Lithium treatment, an approach with well documented efficacy, has recently been losing its treatment value. Lithium continues working, however, for those patients for whom it was proven efficacious; that is, most patients with primary episodic affective disorders. Such responders to lithium prophylaxis can be reliably identified beforehand by a comprehensive clinical assessment. The explanation for the paradox of lithium's lost efficacy lies mostly in the educational bias against a comprehensive patient assessment, and in the shift in diagnostic fashion favouring affective disorders and the treatment methods associated with them in the clinicians' minds.

The adverse effects of antidepressants include their pharmacological side-effects, toxic effects, interactions with other drugs, and symptoms occurring during their withdrawal. The focus of this paper is on the pharmacological side-effects.

When a group of 10 patients who had received surgery for carcinoma of the larynx were compared with 10 control patients who had received radiotherapy for carcinoma of the larynx, four of the former but none of the latter were found to be suffering from depression, a statistically significant difference. Depression was associated with poor communication skills and geographical isolation. Psychiatric intervention is recommended for patients undergoing mutilating forms of surgery.

Single photon emission computerised tomography (SPECT) was used to measure regional brain uptake of technetium-99m hexamethyl-propyleneamine oxine (Tc99m-HMPAO) in elderly patients with Alzheimer's disease (AD), multi-infarct dementia (MID) and normals (n = 20 in each group). Different patterns of uptake were found between groups when cortical uptake was normalised to cerebellar uptake. Reductions occurred in all regions in AD, being most marked in temporal and posterior parietal areas. Significant correlations were found in AD between memory impairment and decreased temporal uptake bilaterally, and between duration of illness and reduced uptake in most brain regions. MID patients showed higher uptake in the anterior parietal region than did the other groups. A variable comparing anterior to posterior uptake significantly discriminated the two patient groups.

Fifty-nine women admitted to hospital because of severe depression were studied prospectively during hospital admission and nine months following hospital discharge in order to identify psychosocial and illness factors associated with prognosis. Outcome was measured in terms of both depression scores and recovery at the time of follow-up. In keeping with the findings of other studies, the outcome was often poor, with only 54% having recovered nine months after discharge, poorer outcome being associated with more negative self-esteem measured when the women were depressed and with suicidal ideas. The findings indicate that in severely depressed women likely to be admitted to hospital, psychosocial factors may have less relevance to outcome, at least in the short term, than in less severely depressed patients studied in community or out-patient samples.

The experience and perception of effective sources of help of 101 schizophrenic patients were studied. A combination of professional help, social support, and self-coping efforts was listed as helpful. The more experiences patients had with the various sources of help, the better were their outcomes. Premorbid adjustment, exposure to the magnitude and nature of helpful sources, as well as the patients' own ability and motivation to make use of available helpful sources were thought to be important mediating variables for a better outcome. Apart from psychotropic medications, over half of the patients were not using any one of the sources of help mentioned. It remains an important research question whether or not schizophrenic patients may benefit from direct coaching in self-help skills in conjunction with making optimal use of professional and environmental supports.

Among a large workplace population interviewed over a year, current symptoms were assessed using the Hopkins Symptom Checklist (HSCL). Variation in symptoms by date of assessment was observed among the 314 women but not the 1556 men. Among women, symptoms were greatest during late autumn and winter, and significant inverse correlations were found between available daylight at the time of assessment and standard symptom dimensions of anxiety and somatisation, as well as an expanded mood scale more inclusive of depressive symptoms within the check-list. The amplitude of the seasonal effect was such that the prevalence of female ‘cases', as defined by HSCL criteria, was twice as high during winter than during the rest of the year. The data are consistent with a role for light-dark exposure in eliciting or synchronising annual mood rhythms. The sex-by-season interactions may contribute to the sex differences in overall prevalence of depression.

