Tricyclic (TCA) and monoamine oxidase inhibitor (MAOI) antidepressants are effective in the treatment of panic disorder. Two selective serotonin reuptake inhibitors (SSRIs) have also been licensed in the UK for this indication and studies with three other SSRIs have recently been completed. These provide further evidence for the role of serotonin in panic.

Review of clinical, animal and laboratory studies.

SSRIs have been shown to be effective in the treatment of panic disorder. The reported rates of improvement of 60–70% of patients taking SSRIs are similar to those seen withTCAs and greater than placebo. Other serotonergic agents do not appear to be effective. Animal work and human studies including measures of 5-HT in plasma, cerebrospinal fluid and platelets, challenge paradigms and tryptophan depletion show that the relationship between 5-HT and anxiety is complex.

Clinical trials have shown that of all the serotonergic agents only the SSRIs are effective in panic disorder. They are as beneficial as the TCAs and seem to be better tolerated which may be particularly significant in view of the chronic nature of the condition. Serotonin plays a role in panic disorder and serotonergic dysfunction, however the results and evidence do not fit one theory alone. It is also likely that different brain regions and 5-HTreceptors are involved in specific ways.

The aim was to measure the criminal convictions received by people who leave special hospital and to test previously identified correlates of conviction.

A cohort study design was used and the subjects were all 425 patients discharged from the special hospitals in 1982 and 1983. The outcome measure was a criminal conviction received within 10.5 years of discharge.

Five and a half years after discharge 26% of ex-patients had been convicted of any offence, 9% of a violent offence, 5% of a sex offence and 10% of any serious offence. Ten and a half years after discharge 34% of patients had been convicted of any offence, 15% of a violent offence, 7.5% of a sex offence and 15% of any serious offence. When other variables are controlled for, gender and destination on discharge do not predict conviction. Age, a legal category of psychopathic disorder and prior criminal record do predict, but the effect is small.

The rate of conviction of patients leaving special hospital has fallen over the past 20 years; this is the case for crime in general and for serious crimes in particular. The change in rates of conviction over time for patients of different legal categories, previously thought to be different, is the same. The low predictive power of the variables examined here suggests that actuarial methods are of limited value in predicting offending in this group.

A relationship exists between mental disorder and offending behaviours but the nature and extent of the association remains in doubt.

Those convicted in the higher courts of Victoria between 1993 and 1995 had their pyschiatric history explored by case linkage to a register listing virtually all contacts with the public psychiatric services.

Prior psychiatric contact was found in 25% of offenders, but the personality disorder and substance misuse accounted for much of this relationship. Schizophrenia and affective disorders were also over-represented, particularly those with coexisting substance misuse.

The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse. The risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion.

The Joint Working Group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners (1996) recommended graded exercise and antidepressants for patients with chronic fatigue syndrome. We assessed efficacy and acceptability of these treatments.

Six-month prospective randomised placebo and therapist contact time controlled trial with allocation to one of four treatment cells: exercise and 20 mg fluoxetine, exercise and placebo drug, appointments only and 20 mg fluoxetine, appointments and placebo drug. Drug treatment was double blind and patients were blind to assignment to exercise or appointments.

Ninety-six (71%) of 136 patients completed the trial. Patients were more likely to drop out of exercise than non-exercise treatment (P=0.05). In an intention to treat analysis, exercise resulted in fewer patients with case level fatigue than appointments only at 26 weeks (12 (18%) v. 4 (6%) respectively P=0.025) and improvement in functional work capacity at 12(P=0.005) and 26 weeks (P=0.03). Fluoxetine had a significant effect on depression at week 12 only (P=0.04). Exercise significantly improved health perception (P=0.012) and fatigue (P=0.028) at 28 weeks.

Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only.

The reported prevalence rates of dementia in people with Down's syndrome have varied considerably across studies. The aim of this study was to investigate the extent of clinical change with age using an established diagnostic instrument in an unbiased, population-based sample of older people with Down's syndrome.

Changes in memory, personality, general mental functioning and daily living skills were assessed using a modified version of the informant interview of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX).

Age-specific prevalence rates of dementia varied according to the diagnostic criteria used. Using CAMDEX criteria for Alzheimer's disease, prevalence rates increased from 3.4 to 10.3 to 40% in the 30–39, 40–49 and 50–59 age group, respectively.

Overall, the age-related pattern of presentation and dementia diagnoses differs from that seen in the general elderly population. However, age-specific prevalence rates of Alzheimer's disease were similar but 30–40 years earlier in life.

Three studies compared olanzapine and haloperidol given orally in maintenance therapy for schizophrenia and related psychoses.

Data were from double-blind extensions of acute studies. The subjects met criteria for schizophrenia, schizophreniform disorder or schizoaffective disorder. Subjects had responded to acute therapy (Brief Psychiatric Rating Scale total score decreased $ 40% from baseline (Studies 1, 2, and 3) or was $ 18 (Studies I and 2)) and were out-patients at their last acute phase visit. Relapse was defined as hospitalisation for psychopathology. Subjects treated with olanzapine in the three studies were pooled to form the olanzapine group and subjects treated with haloperidol were pooled to form the haloperidol group.

Olanzapine-treated subjects experienced less relapse (P=0.034). The Kaplan-Meier estimated one-year risk of relapse was 19.7% with olanzapine and 28% with haloperidol.

