The hypothesis that cognitive impairment in Alzheimer's disease is related to cholinergic degeneration in the brain is still, a decade after its formulation, subject to critical evaluation. In marked contrast to the monoamine hypotheses of affective disorders or schizophrenia – based primarily on the mechanisms of action of therapeutic drugs, and yet lacking convincing pathological data on the human brain itself – the cholinergic hypothesis of Alzheimer's disease currently rests largely on evidence of neurochemical pathology in affected tissue, but still depends on effective therapy for its ultimate validation. The urgent need for a means of countering cognitive impairment in degenerative dementias such as Alzheimer's disease (probably the most important cause of intellectual decline in old age) hardly needs emphasising. In this annotation, a number of key questions specifically relating to the cholinergic involvement in Alzheimer's disease are considered. These questions are already being answered both within and, as so often in the history of biological psychiatry, outside the immediate area of investigation.

Techniques of molecular genetics, including recombinant-DNA technology, are likely to have a key role in modern psychiatric research and practice. This article reviews some methods of DNA analysis and their applications to clinical science: specifically, how these methods can be used to localise, identify, isolate, and clone clinically important genes, and how this should enable us to elucidate the molecular pathology of most inherited (psychiatric) disorders. The implications of these developments for prevention and treatment of genetic disease are discussed.

The Camberwell Collaborative Depression Study is an investigation of a series of 130 patients (76 female; 54 male) attending the Maudsley Hospital Services with unipolar depression of recent onset (the probands), and of their first-degree relatives. This paper describes the first element of the study, the investigation of the index cases or probands, which was carried out by members of the MRC Social Psychiatry Unit over the period 1982–1985. A description of the methods of the study is followed by an analysis of life events in relation to the symptomatic pattern of the depressive state. An ‘endogenous' group was defined as cases of depression falling within Catego classes D and R, and compared with a ‘neurotic’ group conforming to classes N and A. The hypothesis that the ‘endogenous' group of disorders would be relatively independent of prior life stress was not confirmed. Depressed women were more likely to have experienced life events or difficulties than their male counterparts, and there was some evidence that sex, but not age or social class, influenced the relationship between adversity and the type of depression. Examination of the timing of life events was strongly suggestive of a causal effect, with a pronounced rise in the month before onset. This was not limited to the most severe events. Differences between the ‘endogenous' and ‘neurotic’ groups in the temporal patterning of events before onset are discussed. The findings are interpreted in terms of the literature on the topic.

Out of a consecutive series of 130 potential probands with recent onsets of depression, 124 were deemed ‘in scope’ for a family interview study of social and genetic influences on depression. We were able to interview first-degree relatives of 83 probands (67% of those families ‘in scope’). Unexpectedly, interviewed first-degree relatives had, on average, a significantly lower occupational status than the depressed probands. However, the rates of depression among the first-degree relatives were high. Based on a PSE-Catego classification, 17.2% of 244 relatives were current ‘cases' of depression at the time of interview. This was significantly greater than the estimated population prevalence. Using a Past History Schedule in combination with the PSE, the lifetime prevalence of depressive illness, expressed as the proportion who had ever fulfilled PSE-Catego case criteria, was 38.9%. High rates of psychiatric treatment were also found in family members. The lifetime prevalence of any form of hospital treatment for depression in 315 first-degree relatives was 15.5%. This gives an age-corrected morbidity risk to age 65 years of 24.6%, as compared with a population estimate of 8.9%. In common with previous studies, significantly higher rates of depression were found among female than among male first-degree relatives for broader categories of disorder, but there was a small and non-significant excess of men among those relatives who had received in-patient treatment for depression. This apparent lessening of sex differences with more severe categories was not supported by an examination of ‘lifetime ever’ depressive symptoms, where severity was expressed as highest ever PSE-Catego-ID level. Here the proportion of women who had ever had depressive symptoms remained higher throughout the upper range of the Index of Definition. The findings raise the possibility that male relatives of depressed probands under-report their symptoms, but that their doctors compensate by adopting a lower threshold of psychiatric referral when faced with depressive symptoms in a man.

