Deinstitutionalisation is at an advanced stage in the US, both in duration, and in reduction in state hospital beds. The new generation of chronically and severely mentally ill persons has posed the greatest problems. They no longer receive life-long hospital admission and thus permanent asylum from the demands of the world. Resistance to treatment and substance abuse are problems. Early proponents of deinstitutionalisation believed it would be cheaper, better, and give the mentally ill their freedom. In reality, good community care does not cost less. While a number of community programmes in the US have been impressive, they have served only a small proportion of the total population of severely mentally ill persons. More freedom has been of benefit for many, but has proved difficult for some patients. Some patients have been deinstitutionalised who cannot be effectively treated in the community. The homeless mentally ill epitomise all these problems.

Complex segregation analyses were performed on families ascertained through 40 unselected consecutive patients with Tourette's syndrome to examine the hypothesis that its transmission is consistent with genetic inheritance. Analyses were done using several diagnostic classifications. All results were consistent with an autosomal dominant gene with high penetrance. The penetrances ranged from 0.882 to 1.000 for males and 0.452 to 0.980 for females, depending upon the specific classification scheme incorporated into the analyses.

d-Fenfluramine is a 5-HT agonist which decreases food intake and excessive carbohydrate intake in humans. A placebo-controlled trial of d-fenfluramine (45 mg/day) was conducted in 43 patients with bulimia nervosa. The patients entered an eight-week trial of medication during which they also received cognitive-behavioural therapy. Treatment response was assessed using food diaries to record eating behaviour, and self-rating questionnaires to measure psychopathology. The drug trial, and a follow-up assessment after a further eight weeks, were completed by 39 patients. Abnormal eating behaviour and psychopathology improved significantly in both the d-fenfluramine and placebo groups during the treatment trial. The study failed to show that the addition of d-fenfluramine affords an advantage over brief psychotherapy alone. Although d-fenfluramine is effective in suppressing the overeating, excessive snacking, and excessive carbohydrate consumption which are frequently found in overweight or obese patients, this study suggests that the drug is not an effective treatment for bulimia nervosa.

A sample of 26 HIV seronegative, 59 HIV seropositive asymptomatic and 7 HIV seropositive symptomatic homosexual and bisexual men were assessed over two visits, a mean of 11 months apart, using the BDI, STAI, and CIS. Significant differences emerged between the symptomatic group and the other two groups. Past psychiatric history and the somatic items in the assessments accounted for some of these differences. The seropositive asymptomatic and the seronegative groups did not differ on any of the mood or psychiatric assessments, suggesting minimal effect on psychological well-being of seroconversion in the absence of symptoms.

The quality of life of detained patients has not received adequate attention despite the responsibilities placed on hospital staff and the special problems faced by these patients. Legal principles to ensure quality of life have not been formalised, and the acceptable standards that a patient can expect have not been tested in the UK courts. Contemporary models of ensuring quality are being imposed with increasing pressure on health care professionals, but high-quality management has sometimes lagged behind. This has led to a poor quality of life for certain patients. It is important for future research to overcome difficulties in developing objective measurements and set the appropriate standards of quality of life that detained patients should expect. This would provide a basis against which both appropriate standards of care and the necessary resource allocation could be measured.

A random sample of 100 new patients referred consecutively to the psychiatric hospital was assessed using the Arabic translation of the PSE. An abstract form was designed to include all PSE scores as well as the necessary extra data to make ICD-9, ICD-10, and DSM-III-R diagnoses. Kappa correlation was calculated for inter-rater and intra-rater reliability. Overall reliability and reliability of each major psychiatric diagnosis were compared between the three systems. The use of the PSE helped in achieving good agreement between Arab psychiatrists for all the three systems, but ICD-10 was found to have the highest reliability figures both for three-digit and four-digit psychiatric diagnoses.

