A category of suicide which only accounts for about 5% of the annual suicidal deaths in the country may at first seem unimportant. Suicide is seen around the world in different races and cultures, so it is a fact of human nature. However, the suicide of an in-patient is uncommon, and produces great guilt in doctors and nurses when it happens. The result is often a defensive fatalism. However, if we do not allow feeling to block thought and observation, it is possible to learn from each of these deaths something about human beings which we can use in the practice of psychiatry.

“Do we have a problem?” said the chief nursing officer. He had a list of 16 Exe Vale in-patients who had committed suicide in a period of 30 months. We looked at the list and then looked for something to compare it with in other hospitals; and that was where the trouble began. Such data as were available had been collected in diverse ways and often in the wake of special difficulties, e.g. the Warlingham Park Hospital enquiry (Croydon Area Health Authority, 1974/75). Comparisons were unrewarding, so we looked at our own 16 cases for indications of local problems. We also extended the study to the ten-year period 1972–81, during which there were 40 in-patient suicides. Since then more deaths have occurred—two in 1982 and four in 1983. These are referred to here only where special features warrant mention. Local monitoring of deaths continues; and certain deaths are notified to the Hospital Deaths Study of the Royal College of Psychiatrists.

Assessment of suicide risk is an important and complex issue. We know that a considerable proportion of those who kill themselves seek help before they do so (Robins et al, 1959; Barraclough et al, 1974), and it is therefore essential both to recognise indices of suicide risk and to react appropriately to them. This means being sensitive to many personal, social and environmental factors, rendered more problematic by the fact that each individual is uniquely responsive to life events. The traditional approach, based on clinical epidemiological considerations, has long identified such factors as depression, alcoholism, increasing age, social isolation, physical illness and significant loss as important correlates of suicide, but there is now increasing evidence of other important factors which are frequently associated with suicide. Patients who commit suicide exhibit a wide range of behavioural problems which may hamper recognition of underlying suicide risk (Seager & Flood, 1965); and young adults with a history of chronic social turmoil are highly represented amongst suicides (Ovenstone & Kreitman 1974).

When a psychiatric in-patient commits suicide by jumping out of the hospital building, the death is liable to attract Press attention and become public knowledge. In 1981, the psychiatric unit situated on the fifth floor of the Queen Elizabeth Hospital in Birmingham (UK) was closed by the Chairman of the District Health Authority on the advice of the coroner. This was a direct result of several in-patients committing suicide by jumping.

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.

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.

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.

Late paraphrenia is the form of expression of schizophrenia in old age. Twenty five patients diagnosed as suffering from the condition were studied, and their symptoms compared with the diagnostic criteria for schizophrenia of Spitzer et al (1975), the Catego system (Wing et al, 1974), Carpenter et al (1973a) and Langfeldt (1960). The study confirms late paraphrenia as one of the schizophrenias, and discusses differences with previous studies.

Power spectral analysis was performed on the visual evoked potentials (VEPs) recorded in response to flashes of different intensity in both unmedicated schizophrenic and normal subjects. At occipital locations (01, 02), schizophrenics showed less power than normals in the 10–14 Hz frequency range. In the 18–22 Hz range, schizophrenics showed under-activation in the left hemisphere and over-activation in the right. At temporal locations (T3, T4), schizophrenics showed abnormal (left greater than right) hemisphere patterns of activation in 10–14 Hz and 18–22 Hz ranges. There were no group differences in relationships between power and intensity changes at vertex (Cz). The results suggest abnormal cortical-subcortical interactions during analysis of visual information in schizophrenia.

Of 603 patients receiving in-patient or day-patient psychiatric care, one-sixth were taking no psychotropic drugs, but nearly 50% of those receiving medication had a combination of two or more such drugs. Hypnotics and minor tranquillisers were frequently prescribed together with neuroleptics and antidepressants. One-third of all patients receiving neuroleptics received a combination of oral and depot preparations, while half of all patients on neuroleptics were prescribed anti-parkinsonian drugs. One-fifth of patients treated with neuroleptics had a diagnosis other than schizophrenia, and one-third of patients treated with antidepressants had a diagnosis other than affective disorder. A comparison of our findings with those from Oxford show some significant differences, particularly in the use of depot, oral, of combined neuroleptic drugs. An analysis of prescribing could be a useful part of self-audit for hospitals.

