Eighty patients admitted to hospital with major depression were randomly allocated to six weeks of treatment with tranylcypromine, amitriptyline, or tranylcypromine and amitriptyline in combination, in a double-blind study. Scores on the HRSD improved significantly in all three groups, but there were no differences between the three groups. Patients on tranylcypromine and amitriptyline combined improved more according to their self-ratings after six weeks, and response was earlier as measured by a clinical global improvement scale. Those with endogenous depression improved more than those with neurotic depression, irrespective of treatment group. Combined treatment was less well tolerated than single treatments and gave rise to more side-effects, although there was no serious toxicity. Orthostatic hypotension was observed more frequently in patients on combined treatment. This group also experienced a significant increase in weight and prolongation of the P-R interval on ECG.

The study consisted of a prospective investigation of 45 consecutively admitted patients who had sustained a mild head injury. In all cases the duration of post-traumatic amnesia was less than 24 hours. Head injury patients had an average of three adverse life events in the year preceding injury compared with 1.5 for controls. Using the PSE, 39% of the group were diagnosed psychiatric cases at six weeks after the injury. For cases the mean level of chronic social difficulties (3.3) was four times that for non-cases (0.8). Six months after injury, 28% of the head injury group had three or more symptoms. These chronic cases were on average ten years older than those whose symptoms had remitted. Chronic cases had, on average, three social difficulties, twice as many as found among those whose symptoms had remitted. The emergence and persistence of the postconcussional syndrome are associated with social adversity before the accident. While young men are most at risk of minor head injury, older women are most at risk of chronic sequelae.

The extent of crime, vagrancy, death, and readmission in a prospective cohort of long-term mentally ill patients was measured during their first year out of hospital. All 278 long-stay psychiatric patients discharged during the first three years (1985-1988) of the closure of Friern and Claybury Hospitals were included. One patient was imprisoned, one committed suicide, and one became vagrant; five others may also have become vagrant. The mortality rate was similar for the leavers and their matched controls, who remained in hospital. There was one suicide among the matches. Mental deterioration most often caused readmission. On recovery, most patients returned to their community home. Six per cent of the cohort were readmitted and have remained in hospital for a year or more. With careful planning and a financial ‘dowry’ for each patient, the closure of large mental hospitals does not lead to a marked increase in vagrancy, crime, and mortality for the long-term mentally ill. However, the patients who have yet to leave have more problems of social behaviour and are likely to be more difficult to resettle.

A cross-national randomised trial of alprazolam for chronic panic disorder with agoraphobia was run. Compared with previous trials it had three new features: an exposure therapy contrast group, a six-month treatment-free follow-up, and a low rate of early placebo drop-outs (‘non-evaluables’). The dose of alprazolam was high (5 mg/day). The 154 patients had eight weeks of: alprazolam and exposure (combined treatment); or alprazolam and relaxation (a psychological placebo); or placebo and exposure; or placebo and relaxation (double placebo). Drug taper was from weeks 8 to 16. Follow-up was to week 43. Results were similar at both sites. Treatment integrity was good. All four treatment groups, including double placebo, improved well on panic throughout. On non-panic measures, by the end of treatment, both alprazolam and exposure were effective, but exposure had twice the effect size of alprazolam. During taper and follow-up, gains after alprazolam were lost, while gains after exposure were maintained. Combining alprazolam with exposure marginally enhanced gains during treatment, but impaired improvement thereafter. The new features put previous trials in a fresh light. By the end of treatment, though gains on alprazolam were largely as in previous studies, on phobias and disability they were half those with exposure. Relapse was usual after alprazolam was stopped, whereas gains persisted to six-month follow-up after exposure ceased. Panic improved as much with placebo as with alprazolam or exposure.

The Interview Schedule for Social Interactions (ISSI) was used to assess the social environment of 65 British inner-city patients suffering from severe neurotic disorder; all patients were offered a 12-week course of intensive day treatment with an educational and psychodynamic basis. Compared with a general population in Canberra, the neurosis sufferers had lower (morbid) scores on the ISSI for the extent and quality of their social relationships. Of the 34 subjects who completed treatment and attended for the post-treatment investigation, 21 attained a PSE score below the level for ‘caseness'. Twenty-five subjects who attended for follow-up at 18–24 months had improved significantly on all four of the standard ISSI measures, although they had not done so immediately after treatment. This suggests that although symptoms may improve at the time of treatment, social relationships improve only over several months.

