Since the pioneering study of psychiatric morbidity in primary care by Shepherd et al in 1966, it has become increasingly apparent that a substantial proportion (between 20% and 25%) of patients consulting their GP are suffering from some form of psychiatric disturbance (Goldberg & Blackwell, 1970; Hoeper et al, 1979). The composition of this psychiatric morbidity has been shown to be almost wholly affective in nature and largely mild in degree. In their important review Jenkins & Shepherd (1983) recently summarised the now extensive findings relating to overall minor psychiatric morbidity in primary care. However, recent collaborative studies between psychiatrists and GPs have identified that within this dilute pool of minor disorders, lurks a significant but poorly served population of patients suffering from depressive disorders which are by no means minor in degree. A number of crucial issues regarding this depression in primary care emerge which the present paper aims to review. In particular, how common is it, and how severe? How does it present and what, if any, are its special characteristics? What is the precise relationship between depressive symptoms and depressive illness presenting to the GP and what is the relationship between physical illness and depression? And finally, what is the course and outcome of depression in this setting and what are the indications for and effect of treatment?

Because of its rarity, the neuroleptic malignant syndrome has been studied in a survey of the world literature. Similar conditions which occurred before the advent of neuroleptics have also been included, as they may indicate that the drugs are not totally to blame. It is also apparent that with modern treatments, the condition is not usually lethal. The implications of this for theories of dopaminergic disturbances underlying the mental illnesses involved are considered. An overall picture of the syndrome, its treatment and outcome, is presented from over 200 published references. The spread of recognition of the condition throughout the world and especially across linguistic barriers has been followed.

In a prospective study, 100 cancer patients and their relatives were separately interviewed using a structured interview to examine whether the diagnosis of cancer should be communicated to patients and relatives; the reasons for doing so or not, the emotional reactions of patients and families; any change in the attitude of relatives; behaviour of patients and patient's expectation, on diagnosis, of the course of their illness. The majority of patients, who knew their diagnosis (71 %), wanted to be told the truth. The majority of relatives wanted to know the truth themselves (81 %) without the patients being told (77%). Patients did show immediate emotional reactions like anxiety and dejection, however they appeared to accept the diagnosis. Findings suggest that in an Indian setting the attitude of family members is more positive. The role played by sociocultural factors in the acceptance of the truth is discussed.

The characteristics of West Indian patients admitted to a Birmingham hospital following deliberate self-poisoning were compared with those of White self-poisoners. West Indian patients were more likely to be young, female and single. They were less likely to have previously self-poisoned, have received previous psychiatric treatment, or be suffering from a personality disorder or alcoholism, but were more often followed-up by a social worker. Rates of self-poisoning for those aged under 25 were similar but for those aged over 25 were lower for West Indians than Whites.

The phenomenology of solvent inhalation was investigated comparing a group of young people who misused toluene (n = 31) with a group misusing butane (n=12). Marked changes of mental state were invariable. Most users reported elevation of mood and hallucinations but a rich variety of phenomena was elicited. Nearly one-quarter of subjects had the potentially dangerous delusion of believing they were able to fly or swim. In the toluene group thoughts were more likely to be slowed, time appeared to pass more quickly and tactile hallucinations were more commonly reported than in the butane group. Withdrawal phenomena and tolerance were also looked at.

The patterns of use and related harm of solvent inhalation were investigated in a group of young people who misused toluene (n = 31) and a group misusing butane (n= 12). The two groups were similar in terms of patterns of use and solvent related harm. The toluene users were more likely to sniff only in a group setting, probably because of the long duration of intoxication. The toluene group were more approving in their attitudes towards taking other drugs.

