Alzheimer's disease and other types of dementia are characterised by numerous psychiatric and behavioural changes. Little is known of their natural history.

To investigate the sequence and pattern of these changes throughout the course of dementia.

One hundred people, initially living at home with carers, entered a prospective, longitudinal study. At four-monthly intervals, behavioural and psychiatric symptoms were assessed using the Present Behavioural Examination and Mini-Mental State Examination. Follow-up continued for up to nine years (mean 3.3 years; s.d. 2.4). Patterns of onset and disappearance of these symptoms, their sequence and association with time of death and cognitive decline were analysed. Autopsy confirmed a diagnosis of pure Alzheimer's disease in 48 subjects. Data for this subgroup are presented.

Some changes tend to occur earlier than others but changes can occur at almost any time in the course of dementia.

The natural history of behaviour changes in Alzheimer's disease shows great individual variation although some changes tend to follow a recognisable sequence.

Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both.

To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment.

Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24, 95% CI 1.02–1.52) or psychotherapy (RR=1.16, 95%CI 1.03–1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61, 95% CI 1.23–2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79–1.16).

Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

Depression is common in old age and is associated with risk of dementia, but its neuropathological correlates in the community are unknown.

To investigate for the first time in a population-representative sample of people with no dementia the association between depression observed during life and neurofibrillary tangles, diffuse and neuritic plaques, Lewy bodies, brain atrophy and cerebrovascular disease found in the brain at post-mortem.

Out of 456 donations to a population-based study, 153 brains were selected where donors had no dementia measured in life. Alzheimer and vascular pathology measures, Lewy bodies and neuronal loss were compared between those with (n = 36) and without (n = 117) depression ascertained using a fully structured diagnostic interview during life. Brain areas examined included frontal, parietal, temporal and occipital cortical areas as well as the entorhinal cortex, hippocampus and brain-stem monoaminergic nuclei.

Depression was significantly associated with the presence of subcortical Lewy bodies. No association was found between depression and cerebrovascular or Alzheimer pathology in cortical or subcortical areas, although depression was associated with neuronal loss in the hippocampus as well as in some of the subcortical structures investigated (nucleus basalis, substantia nigra, raphe nucleus).

Late-life depression was associated with subcortical and hippocampal neuronal loss but not with cerebrovascular or Alzheimer pathology.

HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents) is a recently developed measure of outcome for use in child and adolescent mental health services (CAMHS).

To examine HoNOSCA's sensitivity to change, convergent validity and clinical usefulness.

Prospective study of new CAMHS attenders. Questionnaires completed by clinicians, parents and referrers at initial assessment and after 6 months.

Follow-up HoNOSCAs on 203 children indicated statistically significant change. There were significant associations between change in HoNOSCA scores, changes in other clinician- and parent-rated scales (r=0.51 to 0.32) and in global outcome ratings by referrers, parents and clinicians. Intraclass correlation coefficients for the summated HoNOSCA scores were high. HoNOSCA change was positively correlated with initial HoNOSCA score (r=0.46, P<0.001) and it was linked to psychiatric diagnosis.

HoNOSCA is a sensitive, valid measure of change among CAMHS attenders.

There is a need for a rapid-acting, non-injection, acute treatment for agitation.

To evaluate inhaled loxapine for acute treatment of agitation in schizophrenia.

This phase III, randomised, double-blind, placebo-controlled, parallel-group study (ClinicalTrials.gov number NCT00628589) enrolled 344 individuals who received one, two or three doses of inhaled loxapine (5 or 10 mg) or a placebo. Lorazepam rescue was permitted after dose two. The primary efficacy end-point was change from baseline in Positive and Negative Syndrome Scale–Excited Component (PANSS–EC) 2 h after dose one. The key secondary end-point was Clinical Global Impression–Improvement scale (CGI–I) score 2 h after dose one.

Inhaled loxapine (5 and 10 mg) significantly reduced agitation compared with placebo as assessed by primary and key secondary end-points. Reduced PANSS–EC score was evident 10 min after dose one with both 5 and 10mg doses. Inhaled loxapine was well tolerated, and the most common adverse events were known effects of loxapine or minor oral effects common with inhaled medications.

Inhaled loxapine provided a rapid, well-tolerated acute treatment for agitation in people with schizophrenia.

Deployment to the 2003 Iraq War was associated with ill health in reserve armed forces personnel.

To investigate reasons for the excess of ill health in reservists.

UK personnel who were deployed to the 2003 Iraq War completed a health survey about experiences on deployment to Iraq. Health status was measured using self-report of common mental disorders, post-traumatic stress disorder (PTSD), fatigue, physical symptoms and well-being.

Reservists were older and of higher rank than the regular forces. They reported higher exposure to traumatic experiences, lower unit cohesion, more problems adjusting to homecoming and lower marital satisfaction. Most health outcomes could be explained by role, experience of traumatic events or unit cohesion in theatre. PTSD symptoms were the one exception and were paradoxically most powerfully affected by differences in problems at home rather than events in Iraq.

The increased ill-health of reservists appears to be due to experiences on deployment and difficulties with homecoming.

Well-designed prospective studies of substance misuse in first-episode psychosis can improve our understanding of the risks associated with comorbid substance misuse and psychosis.

To examine the potential effects of substance misuse on in-patient admission and remission and relapse of positive symptoms in first-episode psychosis.

