Factors associated with aggression among psychiatric in-patients are still poorly understood. Inconsistent published findings are partly attributable to methodological problems. Much previous research has been undertaken in specialist settings, where conditions are likely to differ from those in acute admission wards.

Levels of aggression were ascertained weekly by staff report, using a reliable measure, for every patient on five acute admission wards and one locked intensive care ward at two hospitals prospectively over a five-month period.

Levels of aggression varied considerably among the admission wards. Aggression was more common on the locked ward and among younger patients. Factors associated with aggression changed with time since admission (seldom examined in previous studies). Complex associations were found with gender, ethnic group and diagnosis.

Some of the findings might be explicable by differences in ward environment, and staff–patient interactions. Further investigation into these is warranted.

The reported prevalence rates of dementia in people with Down's syndrome have varied considerably across studies. The aim of this study was to investigate the extent of clinical change with age using an established diagnostic instrument in an unbiased, population-based sample of older people with Down's syndrome.

Changes in memory, personality, general mental functioning and daily living skills were assessed using a modified version of the informant interview of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX).

Age-specific prevalence rates of dementia varied according to the diagnostic criteria used. Using CAMDEX criteria for Alzheimer's disease, prevalence rates increased from 3.4 to 10.3 to 40% in the 30–39, 40–49 and 50–59 age group, respectively.

Overall, the age-related pattern of presentation and dementia diagnoses differs from that seen in the general elderly population. However, age-specific prevalence rates of Alzheimer's disease were similar but 30–40 years earlier in life.

A randomised controlled trial was conducted in an acute treatment setting to examine the effectiveness of compliance therapy, a brief pragmatic intervention targeting treatment adherence in psychotic disorders, based on motivational interviewing and recent cognitive approaches to psychosis.

Seventy-four patients with psychotic disorders according to DSM–III–R criteria recruited from consecutive admissions to an acute in-patient unit, received 4–6 sessions of either compliance therapy or non-specific counselling, and were followed-up over 18 months. The principal outcome measures were observer-rated compliance, attitudes to treatment, insight and social functioning.

Significant advantages were found for the compliance therapy group post-treatment on measures of insight, attitudes to treatment and observer-rated compliance which were retained over the follow-up period. Global social functioning improved relatively more over time in the compliance therapy group compared with the control group. Survival in the community prior to readmission was significantly longer in the compliance therapy group.

The results support the effectiveness of compliance therapy in improving functioning and community tenure after an acute psychotic episode.

We compared the anti-depressant and cognitive effects of up to eight sessions of bilateral, brief pulse electroconvulsive therapy (ECT) administered twice (ECT x 2) or three times weekly (ECT x 3), to confirm that ECT x 3 acts more rapidly although the two schedules are equivalent in antidepressant outcome, and to establish whether ECT x 3 is indeed associated with more severe memory impairment.

Patients with major depression, endogenous subtype were randomly assigned to ECT x 3 or ECT x 2 plus one simulated ECT per week, both up to a maximum of eight real ECT. Depression was evaluated by the Hamilton Depression Scale the day after each treatment and cognitive function by a test battery administered before and after the ECT series and at one month follow-up.

Assessed categorically or parametrically, there was no significant difference in antidepressant outcome between the two schedules. Rate of response was significantly more rapid with ECT x 3 but was associated with more severe memory impairment.

Twice weekly administration is an optimum schedule for bilateral ECT unless clinical indications require the more rapid antidepressant effect of three times weekly treatment.

Three studies compared olanzapine and haloperidol given orally in maintenance therapy for schizophrenia and related psychoses.

Data were from double-blind extensions of acute studies. The subjects met criteria for schizophrenia, schizophreniform disorder or schizoaffective disorder. Subjects had responded to acute therapy (Brief Psychiatric Rating Scale total score decreased $ 40% from baseline (Studies 1, 2, and 3) or was $ 18 (Studies I and 2)) and were out-patients at their last acute phase visit. Relapse was defined as hospitalisation for psychopathology. Subjects treated with olanzapine in the three studies were pooled to form the olanzapine group and subjects treated with haloperidol were pooled to form the haloperidol group.

