Community care has lost its innocence. Critics and evangelists vie for television space and newspaper headlines. The Chief Medical Officer had to beg for clarification of a term that had developed too many meanings and an “ethos of virtue” (Acheson, 1985). How should it be defined? Can a hospital be part of the community? Does it mean care ‘in’ ‘by’ the community? The Department of Health and Social Security (DHSS) definition seems to be “the provision of alternatives to long-term institutional care for the chronically sick or those suffering from long-term handicaps or disabilities” (Hunt, 1985). Lord Trefgarne (1984) put the policy aim, more simply, as “to move out of hospital those people who do not really need to be there”.

The possibility of a rise in rates of depression among adolescents and young adults was first reported in the 1970s. Particular note was taken of the emergence of childhood depression and the increase in suicide attempts and death among adolescents and young adults. Data from large-sample family studies and community epidemiological surveys have been reviewed and reanalysed, using life-table statistical methodology. Evidence for secular trends are presented, and the problems of disentangling period and cohort effect are discussed. It appears that the ‘baby boomers' -those born in the years after World War II- have had increased rates of depression and other related illnesses, including drug abuse and alcoholism. The theoretical aspects of this are discussed, particularly for gene-environment interactions.

Ninety-one subjects diagnosed clinically as having a ‘neurotic depression’ were interviewed and then re-assessed at 6 weeks and 20 weeks. Four symptom profiles of clinical features were derived: ‘negative cognition’, ‘lack of drive’, ‘anxiety’, and ‘arousal’, the last being independent of the other three dimensions and of the severity of depression. Symptom profile scores were then examined against antecedent risk variables and outcome. Links between profile scores and personality variables suggest that personality may colour the clinical presentation of neurotic/reactive depressions, and challenge the assumption that a typology of these depressive disorders based on clinical features is achievable. The break-up of an intimate relationship in the preceding 12 months was a strong predictor of a good outcome. Further analyses suggested, firstly, that there was a distinct subgroup delineated by this life event, with features weighted to the ‘arousal’ symptom profile, including many symptoms often associated with diagnosis of ‘endogenous depression’; and, secondly, that this life event and a good outcome were directly linked, being uninfluenced by personality or other mediating variables.

It has been suggested that the quality of early parenting received by depressed adults is more negative than that received by non-depressed people. Since perceptions of parenting are usually examined only when subjects are depressed, depressed subjects' negative reports may be distortions due to their depression, rather than accurate recollections. In the present study, both depressed and remitted women reported experiencing greater parental overprotection than did non-depressed women, but only depressed subjects also reported less parental caring. The results are discussed with respect to the early experiences of depressed individuals, the distinction between parental caring and over protection, and the importance of interpersonal factors associated with depression.

Chronic depression is defined as “symptomatic non-recovery for a period of 2 or more years”. Chronic primary major depressives (n = 24) were compared retrospectively with a control group of primary major depressives (n = 20) who had recovered from their illness episode within 2 years. The former had a significantly higher familial loading for affective disorder and showed an increased incidence of independent undesirable life events during the 6 months prior to and 2 years after the onset of their illness. Female chronic depressives also had a significantly greater number of previous illness episodes and a more frequent history of thyroid dysfunction. Personality as measured on the EPQ, psychiatric problems arising as secondary complications of the depressive illness, and developmental object loss did not differentiate chronic from non-chronic depressives.

The growth hormone response to clonidine was measured in ten drug-free recovered patients, seven of whom had previously been tested when endogenously depressed, and compared with the response in ten individually matched controls. In eight of the patients there was an impairment of the growth hormone response, despite clinical recovery, although the hypotensive effect of clonidine in these patients was normal. This is suggestive of a persisting abnormal alpha2-adrenoceptor function in forebrain regions after recovery from an episode of endogenous depression, and may represent a trait marker for this condition.

The study tests the hypothesis that delusional and non-delusional depressive illnesses are distinct entities in late life. Two groups of 24 patients with late-onset depression, one with and one without delusions, were compared retrospectively. At the index admission, deluded patients were significantly more depressed, were in hospital for longer, responded poorly to antidepressants alone and required more physical treatments, especially ECT and major tranquillisers. Although illness severity was a major factor accounting for these differences, the finding that only the deluded group experienced delusional relapses suggests an underlying intrinsic susceptibility. The discharge status was similar for both groups, as were relapse rates over 48 months and the clinical course of depressive symptoms over 42–104 months. The findings are consistent with studies of younger patients which point to a distinction between these two types of depression, but not with recent work suggesting a very poor prognosis for delusional depression in late life.

A retrospective review of 131 psychiatric referrals of hospital in-patients aged 65 years and older was made to examine the referral rate, the characteristics of referred patients, and the pattern of diagnoses and recommendations made by the psychiatrist. The referral rate was much less than the estimated prevalence of psychiatric morbidity in similar populations. The majority of referrals received a psychiatric diagnosis, most commonly an organic psychiatric syndrome (37%) or depression (23%). Comparison of various aspects of referral for the periods before and after the introduction of a specific psychiatric liaison service for the elderly showed little change apart from a small increase in referral rate.