This study examines the impact of pregnancy on the reported eating behaviour of 20 untreated normal body weight bulimia nervosa women; it also reports foetal and obstetric abnormalities and indicates the initial eating habits of the infants. The prevalence of binge-eating and self-induced vomiting reduced sequentially during each trimester of pregnancy. By the third trimester 15 women (75%) had stopped all bulimic behaviour and in the remainder the disturbed eating was less severe. Symptoms tended to return in the Puerperium and in nearly half the sample abnormal eating was more disturbed after delivery than before conception. However, the improvement associated with the pregnancy described by seven patients was maintained and for five it appears to have been curative. The common fear among pregnant bulimics that their abnormal eating behaviour may damage their unborn child cannot be dispelled by this study; the incidence of foetal abnormality (including cleft palate and cleft lip), multiple pregnancies and obstetric complications (including breech presentation and surgical intervention) was high. The nutrition and development of the infants was good although three mothers (15%) reported slimming their babies down within the first year.

The development of a 10-item self-report scale (EPDS) to screen for Postnatal Depression in the community is described. After extensive pilot interviews a validation study was carried out on 84 mothers using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardised Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specficity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring. The use of the EPDS in the secondary prevention of Postnatal Depression is discussed.

We followed up 30 recovered depressives for an average of 2 years. At 18 months, despite prophylactic medication, 30% had relapsed. Persistent DST suppression during the index illness was found to be a predictor of good prognosis.

The pathophysiology of hypercortisolaemia in major depression was examined. ACTH was measured using a novel immunoradiometric assay of high specificity and sensitivity. Twenty-eight patients with major depression and 18 control subjects were studied. Blood samples for basal hormone concentration were taken at 09:00, 16:00 and 23:00 on day 1, followed by administration of 1 mg dexamethasone at 23:00. Further samples were taken at 09:00 and 16:00 on day 2. Dexamethasone concentration was measured in day 2 samples and no significant difference was found between the depressed group and control subjects. In the depressed group Cortisol concentration was elevated at 23:00 on day 1, and ACTH concentrations were elevated in post-dexamethasone samples. ACTH and Cortisol concentrations were not directly correlated in individual patients. The elevated plasma Cortisol associated with major depression is not solely mediated by changes in ACTH.

Cross-cultural investigation in psychiatry is revealing the need for standardised instruments in diagnosing and assessing depression. Recently, a new instrument was developed to evaluate depressed patients, namely the Montgomery-åsberg Depression Rating Scale (MADRS). The present study introduced the MADRS in Brazil, comparing it to the Hamilton Depression Rating Scale, the Visual Analogue Mood Scale (a self-rating scale), and with the global clinical assessment of independent Brazilian psychiatrists. The results show correlation between MADRS and the three other assessments, indicating that it is a useful and operational instrument to evaluate depressed patients. They also support the application of the MADRS in cross-cultural studies of depression in Brazil and other countries. These results are critically discussed.

Using four brief assessment scales, profiles of mental health and psychological well-being were obtained from 507 old (aged 65–74 years) and 535 very old (aged 75 +) individuals randomly sampled from the community. Assessments of dementia and depression were subsequently validated against diagnostic ratings made by experienced psycho-geriatricians. Levels of agreement between psychometric and clinical ratings of dementia x = 0.83) and depression (x = 0.66) were satisfactory. The old and very old groups reported similar levels of anxiety and personal disturbance, and showed a similar prevalence of depression. However, those aged 75+ showed higher levels of dementia and significantly lower levels of social involvement and morale.

We followed up 181 elderly living at home over 2 years. The changes shown on a brief dementia rating scale (the Abbreviated Mental Test Score (AMTS)) were monitored. At follow-up, subjects were classified as organic or non-organic by three potential screening tools-a screening questionnaire (the Psychogeriatric Assessment Schedule), a psychometric test (the Inglis' Paired Associate Learning Test) and a dementia scale (the AMTS). The value of these as screening tools for community samples was considered as a function of their sensitivity to cognitive decline. The classifications made by each were significantly related to previous cognitive change, but all were conservative, missing many subjects who had declined. Of the three, the AMTS appeared the most useful as a predictor of previous change on the AMTS. It remains to be seen whether it is equally useful with different samples and with different measures of outcome.

