More than 100 years after Freud's original endorsement of the drug, the use of cocaine is a problem for both users and for society, which struggles to organise effective responses to the epidemic of the last decade. During the 1980s the rapid spread of smokeable cocaine (including ‘crack’) was seen in the Americas (particularly the US). The initial simple predictions of an identical European epidemic were mistaken. The available data on the extent of cocaine use and of cocaine problems in the UK are examined. New forms of cocaine have been developed by black-market entrepreneurs (‘freebase’ and ‘crack’), and new technologies have emerged for their use; with these new technologies have come new effects and new problems. The general psychiatrist now needs a knowledge of directly and indirectly related psychopathology which has an increasing relevance to the diagnosis and management of the younger patient.

The title of this paper should not be taken to imply that the Mental Health Act tribunal system is not currently effective. There has been little serious criticism of the work of the tribunals, and they appear to have become accepted as a permanent aspect of the detention of patients. Some doctors appear to regard them as an irritation that distracts from the care of patients, and civil liberties pressure groups tend to question their real effectiveness. Careful, detailed studies have also tended to be critical, pointing out many defects that require attention. Peay (1989) has done some impressive research into the work of tribunals which must form the basis of any future reform. Cavidino (1989) has done a much wider study, but underpinned by a ‘theory’ which detracts from its value for tribunal members, and its treatment of tribunals is peripheral, and therefore superficial.

The introduction of clozapine to current psychiatric practice is considered against a background of potential problems of resource allocation posed by the development of a number of ‘budget-busting’ drugs. It would appear that clinicians may increasingly have to operate within a climate in which the rights of individual patients to expensive treatments will seem to be pitted against the abilities of their communities to afford such treatments. Both clinicians and pharmaceutical companies have roles in the development of such conflicts.

Economists in the UK have developed a particular view of ethical choice which puts the main focus on short-term, static decisions. As resources are scarce, decisions have to compete (O'Donnell et al, 1988). Although economists have also stressed the moral imperative of improving efficiency, the theme of choice as inexorable has come through much more strongly. Economists in the UK have been more hesitant about giving any clear advice on how to deal with the special problems of supply efficiencies and professional monopoly in health services.

A feature of the recent history of medicine has been the introduction of treatments whose costs are orders of magnitude higher than doctors are used to justifying. Having previously been left almost untouched by these developments, psychiatrists are beginning to find themselves in the position previously occupied by renal physicians, transplant surgeons, and oncologists – having to face uncomfortable decisions about costs versus benefits and the rationing of medical care. To a considerable extent this is a consequence of the launch of the new, ‘atypical’, and ‘superior’ neuroleptic, clozapine.

An analysis was conducted on the basis of available data to assess the economic consequences of clozapine therapy for people with moderate to severe schizophrenia in long-stay institutions or staffed group homes, with a view to providing an estimate of the likely costs and benefits of the drug. Data from a cost-effectiveness study conducted in the US, supplemented by other literature sources, were used to construct a clinical decision tree for likely clinical outcomes for such patients. A panel of UK psychiatrists provided consensus on how these patients would have been managed in the UK. The costs associated with each patient outcome were estimated, and a sensitivity analysis performed to test the assumptions made. For the patients themselves, clozapine would lead to a net gain of 5.87 years of life with no disability or only mild disability. The base case analysis showed that the direct costs of using clozapine were £91 less per annum (or £1333 per lifetime) than for standard neuroleptic therapy, when the effect on all health-care resources was taken into account. In addition, the sensitivity analysis showed that clozapine would be cost-saving or cost-neutral under many different assumptions. A prospective health economic study with clozapine in the management of schizophrenia would be desirable to confirm these results.

Psychiatric symptoms and cognition were assessed in 13 patients with schizophrenia, one patient with schizoaffective disorder, and one patient with psychosis not otherwise specified while they received a conventional neuroleptic and again after an average of 15 months on clozapine. Despite improvements in psychiatric symptoms, attention, memory, and higher-level problem-solving were essentially unchanged. This suggests that certain cognitive deficits are relatively independent of psychotic symptoms in schizophrenia, and are probably central and enduring features of the disorder. Cognitive disability appeared to have been rate-limiting in the sample's rehabilitation, as patients' social and vocational adjustment remained marginal during the study. We also observed that treatment with clozapine was associated with a decline in some memory functions; the potent anticholinergic properties of the drug may have been responsible for this.