On two occasions one year apart, the cognitive performance of 12 patients with presenile dementia Alzheimer type (ATD) and 14 with alcoholic Korsakoff syndrome (KS) was assessed both psychologically using the Christensen version of Luria's neuropsychological investigation and physiologically by measuring P300 (P3) and other long-latency auditory event-related potentials. All patients with ATD showed evidence of psychological deterioration and most also showed changes in auditory P3, whereas on all measures the KS group remained essentially unchanged. The extent of the changes in the ATD group varied, but in general those patients with most psychological deterioration also displayed the biggest changes in P3 wave form. There were two patterns of decline: a majority followed the traditional progressive course associated with Alzheimer disease; and in a minority, decline was slower. Methods for determining the rate of decline in individual patients with ATD, together with the prognostic implications, are discussed.

The authors report a patient whose Parkinson's disease and mania both responded well to electroconvulsive therapy (ECT) after failing to respond to chemotherapy. The authors review the literature and suggest that ECTis a safe and effective treatment for affective syndromes associated with Parkinsonism. The presence of dementia in these patients appears to be an indicator of poor prognosis. This paper is believed to be the first report of successful use of ECT in mania occurring together with Parkinsonism.

The effects of a series of six ECT treatments were observed on the CSF concentrations of HVA, MHPG, and 5-HIAA in 12 patients suffering from schizophrenia. Four patients were previously neuroleptic drug-free, and eight had received only oral neuroleptic drugs at the same dose for more than 4 weeks. A significant increase in the concentration of HVA was observed after the first ECT treatment but not after the final treatment. No significant changes were observed in the concentrations of MHPG and 5-HIAA. The patients improved clinically, and the results suggest that ECT has important effects on dopaminergic systems.

The effects of two experimental interview styles, designed to differ in the extent of their use of active feeling-oriented techniques but similar in their use of active fact-oriented techniques, were compared in initial diagnostic interviews with the mothers of children referred to a psychiatric clinic. The style that employed a higher level of actively responsive feeling-oriented techniques elicited more emotional expression and more often obtained certain feelings of potential diagnostic significance. The actively responsive style was more effective in increasing the amount of feeling expressed if mothers' spontaneous rate of expression was relatively low.

This paper describes the demographic and clinical features of five non-white, normal body weight bulimics, all from the same catchment area. Comparisons with white bulimic referrals from the same area showed clinical similarities, but the non-white bulimics gave an account of gross emotional deprivation: all came from broken homes; four had been separated for long periods from their mothers; two had been subjected to incestuous abuse; and four had been cared for by white women. Response to treatment was poor. The ratio of non-white referral to white was at most one tenth of the ratio of non-white to white women in the catchment area.

A rare opportunity to study deprivation and criminality across generations arose from the follow-up of the families who participated in the Newcastle Thousand Family Survey. The data on these families had been preserved and it was possible, using criminal records, to examine longitudinally whether children who grew up in ‘deprived’ rather than ‘non-deprived’ families were more at risk of offending during later childhood and beyond. The results of this study suggest that this is indeed so.

Among the mentally ill, those with well-developed delusions are more likely to commit violent crimes against persons than those with chronic, undifferentiated psychoses. Reports of violence associated with delusional misidentification are reviewed and four patients described who were either perpetrators or victims of assaults as a consequence of the syndromes of Frégoli, lntermetamorphosis, Subjective Doubles and Capgras. The cases illustrate the multiplicity of factors which have to be taken into consideration in order to predict whether an individual will act in a violent manner on these delusions.

This paper reports on goal-oriented group treatment for adolescent girls who have been sexually abused within the family. The treatment approach on which the therapeutic work was based and the treatment programme are described briefly. The group treatment was seen as part of a family approach to child sexual abuse in the family. The membership and structure of the group and the aims of treatment are described. Some characteristics of the specific group processes are detailed and illustrated by clinical examples. Clinical results on outcome and results from an independent follow-up study are described, and some relevant clinical issues are discussed.

Among 115 women referred to a regional psychotherapy unit, childhood sexual abuse was reported at the referral or assessment stage by 19, and referred to covertly by 5. A significant number of cases must remain undetected. For the purpose of this study, sexual abuse includes any form of sexual activity between a female child and a familiar adult or young person older than her, which was perceived by the subject to be of a sexual nature and distressing to her. The symptoms in adulthood have been described as similar to those of Borderline Personality Disorder. Development, treatment and implications are discussed.

A group of 30 black African patients and a group of 30 occidental patients, all presenting a hysterical structure, were compared with regard to clinical manifestations, provoking psychosocial stressors and histrionic personality traits. Cultural characteristics in several areas are discussed as possible explanations of the differences found.

The onset of post-traumatic stress disorders in a group of firefighters who had an intense exposure to a bushfire disaster was investigated using a longitudinal research design. Contrary to expectation, the intensity of exposure, the perceived threat, and the losses sustained in the disaster, when considered independently, were not predictors of post traumatic stress disorder. By contrast, introversion, neuroticism, and a past history and family history of psychiatric disorder were premorbid factors significantly associated with the development of chronic post-traumatic stress disorders.

Urinary output of homovanillic acid and 4-hydroxy-3-methoxymandelic acid was decreased both in patients with panic attacks and in normal controls during lactate infusion, whereas that of tribulin (an endogenous monoamine oxidase inhibitor and benzodiazepine receptor binding inhibitor) was increased. There was no change in urinary excretion of any of these compounds during saline infusion. These findings provide further evidence of a link between tribulin output and stress and anxiety in man and point to its possible in vivo action as a monoamine oxidase inhibitor.