Recent research from North America has demonstrated higher than expected rates of drug and alcohol abuse among the seriously mentally ill. Schizophrenics appear to be particularly susceptible to the negative effects of substance abuse. These include psychiatric and social complications, with antisocial behaviour, particularly violence emerging as one of the most worrying features. This review examines the strength of the association and explores the possible explanations for the apparent link between schizophrenia, substance abuse and violence.

The literature was searched using Medline, supplemented with a manual literature search.

Very few articles specifically approached the problem of violence among substance abusing schizophrenics, but over 80 papers were identified which were helpful in exploring the link between dangerous behaviour and substance abuse by schizophrenics.

While there is circumstantial evidence to support the hypothesis that schizophrenics who abuse drugs or alcohol are at an increased risk of behaving violently, longitudinal studies are required to facilitate a better understanding of the mediating mechanisms.

This investigation sought to determine the prevalences of various psychopathologies in outstandingly creative individuals, and to test a hypothesis that the high prevalence of mental abnormalities reported in prominent living creative persons would not be found in those who had achieved and retained world status.

The family background, physical health, personality, psychosexuality and mental health of 291 famous men in science, thought, politics, and art were investigated. The membership of the six series of scientists and inventors, thinkers and scholars, statesmen and national leaders, painters and sculptors, composers, and of novelists and playwrights was determined by the availability of sufficiently adequate biographies. Extracted data were transformed into diagnoses in accordance with DSM–III–R criteria, when appropriate.

All excelled not only by virtue of their abilities and originality, but also of their drive, perseverance, industry, and meticulousness. With a few exceptions, these men were emotionally warm, with a gift for friendship and sociability. Most had unusual personality characteristics and, in addition, minor ‘neurotic’ abnormalities were probably more common than in the general population. Severe personality deviations were unduly frequent only in the case of visual artists and writers. Functional psychoses were probably less frequent than psychiatric epidemiology would suggest, and they were entirely restricted to the affective varieties. Among other functional disorders, only depressive conditions, alcoholism, and, less reliably, psychosexual problems were more prevalent than expected in some professional categories, but strikingly so in writers.

Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.

The association was examined between reporting child sexual abuse (CSA) and a range of social, interpersonal and sexual difficulties in adult life.

A random sample of 2250 women were posted a questionnaire exploring a range of abuse experiences. All 248 reporting CSA were invited for interview, together with an equal number of controls. At interview a detailed inquiry was made into the CSA and into current interpersonal, social and sexual function.

Significant associations emerged between reporting CSA and a decline in socioeconomic status, increased sexual problems, and the disruption of intimate relationships by difficulties with trust as well as a propensity to perceive their partners as uncaring and overcontrolling. CSA was more common in those from disturbed and disrupted families and in those who also reported physical and emotional abuse. This explained part, but not all, of the apparent association between CSA and negative outcomes.

Those reporting CSA are more likely to suffer social, interpersonal and sexual difficulties in adult life.

The validity of excluding bereavement-related depressive episodes which satisfy all the criteria of major depression is examined in this community study.

A total of 658 subjects were interviewed in their homes using the Diagnostic Interview Schedule. The length of the episodes of depression, the dysfunction they caused, and the frequency of seeking and receiving treatment were assessed.

The risk of recurrence did not differ whether the depressive episodes that satisfy the DSM–III–R criteria of major depression were or were not related to bereavement.

Excluding from the repertoire of depressions all those related to external stressors might need more research, but singling out those related to bereavement does not seem to be supported by our community-based data.

The prevalence of psychotic phenomena in confirmed Alzheimer's disease (AD) and their potential neuropathological correlates have rarely been the subject of prospective investigation.

Psychopathological disturbances were recorded prospectively according to the Geriatric Mental State Schedule and the CAMDEX. The frequency of these phenomena and neuropathological changes were examined in 56 patients with definite AD.

Hallucinations had been documented in 13 patients, paranoid delusions in 9 and delusional misidentification (e.g. the Capgras-type and the ‘phantom boarder’ symptoms) in 14 patients. Misidentifications were associated with lower neurone counts in the area CA1 of the hippocampus. Delusions and hallucinations were observed in patients with less severe cell loss in the parahippocampal gyrus and with lower cell counts in the dorsal raphe nucleus. A decrease of neurones in the locus coeruleus in a subset of depressed patients with AD had been reported earlier. Delusions and delusional misidentification were common in 5 patients with basal ganglia mineralisation, but there was no statistically significant association of these symptoms with the presence of Lewy bodies in the brainstem and neocortex of our patient sample.

These findings are compatible with the view that morphological changes in certain brain areas may promote the development of psychotic phenomena in AD. AD may offer a model for the understanding of pathomechanisms underlying the development of psychopathological disturbances in other psychoses with more discrete neuropathological changes.

The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity.

We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale.

After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf.

These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.

From both a clinical and an aetiological perspective, major depression (MD) is probably a heterogeneous condition. We attempt to relate these two domains.

We examined which of an extensive series of clinical characteristics in 646 female twins from a population-based register with a lifetime diagnosis of MD predicts the risk for MD in co-twins. MD was defined by DSM–III–R criteria.

Four variables uniquely predicted an increased risk for MD in the co-twin: number of episodes, degree of impairment and co-morbidity with panic disorder or bulimia. One variable uniquely predicted decreased risk: co-morbidity with phobia. Variables that did not uniquely predict risk of MD in the co-twin included age at onset, number and kind of depressive symptoms, treatment seeking, duration of the longest episode and co-morbidity with generalised anxiety disorder and alcohol dependence.