Bereavement by murder or manslaughter is often associated with a high incidence of factors which increase the risk of lasting psychological problems after bereavement. In this study it appears that self-perpetuating vicious circles often accounted for the persistence of symptoms, which fitted the diagnostic categories of post-traumatic stress disorders, anxiety states, panic syndromes, obsessive revenge-seeking, and depression. Therapeutic approaches should be aimed at interrupting these vicious circles and fostering the work of grieving.

The case notes documenting the psychological well-being of 100 survivors of torture and other forms of organised state violence were analysed retrospectively. The most common diagnoses were post-traumatic stress disorder (PTSD), major depression, and somatoform disorders. Of these, PTSD showed the strongest association with experience of torture. It is possible that PTSD has a dimensional nature, and that reactions to different stressors are heterogeneous.

Lymphocyte response to stimulation with phytohaemagglutinin (PHA) was assessed in 11 patients with major depression and 8 subjects anticipating bereavement, in order to examine whether altered immune response (PHA stimulation index) was more closely related to depressed mood than to sleep and weight changes. No significant relationship was found between sleep or weight changes and immune response. Depression, measured using the HRSD (with and without sleep scores) and the BDI, was related differently in the two groups. For the depressed patients, increasing depression was associated with reduction in immune response; among those anticipating bereavement (with low depression scores), increasing depression was associated with enhanced immune response. A regression curve using data from both samples demonstrated an inverted ‘U’-shaped curve relating immune response to mild and severe depressed states. The results of this study suggest a hypothesis that may explain previous discrepant results and which requires testing on more subjects.

In an investigation of the timing and precursors of social decline in schizophrenia and affective psychosis, 195 subjects from the Camberwell Collaborative Psychosis Study were currently of lower social class than were their fathers. A comparison between father's occupation and proband's best premorbid occupational level indicated underachievement confined to DSM–III schizophrenia, there being no such effect in affective psychosis. Decline in social status following onset of psychosis, analysed by comparing best premorbid occupation with current occupation, was marked in both schizophrenia and affective psychosis, indicating a non-specific effect. Schizophrenic patients who failed to achieve their fathers' social status had poorer educational qualifications than those who equalled or bettered their paternal social class, despite similar premorbid IQ (NART) scores and age at onset of psychosis. These results indicate that schizophrenia may be manifest before the onset of psychosis, and lend weight to the notion of a developmental origin to this disorder.

Data from the Camberwell Collaborative Psychosis Study were used to examine the proposition that there is an excess of life events preceding the onset of psychoses of all types. Of 97 patients from the study who had episodes within the past year that were datable, 51 had developed psychotic symptoms from an essentially symptom-free state, 29 had been suffering only from neurotic symptoms, and 17 had experienced a marked exacerbation of psychotic symptoms. DSM–III diagnoses were collapsed into three major groups: 51 cases of schizophrenia; 31 cases of mania; and 14 cases of depressive psychosis. Life-event histories were taken for the six months before onset, and when these were compared with equivalent histories from a psychiatrically healthy sample from the local general population, there was a significant excess of life events, particularly in the three months before onset of psychosis. This was apparent in all groups, and remained even when events were restricted to the independent category. The excess of events began rather earlier than has been found in previous studies. In our view, this study provides some of the strongest evidence for a link between life events and the emergence of psychotic symptoms.

A new standardised interview for the retrospective assessment of onset and early course of schizophrenia (IRAOS) was used to study the influence of age and sex on time of onset and psychopathology before first admission in 267 schizophrenic patients admitted for the first time. Mean age at onset, according to various operationalised definitions, differed by three to four years between the sexes. The age distribution at the earliest sign of mental disorder showed an early and steep increase until the age of 25 in males, and a delayed and smaller increase in females, with a second peak in women aged 45–79. Schizophrenia began with negative symptoms in 70% of cases, appearing two to six years before admission, and all positive symptoms appearing up to two years before. Both positive and negative symptoms accumulated exponentially. The early course of the disease was similar across age groups, except there was a longer period of negative symptoms before first admission in late-onset schizophrenia in women. The few significant age differences in symptoms were presumably due to general age-dependent reaction patterns like anxiety and depression or the cognitive development of personality, as indicated by an increase in fully elaborated positive symptoms, especially systematised paranoid delusions, with age.

