In a two-year longitudinal study, a two-stage screening procedure was used to identify subjects in primary care with emotional disorder presenting with a recent onset of physical symptoms and a comparison sample of patients presenting with physical symptoms only. Somatisers (n = 44) were defined as subjects who had an emotional disorder but who presented with physical symptoms that could not be attributed to organic disease. The course and outcome of these conditions were compared with those of pure emotional disorder (n = 11), pure physical disorder (n = 90) and ‘mixed’ conditions (n = 39). The physical symptoms of somatisers were less likely to improve and lagged behind those of the other groups, and 16 of these acute somatisers went on to develop chronic somatoform disorders. Among somatisers, changes in physical symptom levels throughout the follow-up closely mirrored changes in emotional arousal. Emotionally disordered subjects reported more instances of parental lack of care, but somatisers were also more likely than other groups to report parental physical illness and to have had more physical illness themselves in childhood. A logistic regression suggests that adult somatisation is best modelled by parental lack of care followed by childhood illness.

All recently completed controlled two-year studies on intermittent, early neuroleptic intervention treatment have failed to compare favourably with studies on maintenance treatment concerning relapse prevention. The reason for this failure is still unclear. Therefore the implicit, but as yet unproven, hypothesis that a relapse can be predicted from prodromal symptoms was tested from the perspective of our German multicentre study. Results demonstrate that this is not the case. Possible reasons for and clinical implications of this negative finding are discussed.

The context of voluntary befriending schemes to help mothers of young children is outlined. There is evidence that two main UK voluntary befriending schemes to help mothers of young children engage families where there is significant psychosocial morbidity. It is concluded that well conducted befriending schemes can make a significant contribution to the mental health of mothers and children. Whether they do so will depend on their experience and training and the elements they incorporate.

The role of the economist is to evaluate therapeutic options so as to identify both the value of what is given up to provide care (the cost) and the value of what is gained, in terms of improved health status (the benefit). The function of the economic evaluation is to inform choices: these will be determined by clinicians and managers. By informing the choice process, the economic calculus makes decisionmaking more ‘transparent’ and makes those who allocate resources more accountable to their peers, purchasers, and patients.

The uptake, at rest, of 99mTc-exametazime into different brain regions was compared using SPECT for 20 elderly subjects with major depressive disorder, 20 with Alzheimer-type dementia, and 30 age-matched normal volunteers. Uptake was referred to calcarine-occipital cortex as a reference sensory area. Cross-sectional differences between the three groups were highly statistically significant, but reflected primarily the reductions in cortical uptake in the Alzheimer group. A detailed comparison of depressed patients and controls identified decrements in anterior cingulate, temporal and frontal cortex and in caudate and thalamus in men only. These decrements were correlated with impairment of performance on a trail-making task, but were also associated with continuing treatment with antidepressants or benzodiazepines. However, most depressed patients had quantitatively normal scans for posterior parietal association cortex, and this suggests that SPECT may find a limited role in the differential diagnosis of depression and dementia. The reduced brain function in some depressed patients may parallel the findings from studies of brain structure in elderly depressives; there was a weak association between good outcome at 6–18 months and increased tracer uptake in subcortical areas.

Women who showed new psychiatric morbidity after a 30-month follow-up of a random community sample of New Zealand women were compared with those who were free of psychiatric disorder at follow-up. There were 25 new cases among the 215 women who were originally not psychiatric cases and who were re-interviewed. Using the weighted back population data to obtain prevalence figures for the general population, 6.9% became new cases over the two and a half years. Those who developed psychiatric disorder initially showed more psychiatric symptoms at a subdiagnostic level. Baseline factors that preceded the onset of psychiatric disorder were being separated or divorced, coming from a large family, having poor social networks, living alone, having few social role responsibilities such as paid employment or motherhood, and having poor physical health. An additional cross-sectional association at follow-up was poor financial security. Good social networks were closely linked with the number of a woman's social roles and appeared to protect her against the onset of psychiatric disorder. Consistent with the initial cross-sectional study, the follow-up data provide no support for marriage and child-care being risk factors for female psychiatric disorder. However, in New Zealand, these factors indicate social integration and are associated with superior mental health.

Slater's work on the schizophrenia-like psychoses of epilepsy is re-examined in the light of subsequent developments in psychiatry and neurology. Simple causal links of the sort he postulated between epilepsies and psychoses appear increasingly tenuous, despite indications that some psychotic symptoms and some localised structural changes are linked. A resumption of the study of electrophysiological similarities between schizophrenia and limbic epilepsy may offer a useful alternative programme for research.