A sample of 1070 elderly persons aged over 65 living in the Liverpool community was interviewed using the community version of the Geriatric Mental State (GMS) and the findings processed to provide a computerised diagnosis by AGECAT. Levels of organic disorder, probably dementia, reached 5.2%, intermediate between those of London and New York derived from previous studies. Levels for depressive illness overall were below those of other studies at 11.3% while levels for neurotic disorder were much the same at 2.4%. The rise in the prevalence of dementia with age was further confirmed. The GMS AGECAT Package provides a method for standardising both the collection of data and the diagnostic process for comparative epidemiological studies and other research.

When the length of stay of restricted patients admitted to Broadmoor under the legal category of psychopathic disorder was examined, the factor found to be of primary importance was the gravity of the admission offence. If the men's offences did not cause personal injury, they had a good chance of early release. Patients convicted of violent or sexual offences, and particularly those who attacked strangers, made up the great majority of the long-term group. For the mentally ill there was no relationship between length of stay and admission offence: instead the data suggested that severity and chronicity of illness were the main relevant factors.

Goodchild & Duncan-Jones (1985) have proposed a new scoring method for Goldberg's General Health Questionnaire (GHQ) in which increased weight is given to item responses considered to indicate current (but chronic) affective disorders. This report examines both their revised and the conventional scoring of the GHQ in the context of a longitudinal general population study of psychiatric disorder among women. Sensitivity estimates based upon advised cut-points were found to be higher for the revised than for the conventional scoring scheme, and this difference remained when allowance was made for the duration for which disorders had been present prior to assessment with the GHQ. However, Relative Operating Characteristic (ROC) analysis revealed that while both forms of scoring the GHQ discriminated affective conditions (with or without allowance for their duration) there was no significant difference in their ability to do so. The justification therefore for the post-hoc interpretation of certain item responses as indicators of enduring affective states remains controversial and an issue for future research.

The case notes of all non-psychogeriatric patients attending the Psychiatric Day Hospital at the University Hospital of South Manchester during one week in October 1982 were reviewed. Clinical, demographic, social and occupational data were gathered for all patients, and their attendance at the day hospital monitored for the year following the census period. No significant differences between patients could be found on any of the factors that it was predicted would distinguish short from long-stay patients. The best predictor of length of day hospital attendance in the current admission was the total quantity of previous hospital treatment whether as an in-patient or a day-patient. It is concluded that in the day hospital studied all patients had similar characteristics, and the majority could be seen as ‘new long-stay’ patients. The implications of this finding are discussed.

Secondary mania has been described in association with a variety of physical conditions. While there have been a number of reports of mania occurring in individuals with intracranial cerebral lesions, there have been few reporting its occurrence in association with non-penetrating cerebral trauma. Two further cases of mania following non-penetrating head injury and the efficacy of ECT in its management are reported, and a brief review of the literature relating to the subject is given.

Twenty non-alcoholic patients with DSM-III defined simple phobias for small animals received behavioural approach tests and exposure therapy while under the influence of a moderately intoxicating dose of ethanol or after placebo administration. Ethanol did not demonstrate any acute anti-anxiety effect, but retarded the rate of behavioural in vivo desensitisation, without changing the final treatment outcome. State-dependent effects of ethanol on anxiety were not demonstrated. This study supports prior research indicating no anti-anxiety or ‘tension-reducing’ effects of ethanol for simple phobias.

Skin conductance level (SCL) and skin conductance responses (SCR) to a random series of tones were measured in 25 drug-free schizophrenic patients, 15 male and 10 female, before and after standard chlorpromazine treatment. The DSM-III diagnostic criteria were used for selecting subjects. Psychopathology was measured with the Brief Psychiatric Rating Scale. After treatment, patients showed an improved psychopathology and decreased SCL. There was a transition of patients to lower response categories: the number of responders decreased twice and the number of non-responders increased three times. Responders exhibited significantly higher SCL than non-responders and fast habituators were between the two groups.