Olanzapine-treated subjects experienced less relapse (P=0.034). The Kaplan-Meier estimated one-year risk of relapse was 19.7% with olanzapine and 28% with haloperidol.

Olanzapine was superior to haloperidol in the maintenance therapy of schizophrenia and related psychoses.

Knowledge of working capacity from adolescence until adulthood among severely disturbed in-patients is scarce.

In a follow-up study of 61 adolescent in-patients, we studied associations between being on a disability pension 20 years after hospitalisation, and the patients' psychopathology and treatment-related factors during the hospitalisation and seven-year follow-up.

Of the former in-patients. 27% had not been on a disability pension, 20% had short-term pension periods, and 53% were pensioned. Subjects whose overall psychosocial functioning had improved and who had not utilised in-patient services until the seven-year follow-up, had a better prognosis in terms of working capacity Half of the subjects who had not been on pension during the follow-up had received a diagnosis of conduct disorder at discharge, and half of those pensioned had a psychotic disorder.

The patients' level of psychosocial functioning and capability to work in young adulthood were associated with long-term prognosis in terms of working capacity Adolescence seems to be the critical time for intensive psychiatric care combined with vocational rehabilitation programmes.

Hypo-activation of the left dorsolateral prefrontal cortex is inconsistently found in neuroimaging studies of schizophrenia. As the left dorsolateral prefrontal cortex is involved in the generation of action, disordered function in this region may be implicated in schizophrenic symptomatology.

We used H215O positron emission tomography to study dorsolateral prefrontal cortical function in men with schizophrenia (n=13) and male control subjects (n=6) performing joystick movements on two occasions, 4–6 weeks apart. The patients were initially in relapse. To clarify dorsolateral prefrontal cortical function we also scanned another group of control subjects (n=5) performing mouth movements.

The control subjects performing hand or mouth movements activated the left dorsolateral prefrontal cortex to a maximum when the movements were self-selected. The men with relapsed schizophrenia exhibited left dorsolateral prefrontal cortical hypo-activation, which remitted with symptomatic improvement.

Hypofrontality in these patients is a dynamic phenomenon across time, possibly related to current symptomatology. The most appropriate question about the presence of hypofrontality in schizophrenia may be when, rather than whether, it will occur.

This study tests the hypothesis that epilepsy increases the risk of developing schizophrenia and other non-affective functional psychoses using a nationwide sample of people with epilepsy.

A record linkage study between a sample from the National Patient Register, consisting of 67 116 people with epilepsy, and the Danish Psychiatric Register identified all people with non-affective psychoses with onset after the first epilepsy diagnosis. The relation between risk of psychiatric disorder in people with epilepsy and the general Danish population was estimated.

The incidences of the spectrum of non-organic non-affective psychosis, non-affective psychosis and schizophrenia were significantly increased both for men and women, even after exclusion of people diagnosed as suffering from a learning disability or substance misuse.

This study supports the notion of an association between epilepsy and the risk of subsequent non-affective psychosis.

Animal experimental studies suggest that repeated administration of selective serotonin reuptake inhibitors (SSRIs) produces complex adaptive changes in brain serotonin (5-HT) pathways. The effect of these adaptive changes on different aspects of brain 5-HT neurotransmission and their clinical consequences are not well understood.

We studied the effect of repeated administration of the SSRI, paroxetine (20 mg daily), on the Cortisol responses to the 5-HT precursor, 5-hydroxytryptophan (5-HTP), in healthy subjects and depressed patients.

In healthy subjects, following one week of paroxetine treatment there was a large increase in the Cortisol response to 5-HTP. This increase had all but disappeared following 3 weeks treatment. In contrast, in depressed patients treated with paroxetine for 8 weeks, the Cortisol response to 5-HTP was significantly increased.