The authors investigated the dexamethasone suppression test (DST) in 93 female patients with primary (endogenous) major depression; in 20 female paranoid schizophrenics, and in 17 healthy females. Depressed patients had a significantly higher rate of abnormal DST response and significantly higher post-dexamethasone serum cortisol levels than schizophrenics and normal controls. The unipolar and bipolar depressives showed a similar profile of DST abnormalities. Depressed patients with psychotic features had a significantly higher rate of positive DST results than non-psychotic patients.

Daily measurement of mood, and the occurrence of specific eating behaviours, were assessed concurrently over an eight-week period in a sample of 50 patients meeting diagnostic criteria for bulimia nervosa. Results of observer-rated scales of mood showed a significant reduction of scores, whereas self-assessment of mood showed no change over the study period. Negative mood states, although not severe, were more marked when the specific behavioural symptoms of binge-eating, vomiting, or purging occurred, and they increased as abnormal eating behaviours accumulated. It is suggested that the accompanying dysphoric mood states of bulimia nervosa are likely to be a secondary manifestation related to the presence of abnormal eating symptoms, and that they do no constitute a primary depressive illness.

The recognition of rehabilitation as a special interest in psychiatry, and its practice by professional teams, raises the need for some uniformity in examining patient outcome. The features required in a scale designed for this purpose are considered and the Morningside Rehabilitation Status Scales, which have been prepared specifically for psychiatric rehabilitation, have their development and use described. They measure the dimensions of dependency, inactivity in occupation and leisure, social integration/isolation, and current symptoms and deviant behaviour. The measures can be expressed as a profile of the dimensions, with the total a measure of overall level of functioning; reliability has been established, and validity assessed. The soales are not difficult to apply when the patients are known to the staff using them. They should be useful to rehabilitation teams for defining the current status of patients, measuring changes produced by rehabilitation programmes, deciding areas where treatment or service deficits may exist which the team should be attempting to remedy, as well as for teaching purposes.

Thirty-six patients with obstructive coronary artery disease were interviewed before by-pass graft surgery, and again a mean period of 12.3 months (n = 34) after the operation. The operation was successful in providing relief from chest pain in 31 patients. Psychiatric outcome was related to preoperative mental state, social maladjustment, neuroticism, Bortner Type A score, and previous psychiatric history. One quarter of those employed preoperatively failed to return to work after operation, even though they were improved in terms of symptoms and functional capacity. No association was found between measures of either psychiatric morbidity, or employment status at follow-up, and pre-operative physical variables.

Two psychiatric day hospitals were evaluated in terms of the outcomes after three months' attendance by patients. Multiple measures were made using questionnaires, naturalistic observation, and ratings at the start and end of this period, for a total of 83 patients. The results indicated that although both day hospitals were serving similar patient samples, only one was achieving significant clinical improvements; one plausible explanation for the findings was the differences between their respective programmes. The major implication of the result is the need for evaluation of both the outcome obtained by patients following attendance and the therapeutic process by which these outcomes are achieved.

The aim of the study was to discover the relative effectiveness of four methods of treating patients suffering from hyperventilation attacks. The methods used were: breathing and relaxation therapy, hyperventilation provocation training, treatment based on influencing the factors which lead to the development of the syndrome, and drug treatment. The first three methods were demonstrated to be effective, whilst the fourth showed no signs of effectiveness. The condition of patients in the control group remained the same or deteriorated.

The definition and clinical aspects of rapid cycling affective illness are reviewed and various factors associated with the onset and maintenance of rapid cycling enumerated. On the basis of this information and of reports of the response of rapid cycling patients to various treatment interventions, an approach is suggested to the evaluation and treatment of rapid cycling affective illness.

A successful preliminary trial of an inexpensive non-invasive method for detecting successfully administered electroconvulsive therapy is described.