A number of reviews of the effectiveness of cognitive behaviour therapy for depression, though optimistic, have pointed to some difficulties in interpretation of the outcome literature. These difficulties, and the extent to which more recent research has dealt with them, are reviewed. It is suggested that while some of the genuine difficulties have been resolved, and other commonly expressed criticisms may prove to be unfounded, there remain a number of important areas of ignorance which demand further investigation.

The contribution of genetic differences to variation in ageing and the relationship of ageing to certain types of dementia are discussed. Neuropathological changes commonly found in the ageing brain are present in more severe form in Alzheimer-type dementia, Down's syndrome, multi-infarct dementia, and a substantial number of patients with Parkinson's disease. An increased frequency of ageing-associated changes outside the brain have been reported in Alzheimer-type dementia, Down's syndrome, and multi-infarct dementia, although the evidence is generally meagre and in many cases requires further corroboration. Genetic studies of Alzheimer-type dementia support the existence of heterogeneity on the basis of family history and age of onset; early onset is associated with greater genetic risk and severity of abnormality. The increasing evidence of an association between DNA damage, premature ageing, and neuronal cell loss may provide insights into the aetiology of these and other forms of dementia.

Twenty depressed multiple sclerotic patients were randomly allocated either to cognitive-behaviour therapy or to a waiting list control condition. Assessment of depressive symptoms was conducted at pre-treatment, post-treatment, and a four-week follow-up. In comparison to the waiting list control condition, cognitive-behaviour therapy was found to result in clinically and statistically significant improvement on most measures. Although the mechanism by which such treatment achieves its effects is unclear, these results clearly support the use of cognitive-behavioural treatments for depression in this population.

The dexamethasone suppression test (DST) was administered shortly after admission to 102 consecutive in-patients with a Hamilton depression score ≥16. Post-dexamethasone cortisol exceeded 6pg/dl in 16 cases, and levels correlated significantly with Hamilton scores; with the AMP syndromes ‘hypochondria’, ‘apathy’ and ‘catatonia’; and with the IMPS ‘retarded depressive’ syndrome. The criterion of suppression/non-suppression did not distinguish significantly between diagnostic categories (RDC or ICD), nor between endogenous and neurotic depression. (Newcastle scale). Both base-line and post-dexamethasone cortisol levels were reduced by prior treatment with minor tranquillisers, but not by major tranquillisers or antidepressants. DST results cannot be used as straightforward indicators of prognosis.

The foundation of charitable institutions for the care of the mentally ill began towards the end of the eighteenth century as a result of concern amongst the articulate for the disadvantaged in society. It was not long before this same concern was again aroused; this time at the high death rate within many of these asylums. In the case of the York Asylum, which was the subject of a Parliamentary Select Committee in 1815, this was found to be due to poor conditions (Digby, 1983). Recently the Royal College of Psychiatrists has focussed attention on the continuing problem of patients who kill themselves while receiving treatment in hospital (Crammer, 1983). Particular attention was drawn to the reluctance of psychiatrists and those around them to examine the events leading to death; this compares unfavourably with the attitudes of anaesthetists and obstetricians, who have an established procedure for confidential inquiries into unexpected deaths.

In 231 psychiatric in-patients, the 1 mg or 1.5 mg DST with blood samples at 0900 h, 1600 h and 2300 h and a post-dexamethasone plasma cortisol threshold of ⩾ 5 μg/dl were tested for their differential diagnostic utility in clinical psychiatry. Neither test significantly separated endogenous depressed. patients from patients with other depressive or non-depressive psychiatric disorders. Studies of the 1 mg or 1.5 mg DST in 75 healthy subjects revealed about 12% of cortisol non-suppressors, when a post–dexamethasone cortisol threshold of ⩾ 5 μg/dl was used. This seemed to be an unacceptably low specificity of the test in normal subjects. A threshold criterion of ⩾ 8 μg/dl, however, yielded only 2.7% of non-suppressed normal subjects. Analyses of the DST data of the psychiatric patients, using a cortisol threshold of ⩾ 8 μg/dl, also failed to reveal a significantly higher specificity of the DST for endogenous depression. However, it was demonstrated that intervening variables such as stress due to hospital admission, drug withdrawal, suicidal turmoil, weight loss, as well as a low dexamethasone plasma level, enhance the rate of abnormal DST results in psychiatric in-patients, regardless of their diagnostic classification.