The study was a prospective 15-month follow-up investigation of 103 patients with first-episode psychosis recruited from three mental health services.

Substance misuse was independently associated with increased risk of in-patient admission, relapse of positive symptoms and shorter time to relapse of positive symptoms after controlling for potential confounding factors. Substance misuse was not associated with remission or time to remission of positive symptoms. Heavy substance misuse was associated with increased risk of in-patient admission, relapse and shorter time to relapse.

Substance misuse is an independent risk factor for a problematic recovery from first-episode psychosis.

Studies of the impact of mental disorders on educational attainment are rare in both high-income and low- and middle-income (LAMI) countries.

To examine the association between early-onset mental disorder and subsequent termination of education.

Sixteen countries taking part in the World Health Organization World Mental Health Survey Initiative were surveyed with the Composite International Diagnostic Interview (n=41 688). Survival models were used to estimate associations between DSM–IV mental disorders and subsequent non-attainment of educational milestones.

In high-income countries, prior substance use disorders were associated with non-completion at all stages of education (OR 1.4–15.2). Anxiety disorders (OR=1.3), mood disorders (OR=1.4) and impulse control disorders (OR=2.2) were associated with early termination of secondary education. In LAMI countries, impulse control disorders (OR=1.3) and substance use disorders (OR=1.5) were associated with early termination of secondary education.

Onset of mental disorder and subsequent non-completion of education are consistently associated in both high-income and LAMI countries.

Although road traffic accidents are a major cause of injury and death in children and adolescents, research into their psychological consequences consists mainly of case reports.

A prospective study was made of young road traffic accident victims; 57 subjects, aged 5–18 years, who had been injured in road traffic accidents, and their parents, were interviewed 2–16 days post-accident and re-examined after 12–15 weeks.

Post-accident stress symptoms occurred at both times. There was a decrease of symptom severity between the two interviews, but at the later time, 14% still suffered from moderate or severe post-traumatic stress disorder, 17% from serious traffic-related fears, and parents reported increased mood disturbance in their children compared with the pre-accident period. High levels of distress during and immediately after the accident were associated with severe post-traumatic stress symptoms.

There is an urgent need for healthcare staff working with children and adolescents involved in road traffic accidents to be aware of the potential psychological consequences and the importance of the immediate accident experience on subsequent coping.

Secure hospitals are a high-cost, low-volume service consuming around a fifth of the overall mental health budget in England and Wales.

A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy.

We searched for primary studies that followed patients discharged from a secure hospital, and reported mortality, readmissions or reconvictions. We determined crude rates for all adverse outcomes.

In total, 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders. The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175–1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235– 415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916–8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679–5287), with lower rates in more recent studies.

There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.

The White Paper The Health of the Nation targets a reduction in suicide rates. Preventive strategies must be guided by an understanding of the demography and antecedents of suicide. These issues are examined in relation to suicide by old people in Manchester.

One hundred consecutive coroners' inquisitions on people aged over 65 occurring between 1980 and 1991 in which the verdict was suicide were scrutinised and related to Health Service notes.

Suicides were rare, numbers ranging from 0 to seven per annum per Health District. Rates did not vary between district but did within smaller sub-populations. Most individuals died at home; 65% were physically ill, of whom 23% had been hospitalised within the previous year. At least 60% were clinically depressed, with 25% being prescribed antidepressants. A total of 43% had seen their general practitioner in the previous month but only 14% were in contact with psychiatric services.

Many elderly people who commit suicide are not in close contact with primary care services; those who are may not be prescribed appropriate treatment, and few are referred for specialist care. Specialist services will fail to reduce suicide rates unless they embark upon programmes to increase public awareness of therapeutic possibilities and work more closely with primary care agencies to realise these possibilities.

The number of elderly prisoners has increased significantly in Western countries over the past decade. Little is known about the psychiatric morbidity of this population.

To determine the prevalence of psychiatric morbidity in elderly sentenced prisoners.

A stratified sample of 203 male sentenced prisoners aged over 59 years, from 15 prisons in England and Wales, representing one in five men in this age group, was interviewed using semi-structured standardised instruments for psychiatric illness and personality disorder.

More than half of the elderly prisoners had a psychiatric diagnosis. The most common diagnoses were personality disorder and depressive illness.

The prevalence of depressive illness was five times greater than that found in other studies of younger adult prisoners and elderly people in the community. Underdetected, undertreated depressive illness in elderly prisoners is an increasing public health problem.

In spite of intensive research, no causal anatomical lesion has been found in schizophrenia. It may instead be caused by malfunctioning circuits in the corollary discharge, feed forward (CD–FF) systems of thought.

To integrate with the CD–FF hypothesis recent data showing that subcortical motor systems participate in thinking.

We review CD–FF concepts in relation to recent evidence that ‘motor’ brain structures participate in cognitive processing.

Malfunctioning of CD–FF systems that integrate thinking and consciousness could produce auditory hallucinations, delusions and disorganised thought.

We hypothesise that the pathophysiology of schizophrenia lies in integrative circuits of basal ganglia, thalamus and frontal cortex. Fruitful research directions would include elucidation of CD–FF circuits at even higher brain levels, the behaviour of these circuits during dreaming, and their responses to late maturational events including synaptic elimination.