Whereas some metabolites of antipsychotic drugs are psychoactive and contribute to clinical improvement, recent studies have provided evidence that certain metabolites contribute to side-effects which can be disabling enough to negate clinical improvement as regards the psychosis. The route of administration of the drug can determine the amount of metabolite produced in the body and affect how the patient feels in response to the treatment.

Comparative outcome studies of generalised anxiety disorder suggest that psychological therapy is a potentially valuable alternative to anxiolytic medication. However, on average psychological therapy results in modest improvements in symptoms, with about 50% of patients achieving normal functioning. Limited follow-up data indicate that these changes are maintained over six months. Cognitive therapy appears to be most effective, although comparisons with other therapies are limited and non-specific factors are clearly important. There is also evidence of considerable variability in outcome between studies, with the best results obtained with patients who are free of anxiolytic medication and recruited directly from primary care or other non-psychiatric settings. The effects on outcome of patient characteristics known to be associated with more severe illness and complexity of clinical presentation have yet to be explored. A balanced appraisal of the value of psychological therapy with this common condition requires a fuller description of sample characteristics and more systematic investigation of the clinical significance of treatment effects over the long term.

One hundred patients with cryptogenic epilepsy and normal intelligence and 100 age- and sex-matched controls were submitted to psychiatric interview using the Clinical Interview Schedule. Nineteen patients and 15 controls were identified as having psychiatric disorders. Anxiety and depression were the predominating diagnoses in both groups. Personality disorders were occasionally present in subjects with epilepsy. The study shows that patients with cryptogenic epilepsy and normal neuropsychological abilities should not be considered at any higher risk of psychiatric disturbance than a non-neurological patient population.

Current overemphasis on nosological diagnosis has led to a neglect of the process of symptom recognition. There is evidence, however, that the perception of the symptom alone does not guarantee symptom ascertainment since a decision-making component is also involved. To achieve the latter, additional information must be provided by the contextual cues implicit in the ongoing diagnostic hypothesis. Current diagnostic systems, however, still assume a two-stage model according to which symptom and disease recognition are independent cognitive events. This paper suggests that this model is inadequate and that descriptive psychopathology is not transparent. It then describes a neural network simulation to make various aspects of the problem explicit. This takes into account the multidimensional and probabilistic aspects of symptom recognition and is, from this point of view, superior to traditional algorithmic models. It also has the capacity to represent the different cognitive styles involved in symptom recognition.

The follow-up phase of a random community sample of New Zealand women contrasted the social, demographic, and clinical characteristics of those women whose initial psychiatric disorder had remitted with those who continued to describe significant psychiatric morbidity, two-and-a-half years later. Of 272 women studied at baseline and reinterviewed, 57 had originally been psychiatric cases. Twenty-five of those women (44%) were still cases at follow-up. Using figures that statistically reconstructed the original population from the stratified sample, the remission rate in the parent population was 61% over the two-and-a-half years (an average of 24% per annum). Women less likely to experience remission of their psychiatric disorder were of mid-age (45–64 years), with poor finances and with poor social relationships at the initial assessment. Although the age finding replicates a previous report from an Epidemiological Catchment Area study, it is not clear whether it is a universal relationship, true for all cultures. The alterations in social roles faced by women after child-rearing is a possible explanation, at least for New Zealand.

Ten patients with Alzheimer-type dementia and nine age-matched normal controls were examined with SPECT, using split-dose 99mTc-labelled exametazime. The baseline condition involved repetition of the word ‘yes' or ‘no’. The activation condition involved recognition (indicated by a ‘yes' or ‘no’) of words from a previously learned list presented along with distractor words. Patients who performed this task successfully were selected, and efforts were made to match the patients with controls according to their performance on the task, although this was not fully achieved. Uptake of 99mTc-exametazime was estimated at baseline and during the word-recognition task for predetermined regions of interest drawn from a standard neuroanatomical atlas. The baseline task appeared to normalise tracer uptake for frontal, temporal and parietal cortex in the patient group. However, during the recognition task, controls but not patients showed activation effects. These were most prominent in dorsolateral frontal cortex and adjacent anterior cingulate cortex. Among patients, successful performance was correlated with activation of dorsolateral frontal and parietal cortex on the left side. The results confirm the central role of frontal mechanisms in a recognition memory task. The study highlights some of the difficulties of using cognitive challenge tests in clinical groups.