Psychometric examination of a group of diabetic patients and a group of age-matched controls failed to provide evidence of impaired intellectual functioning in the diabetic group. The cognitive status of the diabetics was not related to the duration of the illness, the age at diagnosis, or clinical ratings of peripheral or autonomic neuropathy.

Twelve patients with obsessive compulsive disorder were studied with psychophysiological measures during a randomised, double-blind placebo-controlled drug trial. Significant clinical improvement followed six weeks of treatment with the tricyclic antidepressant clomipramine, but was not evident after an equal period of treatment with the monoamine oxidase inhibitor (MAOI) clorgyline. Compared to placebo, both drugs reduced skin conductance indices of baseline arousal, but only clomipramine reduced skin conductance and heart rate responses to loud tones and tonic and phasic skin conductance responses in a two-flash discrimination task. This suggests that reductions in autonomic responses to important and/or aversive stimuli may be critical to clinical improvement in obsessive compulsive disorder.

The distribution of in-patient psychiatric admissions throughout the city of Bristol during the period 1978–1981 is described. High rates were found from the central urban areas of low social class and with a high concentration of immigrants. The findings suggest that immigrant groups (mainly of West Indian origin) are no more likely than others living in the city centre to become psychiatric hospital in-patients, but when they do so, they are more likely to require compulsory admission.

Sixteen consecutive patients with anorexia nervosa were studied and compared with a control group of other patients coming to an adolescent service, matched for sex and admission status. The anorexic group were not significantly different from the controls in social class and I.Q., and had a male-to-female ratio of one to four. However, they were significantly more likely to have perfectionistic personality traits and to profess to be happy with their families; these families had few external stresses, were very close, and had a high degree of exclusivity.

One hundred and six adult neurotic patients attending a behavioural psychotherapy unit were asked about their use of alcohol and other drugs and the perceived anxiolytic effect of these substances. Their drinking behaviour was not significantly different from that of the general population. Alcohol and other drugs were not perceived as reliable anxiolytics and not regularly used as such. Where alcohol or drug abuse coexist with anxiety-related problems, it is helpful to ask the patient to withdraw from these substances prior to starting behavioural therapy of the latter. We ask patients having behavioural therapy to refrain from alcohol or drug use prior to therapy or homework tasks.

Six normal subjects were given clonidine infusions after 0, 1 and 3 weeks of treatment with desipramine (2 mg/kgm) and at 1 and 3 weeks after withdrawal from desipramine. The sedative and hypotensive effects of clonidine were inhibited after one and three weeks of desipramine treatment, and returned to normal after stopping treatment without any rebound increase. Such a time-course can be explained in terms of the acute effects of the drug, no adaptive changes at receptors need be invoked.

By contrast, the growth hormone response to clonidine tended to be increased after one week of desipramine, reduced after three weeks of treatment, and further reduced after discontinuation. Such a time-course is consistent with an adaptive down regulation at α2 adrenoceptors in response to their acute stimulation, due to noradrenaline re-uptake blockade.

Literature on psychiatric manifestations of hyperparathyroidism published in the last four decades confirms the unusual features of a case of paranoid psychosis secondary to a parathyroid-adenoma-induced hypercalcaemia. Affective and organic symptoms are overwhelmingly dominant in hypercalcaemic patients; the majority of cases reported are women of 50 years or older, who have been vaguely ill for a prolonged time before the actual endocrinopathy appears. The severity of the psychiatric symptoms does not seem to be related to the degree of hypercalcaemia. Recent findings link the role of calcium and related ions in the production of psychopathological symptoms to membrane phenomena, dopaminergic activity, and neuroendocrine regulation.