SSRI treatment in depressed patients produces a persistent increase in the Cortisol response to 5-HTP, a probable measure of neurotransmission at central 5-HT2 receptors. Potentiation of 5-HT2 neurotransmission is unlikely to account for the efficacy of SSRIs in major depression but might underlie their actions in obsessive–compulsive disorder and also perhaps certain of their adverse effects, notably sexual dysfunction.

We describe a national cohort of individuals surviving an episode of deliberate self-harm (DSH). Subsequent admissions for DSH and mortality over the following 13 years were studied.

In 1981, 8304 individuals were discharged from Scottish general hospitals with a diagnosis of attempted suicide (E950–959). They were followed-up to the end of 1994 using the Scottish Linked Data Set. Mortality was compared to the Scottish population using person-years analysis.

2624 people (31.6%) were readmitted with further episodes of DSH. The median number of readmissions was I, range 1–137. The observed: expected ratio for all-cause mortality was 2.26 (95% CI 2.13–2.26). One hundred and sixty-eight people (2%) died from suicide, and 46 (0.6%) from undetermined causes. The observed: expected ratio for suicide plus undetermined deaths was 12.17 (95% CI 10.64-13.91). Accidental deaths in men and homicide deaths in men and women were elevated. The pattern of deaths from other causes suggested that alcohol misuse was a contributory factor.

People admitted to general hospitals in Scotland after attempted suicide are at high risk of readmission for further episodes of DSH. Long-term follow-up of such large cohorts is impractical, but services should review the scope for intervention in alcohol misuse following DSH.

Previous estimates of the prevalence of seasonal affective disorder (SAD) in community samples have been in the range 2–10%, using methods not derived from DSM algorithms. We report the first community-based study to estimate major and minor depression with a seasonal pattern in a community-based sample using a diagnostic instrument derived from DSM–III–R.

A modified version of the Composite International Diagnostic Interview was administered to 8098 subjects in the 48 coterminous states of the USA (the National Comorbidity Survey) to assess the prevalence of major and minor depression with a seasonal pattern.

The lifetime prevalence of major depression with a seasonal pattern was 0.4%, and the prevalence of major or minor depression with a seasonal pattern was 1.0%. Among respondents with major depression, male gender and older age were associated with a higher prevalence with a seasonal pattern.

Prevalence estimates of major and minor depression with a seasonal pattern are much lower than those found in previous studies of SAD in the community probably due to the approach to diagnosis used in the present study which more accurately represents DSM–III–R criteria for major depression with a seasonal pattern. The distribution of the disorder is similar to that found in previous studies except for the higher prevalence among males.

Non-compliance rates with antipsychotic medication can be high, and the personal and societal costs are considerable. A new psychological intervention, compliance therapy seeks to improve compliance and patient outcomes and reduce treatment costs.

A randomised controlled study examined the cost-effectiveness of compliance therapy compared to nonspecific counselling over 18 months for 74 people with psychosis admitted as inpatients at the Maudsley Hospital. Bivariate and multivariate analyses were conducted to test for differences and to explore inter-patient cost variations.

Compliance therapy is more effective and is no more expensive. Consequently, compliance therapy is more cost-effective than non-specific counselling at six, 12 and 18 months.

There are compliance, outcome and cost-effectiveness arguments in favour of compliance therapy in preference to non-specific counselling.

The Daily Living Programme (DLP) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital, London. The cost-effectiveness of the DLP was examined over four years.

A randomised controlled study examined cost-effectiveness of DLP versus standard in/out-patient hospital care over 20 months, followed by a randomised controlled withdrawal of half the DLP patients into standard care. Three patient groups were compared over 45 months: DLP throughout the period, DLP for 20 months followed by standard care, and standard care throughout. Bivariate and multivariate analyses were conducted (the latter to standardise for possible inter-sample differences stemming from sample attrition and to explore sources of within-sample variation).