The hypothesis of a low self-esteem in depressive patients was tested using the Rosenberg Self-Esteem Scale in 24 recovered unipolar and 27 recovered bipolar patients, compared with a normal control group of 26 subjects matched for age and sex. The hypothesis was confirmed only for unipolars; bipolar patients presented a self-esteem score not significantly different from normal scores. Self-esteem was not related to clinical characteristics of the affective disorder, suggesting that low self-esteem may be a basic component of a depression-prone personality. The investigation of the relationship between self-esteem and social adjustment confirmed the presence of social conformism in bipolar patients and rigidly set low self-esteem in unipolar patients. These results should stimulate the evaluation of different psychotherapeutic treatments in the long-term psychosocial management of affectively ill patients.

Dopamine receptors have been divided into two major types – D1 and D2 – based primarily on pharmacological and biochemical criteria. Recent advances in the molecular biology of the dopamine receptor system have allowed the identification and characterisation of at least five distinct neuronal dopamine receptor genes (D1 to D5). These genes encode dopamine receptors belonging to the D1 receptor family, termed D1 and D5, and three D2-like receptors, termed D2, D3 and D4. These receptors are distinguished on the basis of their primary structure, chromosomal location, mRNA size and tissue distribution, and biochemical and pharmacological differences. Although individually these receptor subtypes may not be directly and exclusively involved in the maintenance or expression of schizophrenia, alterations of any of the receptors may contribute to the perturbation or instability of dopaminergic homeostasis in the brain. What was once thought to be a simple two-receptor system seems to have emerged as an intricate and interactive entity. This review summarises what is currently understood about dopamine receptors, their role in antipsychotic drug action, and their association with psychosis.

Patients with newly diagnosed schizophrenia (n = 27) or schizophreniform disorder (n = 22) and 24 healthy volunteers were investigated by CT scan, the investigators being blind to subject status. The patients had never received medication or had been treated only briefly with neuroleptics. The patients had significantly smaller brain volume and brain length than the controls. The patients had greater sulcal enlargement in the case of both Sylvian and interhemispheric fissures and surface sulci in the frontal and parietal regions. The sulcal enlargement was more pronounced in male patients and on the left hemisphere. The study revealed no enlargement of the lateral ventricles and only a trend towards enlargement of the third ventricle in the patients. The findings were not explained by substance abuse or level of education.

Domestic and world opinion is gradually changing towards the idea of tolerating or even legalising active euthanasia. The implications of this are examined using Foulke's concept of the ‘levels' in group discussions. Psychiatrists have a unique experience in using the statutory mental health legislation, in addition to the ordinary law, to regulate medical care. A new ‘special defence’ is suggested, to be enacted by Parliament, intended to justify, but also designed to control, deliberate acts of medical euthanasia.

In a pilot study, SPECT was used to explore differences in rCBF between a group of patients with schizophrenia-like psychoses of epilepsy (SLPE) and a matched group of epileptic controls. Five patients in each group were investigated and those with SLPE showed significant reductions in the index of rCBF in the left medial temporal region. These differences are being investigated further.

This paper does not attempt to review the whole topic of clinical efficacy but will consider general concepts, particularly in the light of the advent of the serotonin (5-HT) uptake inhibitors (SSRIs).

The aetiology of depression is complex. In most cases there is some form of predisposition based on problematical family dynamics, disordered family communication and/or genetic factors; each may be present to a variable extent. On top of this predisposition, some form of stimulus - ‘stress’, an external problem, loss of control, a physical disorder, adverse life circumstances - appears to affect those who are already primed. There are a variety of possible outcomes from this combination of predisposition and stimuli: low mood, depression in the full syndromic sense, and depression with biological features. It seems likely that, particularly with severe depressions (the major syndromic forms and those with biological features), there are neuroendocrine and neurochemical changes to mediate the effects of stress into those of the clinical symptoms and signs. It has been hypothesised that stressors induce adaptive neurochemical changes, failure of which may engender behavioural disturbances (Anisman & Zacharko, 1992). However, there are also many individuals who may not undergo this process, but who probably have some cognitive or learned change leading to dysphoria; this aspect needs to be considered carefully in relation to efficacy.

