Selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclics. Reports have suggested that SSRIs are cost-effective because they are better tolerated and safer in overdose.

A systematic review of all randomised controlled trials (RCTs), meta-analyses, and cost-effectiveness studies comparing SSRIs and tricyclic antidepressants (TCAs).

None of the RCTs provided an economic analysis and there were methodological problems in the majority which would preclude this approach. Meta-analyses suggest that clinical efficacy is equivalent but slightly fewer patients prescribed SSRIs drop out of RCTs. Cost-effectiveness studies have been based on crude ‘modelling’ approaches and over-estimate the difference in attrition rates and the cost of treatment failure. It appears impossible to evaluate the economic aspects of suicide because of its rarity.

There is no evidence to suggest that SSRIs are more cost-effective than TCAs. The debate will only be concluded when a prospective cost-effectiveness study is done in the setting of a large primary care based RCT.

Current acceptance of the need for a wide range of treatments and growing pressure for cost-effectiveness suggest the need for a more discriminating approach to assessment of psychotherapy.

Medline and manual literature searches, and personal experience of over 1000 assessments in a district psychotherapy service.

There is substantial evidence for the general efficacy of psychotherapy; differential benefits are beginning to be identified. Short-term treatments are appropriate in a wide variety of situations and can be surprisingly effective. Chronic/complex psychopathology is likely to need longer term therapy.

Effective use of scarce psychotherapy resources requires knowledge of the research evidence of treatment effectiveness, careful assessment of the patient and a logical and collaborative approach to treatment planning.

The effects of neuroleptic medication on schizophrenic patients are both positive (reduction in symptoms) and negative (adverse side-effects). Given that altered cognitive functioning may be a feature of schizophrenia, the use of neuroleptics raises important ethical and legal issues.

A selective review was carried out of papers addressing ethical arguments for and against obtaining consent from schizophrenic patients, and the ethical and legal requirements which must be met for consent to occur.

Although a balance must be met between arguments for and against obtaining consent, clinicians should seek informed consent in all but exceptional circumstances. Obtaining consent depends on the adequate presentation of information, the absence of duress and the patients' capacity to consent. Various tests of capacity to consent have been proposed.

It is proposed that clinicians employ a proforma to record attempts to obtain informed consent during routine clinical practice.

The prevalence rate of behaviour problems and maternal mental disturbance was estimated using a sample of 1047 families with a 3-year-old child from a mixed urban/rural area.

Parents completed the Child Behaviour Checklist, EAS Temperament Questionnaire, Weiss–Werry–Peters Activity Scale and the GHQ–30.

The rate of behaviour problems (13.2%) was similar to that obtained in studies of urban children. The rate of maternal disturbance (27.6%) was lower than in other population samples. Few differences were found in the prevalence rates in the urban and rural areas.

Preschool children and their parents living in non-urban areas had the same rates of problems as those in conurbations. The service needs of such families are similar regardless of locality.

An age-related dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis is well recognised in animals, but still remains controversial in humans. There is increasing interest that raised corticosteroid levels, due to activation of the HPA axis, may cause both depressive symptoms and cognitive impairments. Steroid effects on cognition may be via the hippocampus, a major site of corticosteroid action and an important structure involved in learning and memory.

To investigate this further, we examined the relationship between the dexamethasone suppression test, cognitive function, depressive symptoms and hippocampal atrophy on magnetic resonance imaging (MRI) in 32 normal controls, 49 subjects with NINCDS/ADRDA Alzheimer's disease and 51 patients with DSM–III–R Major Depression.

Controlling for differences in dexamethasone concentrations, post-dexamethasone cortisol levels were related to advancing age in controls and depressed subjects. However, among subjects with Alzheimer's disease, post-dexamethasone cortisol levels were independently associated with both minor depressive symptoms and hippocampal atrophy on MRI.

An association between advancing age and increased HPA axis dysregulation is supported for controls and depressed subjects. In Alzheimer's disease, HPA axis changes were associated with depressive symptoms and hippocampal atrophy. Longitudinal studies are now needed to determine the causal direction of these associations.

The development of appropriate community care requires knowledge of the characteristics of the severely mentally ill.

All patients with a broad diagnosis of schizophrenia (n=528) were identified via key informants within an inner London health district; Feighner and DSM–III–R criteria for schizophrenia were applied. Clinical and social status, psychopathology (Manchester Scale) and problem behaviours (Social Behaviour Schedule) were assessed in a 4:5 representative sample.

Fifty-seven per cent had experienced at least one compulsory admission. Forty-five per cent (excluding long-stay in-patients) had marked positive psychotic symptoms; social isolation and lack of daytime activity was more common than among comparable populations elsewhere. One hundred and eleven (25%) of the non-hospitalised patients were not in contact with specialist services.