The summaries of clinical data on children attending the Maudsley Hospital during the years 1968-72 were used to identify 80 children meeting operational criteria for depression, and 80 matched psychiatric control children. At follow-up, on average 18 years after the initial contact, information was obtained on the adult outcomes of 62 of the depressed children and 69 of the controls. At least one first-degree relative of 111 (85%) of these probands was interviewed; the great majority of interviews with relatives were conducted ‘blind’ to the proband's symptoms in both childhood and adulthood. The lifetime prevalence of RDC depression was significantly higher in the 128 interviewed relatives of the depressed children than in the 151 relatives of the controls. Higher rates of depression were found among the female relatives of both the depressed and control probands. These findings suggest that depression in young people resembles depression in adults in two key respects: it tends to run in families, and there are higher rates of depression among the female than among the male first-degree relatives.

Thirty-four patients with tricyclic-resistant depressive illness took part in a nine-week, doubleblind, placebo-controlled trial of lithium augmentation. In addition to the maximum tolerated doses of their tricyclic antidepressant, the experimental group (n = 16) received 250 mg lithium daily for three weeks, followed by 750 mg lithium daily for six weeks, while the controls (n = 18) received placebo for three weeks followed by three weeks each of 250 mg lithium daily and 750 mg lithium daily. There was no significant difference between placebo and 250 mg lithium for weeks 0-3 of the trial. However, there was a significantly greater improvement on the MADRS for weeks 3-6 for those subjects on 750 mg lithium than for those on 250 mg lithium. In addition, using a 50% fall in the HRSD as a criterion of drug responsiveness, 22% responded to placebo, 18% to 250 mg lithium, and 44% to 750mg lithium. Thus, lithium in normal, but not in low, dose has a significant antidepressant effect in TCA-resistant depression. Further controlled studies using lithium in normal dose in trials which have a greater duration of placebo exposure are required to confirm the lithium augmentation effect.

A preliminary study of the repetitive mood swings of 72 female psychopaths with a DSM-III diagnosis of borderline personality disorder demonstrated considerable complexity and specificity in what has been previously considered a criterion of personality disorder. A principal-components analysis of the symptom profile for these affective disturbances revealed four factors (anxiety, anger, depression, and tension) which showed individual patterns of association with additional lifetime diagnoses of major mental illness and other personality disorders. The women also had multiple mood-related behavioural disorders, enacted with a feeling of compulsion, which appeared to relieve the original affective symptoms. It is hypothesised that these women could have a distinct affective syndrome that has not previously been described in the literature.

Previous attempts to establish a relationship between impaired cell-mediated immunity (CMI) and major mood disorders have been limited by a failure to explore the relevance of depressive subcategories or to assess CMI by in vivo methods. In this case-control study CMI was assessed in 57 patients with major depression (31 with melancholic, 26 with non-melancholic disorders), and in age- and sex-matched controls by both in vitro and in vivo immunological techniques. Compared with control subjects and patients with non-melancholic depression, patients with melancholia demonstrated reduced in vivo CMI as assessed by delayed-type hypersensitivity (DTH) skin responses. Although increasing age, severity of depression, hospital admission for treatment, and reported weight loss are correlates of melancholia, none of these factors alone, or in combination, accounted for the differences in DTH responses observed between the two depressive subtypes. These data suggest that impaired CMI in vivo may be limited to those with melancholic disorders. At this stage the factors which account for this effect are unclear.

In a case-record study, all first-contact patients with non-affective functional psychosis from a defined area over 20 years were diagnosed according to operational criteria of varying stringency and emphasis, and incidence rates for each set of criteria determined by sex and age at onset; data on premorbid adjustment were also analysed by sex and age at onset. The overall first-contact incidence of non-affective functional psychosis was approximately equal in men and women; however, the ratio of male to female incidence rates rose progressively when RDC (1.2), DSM-III-R (1.3), DSM-III (2.2), and Feighner (2.5) criteria for schizophrenia were applied. Schizophrenia was most common in young males and least common in older males, with females occupying an intermediate position. Schizophrenia in young males, particularly when stringently defined, was especially likely to be associated with single status, poor work and social adjustment, and premorbid personality disorder. The results suggest that schizophrenia syndrome is heterogeneous, and young males are especially prone to a severe neurodevelopmental form of illness associated with premorbid deficits.