Olanzapine was superior to haloperidol in the maintenance therapy of schizophrenia and related psychoses.

The Daily Living Programme (DLP) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital, London. The cost-effectiveness of the DLP was examined over four years.

A randomised controlled study examined cost-effectiveness of DLP versus standard in/out-patient hospital care over 20 months, followed by a randomised controlled withdrawal of half the DLP patients into standard care. Three patient groups were compared over 45 months: DLP throughout the period, DLP for 20 months followed by standard care, and standard care throughout. Bivariate and multivariate analyses were conducted (the latter to standardise for possible inter-sample differences stemming from sample attrition and to explore sources of within-sample variation).

The DLP was more cost-effective than control care over months 1–20, and also over the full 45-month period, but the difference between groups may have disappeared by the end of month 45.

The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care, although sample attrition left some comparisons under-powered.

In recent years there has been a shift to ‘community care’ and the introduction of several ‘atypical’ antipsychotic drugs. We report the impact of these changes.

In Nithsdale, Dumfries and Galloway, Scotland, the population of patients with schizophrenia was identified in 1996. This census replicated a study carried out in 1981. The population with schizophrenia were compared on clinical and social variables. The whereabouts in 1996 of the 1981 population was determined.

In comparison with the 1981 population, more patients in 1996 had positive, negative and non-schizophrenic symptoms. More showed tardive dyskinesia. Social adjustment had not changed. They had spent less time in hospital; fewer (13%) were living with their parents; and fewer (8%) were employed. By 1996, 35% of the 1981 cohort had died (standardised mortality rate male – 154, female – 162).

The mental health of a community of people with schizophrenia living in a rural area in 1996 was poorer than in 1981.

Since people with chromosome 22q11 deletion (CATCH 22 syndrome) have unexpectedly high incidence of major psychosis it has been suggested that 22q area might be involved in the pathogenesis of schizophrenia and bipolar disorders.

A single case report.

A 32-year-old male patient with CATCH 22 syndrome and schizophrenia had extensive midline anomalies of the brain in the regions relevant to psychotic disorders.

22q11-dependent abnormalities in the midline structures of the brain may cause dysfunction in the limbic system and interfere with the interhemispheric information exchange thus predisposing people with CATCH 22 syndrome to psychotic disorders.

Previous studies have suggested that the risk for psychosis, especially affective psychosis, is highly increased during the first 30 days after delivery. The aim of our study was to replicate these findings.

LinkingThe Danish Medical Birth Register and The Danish Psychiatric Central Register from 1 January 1973 to 31 December 1993 revealed 1253 admissions diagnosed as psychosis within 91 days after delivery. The admission rate after delivery was compared with the admission rate among non-puerperal women in the general Danish female population.

The relative risk of all admissions was only slightly increased, RR=I.09 (95% C11.03–1.16). The admission rate concerning first admissions was highly increased, RR=3.21 (95% CI 2.96–3.49) whereas the admission rate concerning readmissions was reduced, RR=0.66 (95% CI 0.61–0.72).

Childbirth is a strong risk factor for first admission with psychosis, but the risk may be less increased than previously assumed.

The aetiology of treatment-resistant major depression is little understood; its apparent intractability may reflect brain abnormality.

Magnetic resonance images of the brains of 20 subjects with major depression lasting for two years or more were compared with 20 healthy control subjects and 20 other subjects who had completely recovered from depression. Subjects were individually matched for age, gender, years of education and premorbid IQ. Grey matter was segmented from the images, and compared between groups on a voxel-by-voxel basis.

Subjects with chronic depression showed reduced grey matter density in the left temporal cortex including the hippocampus. There was also a trend for reduction in the right hippocampus. Left hippocampal grey matter density was correlated with measures of verbal memory, supporting the functional significance of the observed magnetic resonance imaging changes.

Our results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity. Confirmatory longitudinal and prospective studies are required to determine whether these differences pre-date the onset of depression or are the result of the chronic illness process or its treatment.

This study examined the association of common mental disorders in primary health clinic attenders with indicators of poverty and disability in Goa, India.

Adult attenders (n=303) in two primary health clinics were recruited.

There were 141 (46.5%) cases of common mental disorder. The following were associated with common mental disorder: female gender; inability to buy food due to lack of money; and being in debt. Cases scored significantly higher on all measures of disability. Primary health clinic staff recognised a third of the morbidity but used multiple oral drugs, injectable vitamins and benzodiazepines to treat common mental disorders.

Poverty is closely associated with common mental disorder which in turn is associated with deprivation and despair. Primary mental health care priorities in low-income countries need to shift from psychotic disorders which often need specialist care to common mental disorders. Health policy and development agencies need to acknowledge the intimate association of female gender and poverty with these disorders.

We have previously reported that people who are cocaine-dependent have reduced blue cone b-wave electroretinogram (ERG) responses. In this preliminary study, we examined the relationship between blue cone ERG amplitudes and craving response to cocaine cues.

A new series of 14 recently withdrawn subjects who were cocaine-dependent completed a cocaine craving questionnaire at baseline, and again following exposure to laboratory cues; an ERG was also performed.

Cocaine-dependent subjects with a blunted ERG blue cone response (<0.5 μV) showed significantly greater increases in craving following cue-exposure than subjects without the blunted ERG blue cone response.

Subjects with a blunted ERG response may represent a subgroup more vulnerable to cocaine craving and relapse.