The relationship between early treatment response and CT variables was investigated in 50 consecutively admitted patients with DSM-III schizophrenia. Treatment response was defined as the absolute BPRS improvement during patients' hospital stay and was found to be significantly correlated (P<0.05) with the frontal horn ratio (r = −0.36), ventricular ratio (r = −0.32), width of the third ventricle (r= −0.37), width of the frontal interhemispheric fissure (r = −0.33), and average width of the three largest cortical sulci (r = −0.46). According to the results of multiple regression analysis, 35% of the variance in the treatment response was accounted for by the average width of the three largest cortical sulci, the ventricular ratio and the frontal horn ratio. Thus, cerebral abnormalities associated with poor treatment response do not seem to be limited to one particular morphological site, but involve different brain regions.

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.

The prognosis of depression in the elderly was investigated in a mixed-age sample of 242 consecutive referrals, with DSM-III defined unipolar major depressive episode, to a specialist unit for mood disorders. Subjects were followed up at about 1 and 3.8 years. There was no significant difference in outcome between younger (under 40 years), middle aged (40–59 years) and older (60 years or more) depressed patients. For the 61 elderly subjects with depression, prognosis improved with time, with 25% having a lasting recovery at the first and 41% at the second follow-up. Early onset, recurrence, and poor premorbid personality were associated with a worse prognosis. Three (5%) elderly depressives had committed suicide and seven (11%) had died from natural causes by the second follow-up. Despite some methodological limitations, our findings suggest a more optimistic outlook and the need for longer, more assertive treatment for elderly, depressed patients.

Positron emission tomography studies of regional brain metabolic activity, cerebral blood flow and D2 dopamine receptor binding in schizophrenics and controls are reviewed. Methodological influences on the validity of the data generated by these technologies include problems with measurement as well as clinical and anatomical heterogeneity. Work in these fields to date, however, has produced strong support for the role of D2 dopamine receptor blockade in antipsychotic efficacy. Neuroleptic-induced changes in regional brain metabolism over time have also been observed; however, the relationship between such actions and symptomatic change needs to be further clarified. Future studies on time-course of neuroleptic-associated changes in regional brain metabolism, blood flow and dopamine receptor binding in schizophrenics have the potential to provide greater insight into the relationship of these actions to symptomatic changes and drug-induced side-effects.

In a two-stage screening procedure using the Edinburgh Postnatal Depression Scale and Goldberg's Standardised Psychiatric Interview, 232 women six months after delivery were compared with control women individually matched for age, marital status and number of children, obtained from general practitioner lists, who were not pregnant nor had had a baby in the previous 12 months. No significant difference in the point prevalence of depression at six months was found between the postnatal (9.1%) and control women (8.2%) nor in the six-month period prevalence (13.8% postnatal, 13.4% controls), but a threefold higher rate of onset of depression was found within five weeks of childbirth. The possible explanations relate to the long duration of depression in women with young children, and the stressful effect of childbirth and its psychosocial sequelae.

The effectiveness of ritanserin, a selective 5-HT2 and 5-HT1c antagonist, in reducing negative symptoms in schizophrenia was investigated in a double-blind, placebo-controlled trial. Trial treatment was added to a stable neuroleptic treatment in 33 schizophrenic patients with predominantly negative symptoms. Ritanserin reduced the negative symptoms, as measured with the SANS. The main reduction was for the items facial expression, global affective flattening, and relationships with friends and peers. Also a reduction in total BPRS score was found, which approached statistical significance. Significant reductions were observed for the BPRS items emotional withdrawal and depressive mood. Ritanserin or other drugs blocking 5-HT2 and/or 5-HT1c receptors could be important in reducing specific symptoms in schizophrenic patients.

Patients with chronic, refractory irritable bowel syndrome (n =102) were entered into a randomised controlled trial of psychotherapy versus supportive listening. Independent physical and psychological assessments were carried out at the beginning and end of the 12-week trial. For women, psychotherapy was found to be superior to supportive listening, in terms of an improvement in both physical and psychological symptoms. There was a similar trend for men, but this did not reach significance. Following completion of the trial, patients in the control group were offered psychotherapy; 33 accepted and following treatment experienced a marked improvement in their symptoms; ten declined. At follow-up one year later, those patients who had received psychotherapy remained well, patients who had dropped out of the trial were unwell with severe symptoms, and most of the controls who declined psychotherapy had relapsed. This study shows that psychotherapy is feasible and effective in the majority of irritable bowel syndrome patients with chronic symptoms unresponsive to medical treatment.