The DLP was more cost-effective than control care over months 1–20, and also over the full 45-month period, but the difference between groups may have disappeared by the end of month 45.

The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care, although sample attrition left some comparisons under-powered.

It has been suggested that prenatal exposure to maternal stress increases the risk of subsequently developing schizophrenia.

The five-day invasion and defeat of The Netherlands by the German army in May 1940 constituted a severe, well-circumscribed national stressful event. Individuals exposed and non-exposed to this stressor in the first, second and third trimester of pregnancy were followed up for lifetime schizophrenia outcome through the National Psychiatric Case Register.

Cumulative incidence of schizophrenia was higher in the exposed cohort (risk ratio (RR): 1.15, 95% CI: 1.03–1.28), especially in those exposed in the first trimester (RR: 1.28, 95% CI: 1.07–1.53). Significant interaction with gender was apparent in second trimester exposed cohorts (RR men: 1.35, 95% CI: 1.05–1.74; RR women: 0.83, 95% CI: 0.61–1.12).

Maternal stress during pregnancy may contribute to the development of vulnerability to schizophrenia. The apparent longer window of exposure in male foetuses may be related to the slower pace of male early cerebral development.

People with schizophrenia show impaired attention. This could result from reduced latent inhibition (a measure of ability to filter out irrelevant stimuli). Previous studies have found reduced auditory latent inhibition in people with acute schizophrenia: we tested whether this results from psychosis or from drug treatment.

We measured auditory latent inhibition in two studies. One compared antipsychotic-naive people with acute schizophrenia with patients within two weeks of starting antipsychotic treatment. The second compared healthy volunteers given either saline or 1.0 mg haloperidol, intravenously.

Latent inhibition was absent in treated patients, but was clearly present in patients who were naive to antipsychotics. Latent inhibition was absent in volunteers given haloperidol, but was clearly present in those given saline.

The reduced auditory latent inhibition seen in acute schizophrenia is more plausibly due to antipsychotic treatment than to the disorder. Unless neuropsychological models of schizophrenia incorporate evidence from drug-free patients and drug-treated healthy controls, they may be invalid.

Emotional memory is a special category of memory for events arousing strong emotions. To investigate the effects of emotional involvement on memory retention in individuals with Alzheimer's disease we studied peoples' memories of distressing experiences during a devastating earthquake.

Fifty-one subjects with probable Alzheimer's disease who experienced the Kobe earthquake at home in the greater Kobe area were studied. Memories of the earthquake were assessed 6 and 10 weeks after the disaster in semi-structured interviews, and were compared with memories of a magnetic resonance imaging (MRI) examination given after the earthquake.

Forty-four (86.3%) of the subjects remembered the earthquake and 16 (31.4%) of subjects remembered the MRI experience. Factual content of the earthquake was lost in most of the subjects.

Fear reinforces memory retention of an episode in subjects with Alzheimer's disease but does not enhance retention of its context, despite repeated exposure to the information.

Alcohol use disorders (AUDs) among the Yami aborigines in Taiwan were investigated and compared with four other Taiwanese aboriginal groups.

A sample survey was conducted using a semi-structured clinical interview for AUDs among 252 subjects, aged 15 and above, from two Yami villages on Orchid Island.

The prevalences of DSM–III–R and DSM–IV alcohol use disorders were 13.1% and 10.3% by one year, and 17.5% and 15.2% by lifetime, respectively with a male excess. The risk for AUDs in Yami men was significantly associated with a lower educational level, a non-married status, and the length of stay in mainland Taiwan. A protective effect of Christian belief was evident for lifetime risk for AUDs.

The lower prevalences of AUDs in Yami than in other aboriginal groups in Taiwan might be explained by social isolation of the former, and differences in drinking tradition, availability of alcohol, biological vulnerability, and the extent of acculturation between these groups.