The search for predictors of outcome has not been particularly rewarding, and the use of lithium remains empirical: a trial of lithium is the most powerful predictor of outcome. However, lithium is a highly specific treatment for bipolar disorder. In non-bipolar affective disorder, factors of interest are correlates of bipolar disorder: mood-congruent psychotic features, retarded-endogenous profile, cyclothymic personality, positive family history of bipolar illness, periodicity, and normality between episodes of illness.

The extent of social dysfunctioning and its relationship to psychological disorders among Dutch primary care patients was examined. Social dysfunctioning in these patients was rather limited, but was more pronounced in patients with a psychological disorder than in those without. Disabilities were largely restricted to the occupational and social roles, with family role functioning and self-care relatively intact. Social dysfunctioning was moderately related to psychopathology, with higher levels of dysfunctioning in more severe and depressed cases. The extent of social dysfunctioning among patients with both anxiety and depression was similar to that of patients with a single diagnosis of depression. Depressed patients had a similar level of dysfunctioning to non-psychotic psychiatric out-patients. Analyses regarding the effects of diagnosis and severity on social dysfunctioning revealed considerable overlap between these two aspects of psychopathology. This study supports the need for a simultaneous but separate assessment of psychopathology and social dysfunctioning. However, future research should incorporate additional predictors of social dysfunctioning (e.g. personality, life events, long-term difficulties, physical disorders), and prospective studies should be conducted to clarify the temporal sequences of symptom severity, diagnosis, and comorbidity on the one hand, and social dysfunctioning on the other.

Although many studies have shown an increased mortality in schizophrenic patients, the literature provides little information about mortality from specific causes in relation to age, gender, and duration of illness. This study examined mortality and causes of death in a total national sample of 9156 first admitted schizophrenic patients. Suicide accounted for 50% of deaths in men and 35% of deaths in women. Suicide risk was particularly increased during the first year of follow-up. Death from natural causes, with the exception of cancer and cerebrovascular diseases, was increased. Suicide risk during the first year of follow-up increased by 56%, with a 50% reduction on psychiatric in-patient facilities. The study confirms that mortality in schizophrenia is still markedly elevated, and the finding of an increasing suicide risk may be an indicator of some adverse effects of deinstitutionalisation.

The lifetime geographical mobility of a group of 67 patients suffering from schizophrenia was investigated and related to the ecological structure of the city of Nottingham, where they first presented between 1978 and 1980. The study aimed to investigate the processes leading to a threefold rate of schizophrenia in the most socioeconomically deprived area of the city compared to the area of least deprivation. Results suggest that this skewed distribution begins early in the lives of the patients and is well established at least five years before initial contact with the psychiatric services.

In a four-year follow-up study of 1042 elderly people (aged 65 years or older), randomly sampled from the community, levels of dementia were assessed using a two-phase case-finding procedure (screening followed by clinical interview) among survivors. Clinical information on those not reinterviewed was provided by death certificates, hospital case notes, or postal questionnaires. The weighted four-year cumulative incidence of dementia was 3.7% (95% confidence intervals: 2.4%-5.0%), with age-specific rates of 0.9%, 2.8%, 5.2%, 9.0%, and 8.7% for the age groups 65–69, 70–74, 75–79, 80–84, and 85–89 years respectively. While consistent with data from other British regions, it remains likely that these rates underestimate true incidence.

Since existing depression scales were designed for assessment of depression in non-psychotic populations, such scales have items which do not distinguish depressed from non-depressed psychotic subjects. The authors describe a new scale, the Calgary Depression Scale, which was designed for the assessment of depression in schizophrenia. The scale was derived from two existing scales by factor analysis and reliability analysis. It has been further tested in two new samples. In the first it has been shown to be reliable, congruent with a self-report scale and valid. In the second sample it has been shown that there is no overlap with negative or extrapyramidal symptoms.

In psychiatry, the law, and economics, there are many areas of overlap where our knowledge and appreciation are growing and developing. Many doctors ‘understand the words but not the music’, and the same is true for the other professions involved. This is exemplified in relation to suicide.