A descriptive study of the psychiatric findings in 50 insulin—dependent diabetics is presented. Among the symptoms found were a marked reduction in energy level, increased fatigue and irritability, depression, and delayed psychosexual maturation. Diabetes mellitus is commonly considered to be a disease that, if properly controlled, allows the patient to lead a relatively normal life. We found, however, that these symptoms often made the patients' lives uncomfortable, reduced their functional capacity, disrupted their family life, and disturbed the adolescence of those who were affected at an early age.

Dexamethasone suppression Test (DST) and sleep electroencephalogram (EEG) recordings were carried out during three consecutive nights in 39 depressed patients who met Research Diagnostic Criteria (RDC) for major depressive disorder and in nine normal controls. Cortisol response to DST was abnormal in 26 patients and normal in all controls. REM latency and REM density were compared in patients with abnormal DST (n = 26) to values obtained in patients with normal DST (n = 13) and in normal controls (n = 9). Rapid Eye Movement (REM) latencies were significantly lower in depressed patients showing cortisol non-suppression after dexamethasone than in patients with a normal DST or in controls. REM densities were significantly higher in depressed patients than in normal controls (P <0.025), but there was no significant difference between DST suppressors and non–suppressors. The DST provided high specificity (100%) and a sensitivity of 67%, while REM latency showed a lower specificity (78%), but a higher sensitivity (85%).

Three groups of patients admitted compulsorily from populations with markedly different rates of compulsory psychiatric admissions were compared on a range of social and clinical data. Whilst West Indian and white patients from inner city areas differed in many respects, they were both more likely than other patients to be referred to the psychiatric services through police agencies, with little GP involvement and were often admitted from public places following disturbed behaviour. However, levels of violence and threatening behaviour were no higher among inner city patients, black or white, and once admitted, these groups showed similar treatment compliance to white patients who had been admitted compulsorily from suburban areas. Implications for primary care and delivery of psychiatric services are discussed.

The supporters of 129 patients referred for psychogeriatric day hospital care were interviewed and followed-up after three and six months. The majority of their dependents suffered from dementia. Thirty-one per cent were still attending six months later, while 37% had been admitted to institutional care. The most positive effects of day hospital were associated with continued patient attendance, the number of distinct advantages foreseen by the supporter, and the lack of any negative expectations concerning their dependents' adjustment to day care. Positive benefits were also closely associated with reductions in the number of problems faced by the supporter.

The condition known as AIDS (Aquired Immune Deficiency Syndrome) was first described by the Centre of Disease Control (CDC), Atlanta in June 1981. A subsequent nationwide survey soon revealed that similar cases had been occurring since 1979. At the time of writing, 3064 cases have been reported to the CDC of which 1,292 (42.2%) have died; 1,275 (41%) have occurred in New York City.

In South-East Scotland, 791 subjects treated with lithium for more than two months during 1967–76 were traced, using public and health service records; 751 were traced alive, 33 had died, and seven remained untraced. The standardised mortality rate was 2.83, and excess mortality was attributable to suicide (increased 36-times) and cardiovascular disease (increased 2.15-times); deaths from nephropathy, cancer or leukaemia were not increased. Comparison of the 33 deaths and 33 matched patients, selected from the 751 survivors, showed that patients dying on lithium were similar in most respects to survivors, but when first starting lithium, they had more signs of physical disease.

The dexamethasone suppression test (DST) was administered to 95 patients referred to a psychogeriatric assessment service. Non-suppression of plasma cortisol was found in 28 out of 48 patients (58%) with senile dementia and all patients with arteriosclerotic dementia or acute confusional states. Non-suppression could not be explained by associated depressive symptoms. The DST was confirmed as a valid diagnostic test for endogenous depression in the elderly, but its value in distinguishing true dementing illnesses from depressive pseudodementia was not supported. The clinical implications of these findings for interpreting DST results in the elderly are discussed.