Difficulties in establishing and maintaining a therapeutic alliance between patients and professionals present a challenge to services in inner London. Many social and occupational needs were not being met by existing community provision.

The new reversible MAOI moclobemide was compared with placebo in the treatment of elderly patients with DSM–III diagnosis of dementia and/or of major depression.

Six hundred and ninety-four elderly patients with symptoms of depression and cognitive decline entered an international, multi-centre, double blind trial in which they were randomly allocated to treatment with either moclobemide 400 mg daily or placebo for 42 days. Five hundred and eleven patients met DSM–III criteria for dementia and were also depressed (DEM+D); 183 did not meet DSM–III criteria for dementia but met the criteria for DSM–III major depressive episode and also suffered from cognitive decline (MDE+CD).

Analysis of the 17 and 24-item Hamilton Depression Scale scores showed that moclobemide, compared with placebo, produced significantly greater improvement in both the demented and depressed groups (P = 0.001 both diagnostic groups). There was an improvement in cognitive function as measured by the SCAG Factor 1 in moclobemide treated patients (P = 0.005 DEM+D; P = 0.02 MDE+CD). There was no evidence of decline in cognitive function as the result of treatment Clinical global assessment of tolerance was ‘excellent’ and ‘good’ in 88% of the moclobemide and in 92% of the placebo treated patients. The proportion of patients discontinuing treatment prematurely was similar in both treatment groups. There were no significant differences in side-effects between treatment groups. There were no significant changes in vital signs, ECG or laboratory findings in either treatment group. There were no dietary restrictions and no report of any tyramine reaction.

Moclobemide was shown to be a safe, well tolerated and effective antidepressant, which did not cause impairment of cognitive function in elderly patients with a DSM–III diagnosis of dementia and/or DSM–III major depression.

So far no comprehensive systematic review has been published about epidemiologic studies on suicides among medical practitioners. The aim here is to describe the variation of published estimates of relative risk of doctors to die from suicide.

A systematic review of published original articles on population-based studies, registered mainly in MEDLINE and fulfilling specific methodological requirements. Incidence rates and standardised mortality ratios were calculated for male and female doctors in relation to the reference groups.

The estimated relative risk varied from 1.1 to 3.4 in male doctors, and from 2.5 to 5.7 in female doctors, respectively as compared with the general population, and from 1.5 to 3.8 in males and from 3.7 to 4.5 in females, respectively, as compared with other professionals. The crude suicide mortality rate was about the same in male and female doctors.

In all studies the suicide rates among doctors were higher than those in the general population and among other academic occupational groups.

Investigation of the geographical distribution of schizophrenia and its relationship to socio-demographic factors is useful for planning services.

Individuals with schizophrenia (n=980) were identified by key informants within an inner London borough and point prevalence calculated for broad, Feighner and DSM–III–R schizophrenia. The distribution of cases was tested for significant variation using the Poisson process model. Regression models using the Jarman-8 score and its component variables were tested for their ability to predict the prevalence of schizophrenia.

A high point prevalence of schizophrenia (5.3 per 1000 resident population) was demonstrated. Case distribution showed a marked and significant variation associated with socio-demographic factors. The prediction of prevalence was more accurate for broad than for narrower definitions of schizophrenia; unemployment rate performed best.

Unemployment rates and Jarman-8 scores may provide crude estimates for resource allocation in planning mental health services, highlighting the need for additional services in deprived inner city areas.

The natural course of cognitive performance, electrophysiological alterations and brain atrophy in ageing and Alzheimer's disease (AD) has been investigated in numerous studies, but only few attempts have been made to examine the relationship between clinical, electroencephalographic (EEG) and morphological changes with quantitative methods prospectively over longer periods of time.

Fifty-five patients with clinically diagnosed AD and 66 healthy elderly controls were examined biannually using a cognitive test (CAMCOG), EEG band power and volumetric estimates of brain atrophy.

On average cognitive performance deteriorated by 28 points on the CAMCOG in the AD group, the alpha/theta ratio decreased by 0.2, and the proportion of intracranial cerebrospinal fluid volume increased by 3.5% during a 2-year period. Similar changes were observed after a second 2-year interval. A multiple regression model demonstrated a significant influence of age on cognition and atrophy and a significant influence of the estimated duration of symptoms on cognition, alpha/theta ratio and brain atrophy at the initial examination. Cognitive performance at the first examination exerted significant effects on the performance and also on brain atrophy at re-examination after 2 or 4 years, whereas the EEG and neuroimaging findings at the previous examination were exclusively related to the corresponding findings at the follow-up examinations. In the control group no significant cognitive, EEG and morphological changes were observed after 2 and 4 years.