The first prospective, controlled study of a large, long-stay, in-patient population as their hospital services were reprovided in the community is reported. Two-hundred-and-seventy-eight patients were matched individually with similar patients who remained in hospital. Clinical and social outcomes over a one-year follow-up are presented for the first three years of the reprovision process. Compared with matches, the leavers at follow-up had more diverse social networks that contained a higher proportion of contacts named as friends. The care facilities in the community allowed more opportunities for patient autonomy than the hospitals across all aspects of the environments measured. At follow-up, more leavers than matches wanted to remain in their current placement, while fewer leavers than matches said there was nothing they liked about their current placement. More leavers than matches found their medication helpful.

Lymphocyte response to stimulation with phytohaemagglutinin (PHA) was assessed in 11 patients with major depression and 8 subjects anticipating bereavement, in order to examine whether altered immune response (PHA stimulation index) was more closely related to depressed mood than to sleep and weight changes. No significant relationship was found between sleep or weight changes and immune response. Depression, measured using the HRSD (with and without sleep scores) and the BDI, was related differently in the two groups. For the depressed patients, increasing depression was associated with reduction in immune response; among those anticipating bereavement (with low depression scores), increasing depression was associated with enhanced immune response. A regression curve using data from both samples demonstrated an inverted ‘U’-shaped curve relating immune response to mild and severe depressed states. The results of this study suggest a hypothesis that may explain previous discrepant results and which requires testing on more subjects.

Previous attempts to establish a relationship between impaired cell-mediated immunity (CMI) and major mood disorders have been limited by a failure to explore the relevance of depressive subcategories or to assess CMI by in vivo methods. In this case-control study CMI was assessed in 57 patients with major depression (31 with melancholic, 26 with non-melancholic disorders), and in age- and sex-matched controls by both in vitro and in vivo immunological techniques. Compared with control subjects and patients with non-melancholic depression, patients with melancholia demonstrated reduced in vivo CMI as assessed by delayed-type hypersensitivity (DTH) skin responses. Although increasing age, severity of depression, hospital admission for treatment, and reported weight loss are correlates of melancholia, none of these factors alone, or in combination, accounted for the differences in DTH responses observed between the two depressive subtypes. These data suggest that impaired CMI in vivo may be limited to those with melancholic disorders. At this stage the factors which account for this effect are unclear.

Despite reports of falling first-admission rates for schizophrenia in the UK and other Western countries, it would be rash to conclude that the incidence of schizophrenia is falling. An attempt was made to tackle the many methodological problems and sources of bias influencing the relationship between admission rates and incidence in an analysis of inception rates for schizophrenia and other psychoses in Edinburgh between 1971 and 1989. However it was calculated, the inception rate for schizophrenia fell significantly, but because there was evidence that diagnostic criteria for schizophrenia had narrowed between 1971 and 1989, and because a substantial and changing proportion of recorded first admissions were not true first admissions, it was impossible to conclude that the incidence of schizophrenia had fallen. Changes in the incidence of psychiatric syndromes are difficult to establish, particularly in retrospect, and future studies must pay more attention to the many possible confounding influences.

Service response to problems in 20 clinical and social competence areas was assessed in 156 long-stay in-patients, using the Needs for Care Assessment (NFC). Although there were few unmet needs for treatment, over 200 instances of unmet needs for the assessment of social skills were found, and reasons for this are discussed, as is the importance of social-skills assessment in this group. In around a third of the sample most of the social-skill areas in the NFC were not applicable.

Repeated assessments of psychopathology, together with personality status, were made over two years on 181 psychiatric out-patients with generalised anxiety disorder (59), panic disorder (66), or dysthymic disorder (56) diagnosed using an interview schedule for DSM–III. Patients were randomly allocated to drug treatment, cognitive and behaviour therapy, or a self-help treatment programme. Although there were no overall differences in compliance rate and efficacy between the three modes of treatment, the psychological treatment methods, particularly self-help, were more effective in patients without personality disorder, and those with personality disorder responded better to drug treatment, primarily antidepressants. The findings suggest that assessment of personality status could be a valuable aid to selection of treatment in neurotic disorders and that self-help approaches are particularly valuable once personality disorder has been excluded.

The study reported by Marks et al is of considerable importance, since it is the largest clinical trial to date comparing the combination of a benzodiazepine and behaviour therapy to either component alone, and the first combined treatment trial to use alprazolam as the pharmacological agent. It was an ambitious project that was apparently well run, and the findings should be of wide interest. However, the potential value of the study is limited by the method, the patient sample, and the analysis and presentation of the data.