Lifetime criminal and psychiatric histories were examined in a consecutive series of 280 individuals of twin birth with a diagnosis of major functional psychosis who were seen and followed up at the Maudsley Hospital between 1948 and 1988. Their 210 co-twins, 35% of whom had a similar diagnosis, were ascertained and followed up over the same period. In the absence of reliable general-population estimates for lifetime conviction rates, co-twins were used as case controls. Among the 220 complete pairs, significantly more probands (25.7%) than co-twins (14.0%) were convicted, although there was no evidence for an independent genetic basis for criminal behaviour. Criminal conviction was significantly related to psychiatric diagnosis. There were specific patterns of offending, particularly among the schizophrenic men, who were also significantly more often convicted (48.6%) than the men with affective psychosis (19.4%), and more likely to receive a prison sentence. The schizophrenic patients were younger at their first conviction (mean age 22.6 years v. 30.8 years) and they had committed more violent offences than the affective group. In both diagnostic groups, ages at first psychiatric contact and first conviction were highly correlated.

A survey of attitudes to mental illness was conducted in a quota sample of about 2000 subjects in Malvern and Bromsgrove. Factor analysis showed three main components – benevolence, authoritarianism, and fear of the mentally ill. Residents of Bromsgrove, which is served by a traditional mental hospital, were slightly more tolerant than those living in Malvern, which has a community-based service, and has seen the closure of two mental hospitals in its vicinity during the last 10 years. The main demographic determinants of tolerance are age, education, occupation, and acquaintance with the mentally ill.

Vignettes representing mentally ill people were presented to about 2000 randomly selected residents in Bromsgrove, served by a mental hospital, and Malvern, served by a community-based psychiatric service. They were asked about the likely cause of the condition, what action they would take, and what agencies were most likely to help. In Malvern, residents seemed more enterprising in involving various agencies and more tolerant. It is possible to derive simple ‘action scores' as an indicator of such tolerance. Although there were significant demographic differences between subgroups, overall identification of vignette subjects as mentally ill was surprisingly low, and so was knowledge both of community psychiatric nurses as an agency, and of the location of dispersed treatment facilities in both areas.

The psychological health and adjustment to life in Britain of a sample of first- and second-generation Chinese immigrants were measured. It was predicted that problems with the English language, inadequate social support, value differences, and unfulfilled expectations would induce more symptoms of psychological distress and depression in first-generation than in second-generation Chinese immigrants. Overall psychological hearth, and hence adjustment, was good. There was evidence for language problems and unfulfilled expectations, but not social support and value differences, being linked to mental health in the second generation. Evidence linking mental health to other personal variables was found in both generations.

The present study compares adults with Gilles de la Tourette's syndrome (GTS) with depressed adults and normal controls on questionnaires measuring obsessionality, depression, and anxiety. The GTS and depressed groups scored significantly higher than the normal controls on all measures. The GTS subjects had similar scores on measures of obsessionality to those of the depressed subjects, but significantly lower scores on measures of depression and anxiety. This suggests that obsessionality is a prominent feature of GTS, and that the psychopathological profile is different to that of patients with major depressive disorder.

Two cognitive measures were used to assess 22 patients who met DSM–III–R criteria for major depressive disorder: the Autobiographical Memory (AM) test and the Dysfunctional Attitude Scale. They were followed up over seven months. Measurement of dysfunctional attitudes did not predict outcome at seven months. Overgeneral recall on the AM test at initial assessment, especially for emotionally positive memories, was highly correlated with failure to recover from depression and accounted for 33% of the variance in HRSD score at follow-up. Overgeneral recall of emotional memories did not change during follow-up. It is suggested that overgenerality is a trait marker indicating vulnerability to persistent depression.