The relationship between life events and depressive disorder was assessed in 83 families ascertained through depressed probands. Contrary to expectation and to previous suggestions, we found no inverse relationship between the presence of familial loading and reactivity to stress. Thus the relatives of probands whose onset of depression followed life events or chronic difficulties had slightly higher lifetime rates of depression than the relatives of probands whose onset was not associated with adversity. There was only a weak and non-significant relationship between recent life events and current disorder among relatives, and no apparent tendency for life-event-associated depression to ‘breed true’ within families. Comparison with a community sample showed that the first-degree relatives of depressives had significantly elevated rates both of current depression and of recent threatening life events. This finding still held when proband-associated life events were discounted, suggesting that both liability to depression and propensity to experience life events are familial.

The context and content of work undertaken with individual clients by community psychiatric nurses (CPNs) and mental health social workers (MHSWs) in Salford were found to be significantly different. Although there were some areas of overlap, the ways in which the two professions worked were quite distinct. MHSWs discussed a wide range of topics and were as concerned with clients' interactions with family and community networks as they were with symptoms. Their interviews with schizophrenic clients followed a similar pattern to those with other groups, and they worked closely with psychiatrists and other mental health staff. CPNs, on the other hand, focused mainly on psychiatric symptoms, treatment arrangements, and medications, and spent significantly less time with individual psychotic clients than they did with patients suffering from neuroses. They were as likely to be in contact with general practitioners as they were with psychiatrists, and had fewer contacts with other mental health staff than the MHSWs. There was evidence that the long-term care of chronic psychiatric patients living outside hospital required more co-ordinated long-term multidisciplinary input.

Annual age-standardised rates for first contacts with psychiatric services in the Aberdeen area from 1969 to 1984 were calculated for schizophrenia, paranoid states, reactive psychoses, all affective psychoses, mania, and depressive neuroses. Highly significant declines occurred in the diagnosis of schizophrenia and of depressive neuroses. No concomitant increase occurred. It is concluded that these results probably indicate that there has been a fall in the incidence of schizophrenia in North-East Scotland. This may have arisen due to changes in the mode of expression and/or the severity of all functional psychoses.

The psychiatric state of 483 women was examined antenatally and at 3, 6, and 12 months postpartum. Comprehensive assessments were made of all women antenatally and of subgroups of the full sample postnatally. Psychiatric state was assessed using the General Health Questionnaire, the Present State Examination and the Montgomery and åsberg Depression Rating Scale. In terms of PSE criteria, the point prevalence of non-psychotic psychiatric disorder antenatally was found to be 6.0%; and postnatally it was estimated to be 8.7% at 3 months, 8.8% at 6 months and 5.2% at 12 months after delivery. These prevalence rates were compared to the rate in a general population sample of non-puerperal women and found to be no greater. In a subgroup of the full sample, the incidence of psychiatric disorder in the year following delivery was estimated to be 15.1%, which is close to a figure previously reported for women in the community. The onset of psychiatric disturbance was soon after delivery in most instances; and, for the majority, the episode of disturbance lasted for 3 months or less. The distribution of PSE Catego classes and syndromes among the antenatal and postnatal samples were found to be similar to those in the non-puerperal comparison sample. Thus, the prevalence, incidence, and nature of non-psychotic psychiatric disorder in the 12 months following delivery do not appear to distinguish it from such disorders arising at other times.

The 28-item General Health Questionnaire (GHQ) has been validated against the criterion of the Clinical Interview Schedule (CIS) in Spanish patients in hospital with several types of endocrinological illnesses. The screening instrument correctly identified 91 of 100 respondents as exhibiting psychiatric disorder. The questionnaire's efficacy was similar at the time of medical discharge, when the rate of disorder was significantly lower. Significant correlations were found between GHQ total scores and endocrine blood measures in Addison's disease, and in Type I diabetes. The four subscales of the GHQ sum to provide additional information concerning somatic symptoms and anxiety.

Three-hundred male alcoholics were selected from consecutive admissions to hospital. They were divided into three diagnostic sub-groups: primary alcoholics; alcoholics with unipolar affective disorder; and alcoholics with bipolar affective disorder. After three follow-up interviews over a 2-year period after hospital discharge, the three sub-groups reported differences in frequency of mood change, amount of treatment received, and hospital attendance, although there were no clear-cut differences in items associated with their alcoholism. There were, however, some indications that bipolar patients functioned at a better level during the follow-up period, particularly those who were older, had a previous history of longer periods of abstinence, and maintained more frequent contact with Alcoholics Anonymous (AA) and their family doctor.