After 2 consecutive follow-up periods, we were able to verify significant deteriorations of cognition accompanied by neurophysiological and neuroradiological changes in AD, but not in normal ageing. In clinically diagnosed AD, cognitive performance at the follow-up examination could not be predicted by the previous alpha/theta ratio or by the previous degree of global brain atrophy, whereas the cognitive test score determined not only performance, but also structural findings at follow-up. Performance on cognitive tests appears to be a more sensitive indicator of the degenerative process than EEG band-power and morphological changes in manifest AD. Neuroimaging, neurophysiology and genetic risk markers may be more important for the early differential diagnosis than for the prediction of the course of illness.

Investigation to see if there are key psychological risk indicators for autism in a random population study of children at 18 months of age; and to assess how well these discriminate children who receive a diagnosis of autism from other forms of developmental delay.

Sixteen thousand children in the southeast of England were screened for autism by their health visitor or GP, during their routine 18-month-old developmental check-up, using the CHAT (Checklist for Autism in Toddlers). From a previous high-risk study we predicted that children at 18 months of age who failed three items (‘protodeclarative pointing‘, ‘gaze-monitoring‘, and ‘pretend play’) would be at risk for receiving a diagnosis of autism. From other evidence, we further predicted that those 18-month-olds who failed one or two of the key items (either pretend play, or protodeclarative pointing and pretend play) would be at risk for developmental delay without autism.

Twelve children out of the total population of 16 000 consistently failed the three key items. Of these, 10 (83.3%) received a diagnosis of autism. Thus, the false positive rate was 16.6% (2 out of 12 cases), and even these 2 cases were not normal. When the 10 children with autism were reassessed at 3.5 years of age, their diagnosis remained the same. Thus the false positive rate among the cases diagnosed with autism was zero. In contrast, of 22 children who consistently failed either protodeclarative pointing and/or pretend play, none received a diagnosis of autism, but 15 (68.2%) received a diagnosis of language delay.

Consistent failure of the three key items from the CHAT at 18 months of age carries an 83.3% risk of autism; and this pattern of risk indicator is specific to autism when compared to other forms of developmental delay.

An earlier study of 291 world famous men had shown that only visual artists and creative writers were characterised, in comparison with the general population, by a much higher prevalence of pathological personality traits and alcoholism. Depressive disorders, but not any other psychiatric conditions, had afflicted writers almost twice as often as men with other high creative achievements. The present investigation was undertaken to confirm these findings in a larger and more comprehensive series of writers, and to discover causal factors for confirmed high prevalences of affective conditions and alcoholism in writers.

Data were collected from post-mortem biographies and, where applicable, translated into DSM diagnoses. The frequencies of various abnormalities and deviations were compared between poets, prose fiction writers, and playwrights.

A high prevalence in writers of affective conditions and of alcoholism was confirmed. That of bipolar affective psychoses exceeded population norms in poets, who in spite of this had a lower prevalence of all kinds of affective disorders, of alcoholism, of personality deviations, and related to this, of psychosexual and marital problems, than prose fiction and play writers.

A hypothesis is developed, which links the greater frequency of affective illnesses and alcoholism in playwrights and prose writers, in comparison with poets, to differences in the nature and intensity of their emotional imagination. This hypothesis could be tested by clinical psychologists collaborating with experts in literature on random samples of different kinds of writers.

The extent to which certain maternal, child and family characteristics are associated in families with a 3-year-old child were examined.

A total population of families with a 3-year-old child and living in the New Forest were identified. Measures of child behaviour and the maternal GHQ-30 were obtained.

Whereas behaviour problems were found to be significantly associated with all maternal and family factors (except social class), difficult temperament was only related to mother's recall of their own childhood as unhappy and overactivity was only significantly associated with maternal disturbance.

The results are consistent with maternal disturbance and difficult temperament acting independently and additively to influence the development of behaviour problems in preschool children.

We wished to establish whether the occurrence of schizophrenia among twins is the same as among the general population.

Through record linkage between the New Danish Twin Register and the Danish Psychiatric Case Register, the twins who have ever received a diagnosis of schizophrenia were identified. Through indirect standardisation for age, sex and dates of admission, the rate of first admission with diagnosis schizophrenia among twins is compared to the same rate in the general population.

A 28% increase in the rate of first admissions for schizophrenia in twins compared to the general population was found. This is statistically significant and does not seem to be caused by any known methodological problems. Twins also had an increased first-admission rate of any psychiatric disorders.

This increased risk does not seem to be explained by known methodological problems, but does differ from earlier studies.