In an investigation of the timing and precursors of social decline in schizophrenia and affective psychosis, 195 subjects from the Camberwell Collaborative Psychosis Study were currently of lower social class than were their fathers. A comparison between father's occupation and proband's best premorbid occupational level indicated underachievement confined to DSM–III schizophrenia, there being no such effect in affective psychosis. Decline in social status following onset of psychosis, analysed by comparing best premorbid occupation with current occupation, was marked in both schizophrenia and affective psychosis, indicating a non-specific effect. Schizophrenic patients who failed to achieve their fathers' social status had poorer educational qualifications than those who equalled or bettered their paternal social class, despite similar premorbid IQ (NART) scores and age at onset of psychosis. These results indicate that schizophrenia may be manifest before the onset of psychosis, and lend weight to the notion of a developmental origin to this disorder.

In a case-record study, all first-contact patients with non-affective functional psychosis from a defined area over 20 years were diagnosed according to operational criteria of varying stringency and emphasis, and incidence rates for each set of criteria determined by sex and age at onset; data on premorbid adjustment were also analysed by sex and age at onset. The overall first-contact incidence of non-affective functional psychosis was approximately equal in men and women; however, the ratio of male to female incidence rates rose progressively when RDC (1.2), DSM-III-R (1.3), DSM-III (2.2), and Feighner (2.5) criteria for schizophrenia were applied. Schizophrenia was most common in young males and least common in older males, with females occupying an intermediate position. Schizophrenia in young males, particularly when stringently defined, was especially likely to be associated with single status, poor work and social adjustment, and premorbid personality disorder. The results suggest that schizophrenia syndrome is heterogeneous, and young males are especially prone to a severe neurodevelopmental form of illness associated with premorbid deficits.

A new community multidisciplinary team based in primary care is described and the experience of the first year discussed. The effect the team has had on the use of psychiatric services in its first year was studied. There was a threefold increase in the rate of inception to care, leading to a doubling in the prevalence of treated psychiatric disorder. There has been a reduction in the demands made on the hospital out-patient services, but no change in the use of in-patient resources or emergency contacts.

One hundred and sixty-four 16–35-year-old offspring of parents with drinking problems, recruited from a variety of clinical and community sources, were compared with 80 respondents of similar ages from similar sources who did not have parents with drinking problems. Each was interviewed using a semistructured interview. Adult adjustment was similar in the two groups, but the offspring of parents with drinking problems did report considerably more disharmony in their families of origin, and many more childhood difficulties. Factor analysis of the adult adjustment data for the samples combined showed four factors which accounted for 41% of the variance; these factors differed little in their effect in the two groups. The groups' reports of the drinking problems of their siblings, however, suggests that this sample might be unrepresentative of the true risk to the children of parents with drinking problems for the development of alcohol-related (although not other) difficulties in adulthood: 16% of this group reported a sibling with a drink problem and a further 9% were unsure, but only one member of the comparison group reported a sibling with a drink problem, and one was unsure. Path analysis showed that both parental problem drinking and family disharmony are related in complex ways to adjustment difficulties in adulthood. ‘Demoralisation’, the largest of the four factors, was particularly related to disharmony in the family of origin: in the absence of disharmony, offspring versus comparison status was negatively correlated to demoralisation in adulthood, suggesting that having a parent with a drinking problem might sometimes be a strengthening experience.

The theory underlying medical classification is not always given sufficient regard. Here systematic methods developed in biology are summarised and compared with parallel developments in nosology. The classification of the functional psychoses is discussed as an example of a methodological problem in medicine. We consider that cladism could have a useful application in nosology, and could lead to classifications based on the concept of interrelationships of disease.

Data from the Camberwell Collaborative Psychosis Study were used to examine the proposition that there is an excess of life events preceding the onset of psychoses of all types. Of 97 patients from the study who had episodes within the past year that were datable, 51 had developed psychotic symptoms from an essentially symptom-free state, 29 had been suffering only from neurotic symptoms, and 17 had experienced a marked exacerbation of psychotic symptoms. DSM–III diagnoses were collapsed into three major groups: 51 cases of schizophrenia; 31 cases of mania; and 14 cases of depressive psychosis. Life-event histories were taken for the six months before onset, and when these were compared with equivalent histories from a psychiatrically healthy sample from the local general population, there was a significant excess of life events, particularly in the three months before onset of psychosis. This was apparent in all groups, and remained even when events were restricted to the independent category. The excess of events began rather earlier than has been found in previous studies. In our view, this study provides some of the strongest evidence for a link between life events and the emergence of psychotic symptoms.