-years of follow-up. No serious events clearly associated with treatment were recorded. The main events reported during treatment, albeit infrequently, were drowsiness and depression, although depression is more likely to be due to the disorder being treated than to the drug. Some of the other alleged unwanted effects of alprazolam in published reports were not encountered. Since PEM is unable to determine the dependence potential of alprazolam, further evaluation of this problem is called for.

The terminology of sexual dysfunction is ugly enough in all conscience—erectile impotence, orgasmic dysfunction and so on—but it has served a useful purpose by bringing these problems into clear focus rather than burying them within the general vagueness of terms such as impotence and frigidity.

The introduction of clozapine to current psychiatric practice is considered against a background of potential problems of resource allocation posed by the development of a number of ‘budget-busting’ drugs. It would appear that clinicians may increasingly have to operate within a climate in which the rights of individual patients to expensive treatments will seem to be pitted against the abilities of their communities to afford such treatments. Both clinicians and pharmaceutical companies have roles in the development of such conflicts.

This paper deals briefly with a few clinical observations made in the course of studies of changes in subjective experience reported by young patients in the early stages of schizophrenia. These studies aimed at delineating the early schizophrenic clinical picture in as specific a manner as possible with a view to later experimental validation, and the clinical findings concerning a group of forty young schizophrenics have been reported elsewhere (Chapman, 1966). The observations on which this paper is based were obtained by the same method of examination and interview technique as previously reported, the observer deliberately identifying with the patient, adopting his particular style of communication and encouraging him in the direct projection of his experiences. Thus these observations have been taken out of a matrix of abnormalities in cognitive function found in schizophrenic patients, and have to do chiefly with their visual imagery and motility. Before proceeding to present and discuss these observations it may be worth while to provide a background against which to view them, by referring first to what we know of normal imagery, and second to the breakdown in perception and cognition found in the patients from whom these observations were derived.

Patients diagnosed as reactively or endogenously depressed were given electroconvulsive therapy (ECT). The endogenously depressed patients tended to respond to the treatment more quickly and favourably. Measures of age and severity of depression were as predictive as the classification into endogenous or reactive depression using the Newcastle rating scale. The degree of psychological stress ascertained and presumed to be operating did not contribute to the prediction of outcome.

Now that the evidence for genetic factors in the major psychoses is very strong but still essentially circumstantial (what is transmitted is unknown), there is a danger that myths about the nonexistence of mental illness may be replaced by equally misleading myths about its inheritance. The need for genetic counselling is therefore likely to increase (counselling is advice given as a result of consultation). Admittedly, the literature on counselling in mental illness is scanty, the author's own experience slight, and the public demand small. Reed (1972) stated that less than 1 per cent of the 3,000 cases seen at the Dight Institute over 20 years were concerned with schizophrenia. Nevertheless, it is probable that much unrequested and ill-informed advice is being given.

This single case history is reported because scant information is available in textbooks of psychiatry and medicine on depression in acromegaly and gigantism. Attention is drawn to relevant recent articles.

Methohexitone sodium (Brietal, Brevital), an ultra-short-acting barbiturate, has recently been introduced as a method of relaxation in behaviour therapy (Friedman, 1966; Brady, 1966). It appears to be safer than thiopentone (Pitts et al., 1965), and has the added advantage that the recovery time is quicker (Jolly, 1960). The present report refers to two patients suffering from premature ejaculation who were successfully treated by systematic desensitization using methohexitone.

General practitioners (GPs) work in an environment different from that of most of their specialist colleagues. Some of these differences stem from being a doctor of first contact, some from working in one part of a multi-tier system for providing medical care, and some from the referral system which deals with the movement of patients between these tiers. Other differences stem from the GP's National Health Service contract to provide continuity of care 24 hours a day, and to make early diagnoses as well as monitoring normal development on one hand and chronic impairment, handicap, and disability on the other. The British GP works with a defined list of registered patients who can present symptoms representing disorders of a wide range of severity, originating in any bodily system. These symptoms can result from any type of pathogenic stimulus, including disordered perception: even temporary variation from the patient's usual subjective experience may arouse natural concern.