This retrospective study evaluated differences between patients with first manifestation of schizophrenic psychosis (ICD 295) or paranoid syndrome (ICD 297) between the ages of 18 and 23 or 40 and 63 years. Gender-specific variations in psychopathology were also examined. The numerous analyses of variance gave few significant differences. Patients with a late onset of the disease scored higher on depressive and autonomic syndrome scales at admission, whereas patients with an early onset showed more psychosocial impairment at discharge and their stay in hospital was longer. Among schizophrenic patients only (ICD 297 excluded), only the higher score for autonomic syndrome of the older patients at admission was confirmed. Men were more apathetic at admission and discharge than were women. Excluding patients with a paranoid syndrome, these differences were again significant. Moreover, schizophrenic men had higher depressive and psycho-organic syndrome scores at discharge. The demonstration of only marginal differences between early- and late-onset schizophrenia does not support the assumption that age of onset markedly influences psychopathology.

First-degree relatives (FDRs) of 1018 schizophrenic and 812 control probands were investigated. Psychiatric morbidity was present in 34.8% of FDRs of schizophrenic probands and in 9.2% of FDRs of controls. There was significantly more psychiatric illness in the siblings and parents than in the offspring of both schizophrenic and control subjects. The morbidity risks for schizoid-schizotypal personality disorders, cannabis-use disorder and paranoid personality disorder were significantly higher in the FDRs of schizophrenic patients than in those of controls, suggesting a biological relationship.

Compulsory treatment for anorexia nervosa was recently once again a topic for discussion following the case of J, a 16-year-old girl who unsuccessfully applied to the Court of Appeal to refuse treatment for her anorexia nervosa. In this instance legal opinion was sought in order to clarify the Children Act 1989. However, much of the media coverage focused on the controversy surrounding the compulsory treatment of anorexia nervosa, under the provisions of the Mental Health Act 1983. There is a lack of research into the compulsory treatment of anorexia nervosa, so debate has to be informed by clinical experience.

“This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male transsexuals and 105 male-to-female transsexuals in the Netherlands. Data were collected by means of structured interviews. The evaluation was made on the basis of subjective data only, that is on what the persons themselves reported on their gender identity, gender role, and physical condition. Allowing for the restrictive methodology of the (ex post facto) study, it is concluded that there is no reason to doubt the therapeutic effect of sex reassignment surgery. No specific differences were found between those who were still in medical treatment and those who had completed treatment. The findings obtained in the female-to-male transsexuals compare favourably with those obtained in male-to-female transsexuals. Finally, the conclusion is drawn that more attention ought to be paid to psychosocial guidance in addition to medical guidance.”

Clozapine-induced agranulocytosis is usually reversible after discontinuation of the drug. A patient who developed agranulocytosis after termination of clozapine therapy responded to treatment with granulocyte macrophage colony stimulating factor.

A 67-year-old man developed concurrent severe agranulocytosis and elevation of hepatic transaminases as a result of treatment with clomipramine. Although such adverse drug reactions can be considered rare events, the potentially serious nature of these reactions vindicate the routine monitoring of blood picture, and liver function tests, after initiation of treatment with tricyclic antidepressants.

Four cases of lithium-induced neurotoxicity are presented which, taken with evidence from previous reports, indicate that specific risk factors for lithium-induced neurotoxicity at normal serum levels are rapid dosage regimes, concomitant neuroleptic therapy, pre-existing EEG abnormalities, undetected cerebral pathology, organic impairment, and genetic susceptibility.

Two cases of Capgras' syndrome are described in which patients committed serious acts of violence towards famly members who had become the subject of delusional misidentification. The cases illustrate some typical features of Capgras' syndrome including its potential for dangerousness. Intoxication with alcohol is proposed as a precipitant for violence in these patients.

Investigations of two cases of the Capgras delusion found that both patients showed face-processing impairments encompassing identification of familiar faces, recognition of emotional facial expressions, and matching of unfamiliar faces. In neither case was there any impairment of recognition memory for words. These findings are consistent with the idea that the basis of the Capgras delusion lies in damage to neuro-anatomical pathways responsible for appropriate emotional reactions to familiar visual stimuli. The delusion would then represent the patient's attempt to make sense of the fact that these visual stimuli no longer have appropriate affective significance.