Our results suggest that the clinical features of MD can be meaningfully related to the familial vulnerability to illness, particularly with respect to recurrence, impairment and patterns of co-morbidity.

Attempted suicide rates are much higher in the UK than in the Netherlands. We have compared the characteristics of suicide attempters referred to general hospitals in Oxford and Utrecht.

We compared the characteristics of referrals for attempted suicide to a general hospital in Oxford and one in Utrecht, for the years 1988 and 1989.

Most of the attempters in Oxford were young whereas attempters in Utrecht were older; this age difference was particularly marked in females. Utrecht attempters appeared more often to have socio-economic problems and to suffer from psychiatric and personality disorders (except substance abuse), even when account was taken of the age differences of the two populations.

There is some evidence for different thresholds for attempted suicide in the UK and the Netherlands, although other social explanations for the difference in attempted suicide rates are feasible and require further study.

The widespread use of benzodiazepines has led to increasing recognition of their unwanted effects. The efficacy of alprazolam and placebo in panic disorder with agoraphobia, and the side-effect and adverse effect profiles of both drug groups were measured.

In London and Toronto 154 patients who met DSM–III criteria for panic disorder with agoraphobia were randomised to alprazolam or placebo. Subjects in each drug group also received either exposure or relaxation. Treatment was from weeks 0 to 8 and was then tapered from weeks 8 to 16.

Mean alprazolam dose was 5 mg daily. Compared with placebo subjects, alprazolam patients developed more adverse reactions (21 % v. 0%) of depression, enuresis, disinhibition and aggression; and more side-effects, particularly sedation, irritability, impaired memory, weight loss and ataxia. Side-effects tended to diminish during treatment but remained significant at week 8. Despite this, the drop-out rate was low.

Alprazolam caused side-effects and adverse effects during treatment but many patients were willing to accept these.

The Ward Daily Behaviour Scale is a new rating instrument that can be used to measure all the daily noteworthy behaviour of patients of various ages and diagnoses on psychiatric wards.

The reliability and validity of the scale were tested on 40 patients.

This instrument proved to be both reliable and valid for use on adult acute in-patient wards.

The scale will be a valuable tool in a wide range of ward-based studies.

We investigated whether a new non-benzodiazepine anti-anxiety drug, alpidem, produces weaker withdrawal symptoms than alprazolam.

Under a double-blind procedure, 122 patients suffering from general anxiety disorders were randomly allocated to either alpidem (50 mg, three times a day) or alprazolam (0.5 mg, three times a day) for six weeks, followed by a two-week placebo withdrawal phase. The diagnosis of withdrawal syndrome (WS) was made, in blind conditions, on the basis of the Withdrawal Symptom Check List (WSCL), after one or two weeks of discontinuation of active treatment.

The WS occurred significantly less frequently in the alpidem group (n = 10, 18%) than in the alprazolam group (n = 26, 48%). Typical withdrawal symptoms on the WSCL were also significantly less severe (P = 0.044) in the alpidem group compared with the alprazolam group.

Alpidem may be a valid alternative to current benzodiazepine anxiolytic therapy because it produces fewer and weaker withdrawal symptoms than alprazolam and is better tolerated.

We wished to explore the sociodemographic and clinical characteristics associated with admission to hospital in patients with a non-organic non-affective psychosis.

Subjects were 484 first-contact patients with a non-affective functional psychosis from an inner-city catchment area over 20 years from the mid-1960s. Sociodemographic and clinical characteristics associated with admission to hospital were analysed.

Around 20% of patients were not admitted, and the proportion did not change significantly over the years. Ethnicity, sex, and marital and employment status did not predict admission. Factors associated with admission included police involvement, and violence to self or others. A diagnosis of schizoaffective disorder, and persecutory delusions, auditory hallucinations, and bizarre behaviour were all more common in patients admitted to hospital.

The study indicates biases which might arise in research based exclusively on patients admitted to hospital.

The study aimed to identify, classify and measure the relative frequency of events preceding violent incidents in psychiatric hospitals.

Possible antecedents for 1000 incidents in three associated psychiatric hospitals over 13 months were investigated with an ‘untoward incident database’.

From eyewitness accounts, 921 incidents (92%) could be related to one of 15 categories of antecedent involving characteristics of the patient, or of the hospital regime, or interactions with other individuals. Overall, the most common antecedents involved patients who were generally agitated or disturbed (286), restrictions on patients associated with the routine hospital regime (192) or provocation by other patients, relatives or visitors (175). Incidents arising from staff members initiating contact with patients were very rare (7). Twenty-one patients were involved in 10 or more incidents, including 19 (90%) who were detained under the Mental Health Act. These patients were more likely to commit assaults after certain antecedents (self-harm, absconding or arson) which were serious incidents in themselves.

Staff training on specific safety issues will be needed under the new Management of Health and Safety at Work Regulations.

We compared three doses of a neuroleptic as a treatment for mania.

Forty-seven newly admitted in-patients with mania were randomised to receive 10, 30, or 80 mg a day of oral haloperidol, under double-blind conditions for up to six weeks. All subjects received prophylactic benztropine.

Repeated-measures analysis of variance and survival analysis showed no difference in outcome by the different doses. Excluding drop-outs (38%), most of whom left the study during the first two weeks, 72% of the subjects responded. Side-effects were minimal; there were no differences among the three doses. Non-responders received more adjunctive lorazepam than responders.

The limited data suggest that more than 10 mg a day of haloperidol offers no advantage in mania.