Despite the relatively high incidence of therapy-resistant depression, there is little clinical evidence to suggest that there are significant biochemical differences between therapy-resistant and therapy-responsive patients. A major problem for investigators is the lack of an internationally recognised definition of resistant depression. Also, it is possible that depressed patients with delusional symptoms or rapidly cycling affective disorders form subgroups that are more likely to be resistant to tricylic antidepressant treatment and are therefore classified as therapy-resistant. Evidence is presented to show that an abnormality in serotonergic function may characterise some therapy-resistant depressed patients.

All new female indigenous Zambian patients (180) admitted to Chainama Hills Hospital from 1 June 1974 to 31 May 1975 were seen by the authors and given a firm diagnosis before they were started on treatment. The diagnostic classification of these patients was compared to that of a similar group of patients (163) admitted to the same hospital from 1 June 1973 to 31 May 1974. Forty-two per cent of the patients in 1974/75 were given a diagnosis of depression as compared to 26 per cent in 1973/74; 14 per cent of those in 1974/75 had a diagnosis of schizophrenia as compared to 21 per cent in 1973/74, and 3 per cent of the patients in 1974/75 fell into the group of ‘not yet diagnosed’ as opposed to 27 per cent in 1973/74. The ‘acute transient psychoses' were noted for their relative rarity in the two groups. A plea is made for all psychiatrists working in Africa to give diagnosis the importance it deserves.

In a case-control, cross-cultural study of the psychiatric morbidity of systemic lupus erythematosus in an Oriental population, 30 patients suffering from SLE and 29 controls with rheumatoid arthritis were interviewed. The SLE patients in Singapore exhibited greater psychiatric morbidity than their Western counterparts. Significant correlation was observed between psychiatric morbidity and the clinical disease activity. The patient's perception of the severity of arthritis, myalgia and dermatological lesions was an important aetiological factor. Culturally determined, disease-related psychological stresses also contributed to the psychopathology.

A sedative or tranquillizing effect may be important in the treatment of mild depressive illness not requiring admission to hospital or ECT (Wheatley, 1969), and Hare et al. (1962, 1964) have suggested that antidepressant drugs may exert their effect by virtue of their sedative action. Other workers also have found similar effects from antidepressant drugs and tranquillizers (Overall et al., 1964; Paykel, 1969).

The enzyme creatine kinase (CK) is present in high concentration in skeletal and cardíac muscle and brain tissue (Dawson and Fine, 1967). Raised serum levels of the enzyme occur in skeletal muscle disease, following myocardial infarction and in hypothyroidism. Raised levels have also been demonstrated in acute cerebral disease (Acheson et al., 1965), but earlier suggestions that this might be due to leakage of enzyme from brain tissue have not been confirmed by isoenzyme separation studies (Dubo et al., 1967), which have shown that the excess enzyme came from striated muscle. Raised serum CK levels associated with acute psychosis have also been reported (Bengzon et al., 1966; Meitzer et al., 1969; Coffey et al., 1970; and Gosling et al., 1972). This has led to the suggestion that serum CK estimation could be used in the differential diagnosis of psychiatric patients (Meltzer et al., 1970; Gosling et al., 1972). Meitzer (1969) has also claimed that the biochemical abnormality reflects ‘a basic patho-physiological process common to the acute psychoses'.

Diurnal changes in the frequency of panic attacks and symptoms of generalised anxiety, phobic anxiety and phobic avoidance in 34 panic-disorder patients and 40 normal controls were evaluated. The panic-disorder patients had significant diurnal changes in generalised and phobic anxiety, but not phobic avoidance. Increased severity of symptoms and prominent diurnal changes were most evident in the panic-disorder patients with a history of depression. Although panic attacks were distributed throughout the 24–hour period, patients with a current episode or history of depression tended to have more frequent panic attacks in the morning or early afternoon. These observations challenge the traditional belief that ‘anxious neurotic’ patients are relatively asymptomatic upon awakening in the morning and then develop more severe symptoms of anxiety later in the day.