Monthly rates of admission of manic patients to the Department of Psychiatry in Galway Regional Hospital were examined for a five-year period. Monthly variation in admission rates was compared with monthly levels of sunshine, temperature and daylength. Results indicated a significant seasonal variation in the prevalence of mania: admission rates were higher in the sunnier months and in months with a greater average daylength. It is suggested that the presentation of mania in this fashion is due to an abnormal response to light in these patients.

Consecutive attenders (525) presenting at the Nottingham Accident and Emergency (A & E) department with deliberate self-poisoning were identified retrospectively. Their case-notes were examined for patient characteristics and clinical management. The Nottingham Psychiatric Case Register was examined for previous contact and use of psychiatric services over a 2-year follow-up period. Significant differences were found between those patients admitted to a ward and those who returned home from the A & E Department, in respect of likelihood of psychiatric morbidity and use of psychiatric services. One in three self-poisoning patients returns home directly from the accident department, and there seemed to be appropriate selection.

Results from a 15–20-year follow-up study of 35 7–12–year-old children with school refusal and 35 age- and sex-matched comparison children are reported. The school refusal cases had applied for out-patient adult psychiatric care more often than comparison children. Also they had fewer children of their own. In respect of overall social adjustment and severe psychiatric disorders requiring in-patient treatment, there were no important differences.

Earlier, we reported that true hallucinations may present as a conversion symptom. We here reiterate this and suggest that cultural sanction may be one factor that can lead to hallucinations being classified as true in non-psychotic psychiatric states.

HIV disease often leads to neuropsychiatric disturbance, either through direct infection of the brain by the virus or through CNS disease secondary to immunodeficiency. Neuropsychiatric complications of AIDS and AIDS-related disorders may present clinically as acute or chronic organic mental syndromes, or may mimic functional psychiatric illness, in particular depression, anxiety, or psychotic states. Two cases of hypomanic states in homosexual men suffering from AIDS are reported. Neither of the two men had a personal or family history of affective disorder. In one man, hypomanic symptoms were caused by early HIV encephalopathy; he rapidly developed typical HIV dementia with a marked downhill course. In the second case, a clear connection between the hypomanic symptoms and direct HIV brain involvement was not established.

In Prudhoe Hospital, a large mental-handicap hospital of 1000 residents, it was found that of the 94 deaths that occurred between 1982 and 1986, three were closely associated with the habit of pica. These deaths occurred in severely and profoundly handicapped males, whose average age was 32, compared with an average age of death of 58 for the combined groups of severely and profoundly mentally handicapped patients (22 cases), and an average age of death of 60 for all degrees of handicap (94 cases). It seems likely that the habit of pica constitutes a cause of considerable morbidity and mortality in certain institutionalised patients.

A case of shop-lifting involving the father of a severely handicapped school-leaver is described. The need to support families during the transition of the handicapped person from school to a work environment is emphasised.

We describe the case of a 33-year-old man with Down's syndrome and severe eating disorders. The clinical symptoms, and their difference from those of anorexia nervosa, are discussed. The patient responded well to a strict behavioural programme after long, in-patient treatment and was still well at a 2-year follow-up examination.

With mentally handicapped people now being moved into the community, information on mentally handicapped criminal offenders is valuable. A group of such offenders was examined by reviewing the case-notes of 92 patients referred on hospital order to two mental-handicap hospitals over 10 years. Compared with the general criminal population, these offenders' ages were higher, the ratio of male to female offenders was similar, and the proportion of married people was lower. The offences committed were for the most part serious, with a greater number of offences against property and public order in the subgroup whose intelligences were in the mentally handicapped range. Their tested intelligences fell almost entirely into the normal and mild mental-handicap range, suggesting that factors other than intelligence testing, such as social skills, were considered in their admission to the hospitals.

A case of a patient with monosymptomatic hypochondriasis exhibiting koro-like symptoms is reported. The patient did not respond to pimozide, but improved with a tricyclic antidepressant and has remained symptom-free for 1.5 years.