Tricyclic antidepressants have similar efficacy and slightly lower tolerability than selective serotonin reuptake inhibitors (SSRIs). However, there are no systematic reviews assessing amitriptyline, the reference tricyclic drug, v. other tricyclics and SSRIs directly.

To review the tolerability and efficacy of amitriptyline in the management of depression.

A systematic review of randomised controlled trials (RCTs) comparing amitriptyline with other tricyclics/heterocyclics or with an SSRI.

We reviewed 186 RCTs. The overall estimate of the efficacy of amitriptyline revealed a standardised mean difference of 0.147 (95% CI 0.05–0.243), significantly favouring amitriptyline. The overall OR for dropping out was 0.99 (95% CI 0.91–1.08) and that for side-effects was 0.62 (95% CI 0.54–0.70), favouring the control drugs. With drop-outs included as treatment failures, the estimate of the effectiveness of amitriptyline v. tricyclics/heterocyclics and SSRIs showed a 2.5% difference in the proportion of responders in favour of amitriptyline (number needed to treat 40, CI 21–694; OR 1.12 (95%CI 1.01–1.24)).

Amitriptyline is less well tolerated than tricyclics/heterocyclics and SSRIs, but slightly more patients treated on it recover than on alternative antidepressants.

Studies highlighting the difficulties associated with lithium suggest that the role of antipsychotic drugs and mood stabilisers in bipolar disorder should be reconsidered.

To review the efficacy and mode of action of antipsychotic drugs in mania, and to consider the differences between official guidelines and routine clinical practice in the use of these agents for mania.

Review of research, guideline- and practice-based literature.

Guidelines recommend lithium or valproate as first-line treatments for mania, and antipsychotic agents only as ‘adjuncts’ for agitation, dangerous behaviour or psychosis. However, in routine practice, antipsychotic drugs are often prescribed. The effectiveness of these agents in mania has been established by several studies; newer atypical compounds demonstrate antimanic efficacy with a reduced incidence of neurological side-effects.

Antipsychotic drugs are important in the treatment of bipolar disorder and mania. Future studies should evaluate the long-term efficacy and safety of newer atypical antipsychotic agents, and the place of anticonvulsants in combination with antipsychotics in bipolar disorder.

Published studies of prevalence of depression in old age in Taiwan have yielded equivocal results.

To study the prevalence of depressive disorders among community-dwelling elderly; further, to assess socio-demographic correlates and life events in relation to depression.

A randomised sample of 1500 subjects aged 65 and over was selected from three communities. Research psychiatrists conducted all assessments using the Geriatric Mental State Schedule. The diagnosis of depression was made with the GMS–AGECAT (Automated Geriatric Examination for Computerised Assisted Taxonomy); data on life events were collected with the Taiwanese version of the Life Events and Difficulties Schedule.

One-month prevalence of psychiatric disorders was 37.7%, with 15.3% depressive neurosis and 5.9% major depression. A high risk of depressive disorders was found among widows with a low educational level living in the urban community, and among those with physical illnesses.

Contrary to most previous reports, we found that the prevalence of depressive disorders among the elderly in the community in Taiwan is high and comparable to rates reported in some studies of UK samples.

Many patients with depression take benzodiazepine drugs long term despite the absence of continuing therapeutic value.

To evaluate a treatment programme involving gradual discontinuation with or without simultaneous selective serotonin reuptake inhibitor (SSRI) prescribing and to determine the long-term outcome after benzodiazepine withdrawal.

Patients went through three phases – change to an equivalent dose of diazepam; subsequent randomisation to either 20 mg of paroxetine or placebo; and gradual reduction of diazepam in depression-free patients – with a follow-up after 2 or 3 years.

A total of 230 patients were recruited and 75% in the paroxetine group and 61% in the placebo group were successfully treated after 6 weeks (P=0.067). After 2 or 3 years 13% of patients were still benzodiazepine free: 26% of those who had successfully tapered off benzodiazepine and 6% of the total group.

Transfer to diazepam followed by gradual withdrawal is an effective way of discontinuing chronic benzodiazepine use. The addition of SSRI treatment is of limited value.

Multivariate genetic research indicates that genetic effects on diverse cognitive abilities are general rather than specific or modular. General cognitive ability (g), a key factor in learning and memory, is among the most heritable behavioural traits.

To give a brief overview of quantitative genetic research on g and to describe initial results from a programme of research that aims to identify genes responsible for the substantial heritability of general cognitive ability.

The research uses a new technique called DNA pooling, which combines DNA from individuals within a group and makes it feasible to screen thousands of DNA markers for a systematic scan of the genome for associations between DNA markers and g. Two independent samples of children with very high g scores and two control samples of children with average g scores were compared in a systematic scan of 147 markers on chromosome 4 and 66 markers on chromosome 22.

Three replicated associations on chromosome 4 were identified using DNA pooling and confirmed using individual genotyping.

These first results of the application of DNA pooling in systematic analysis of allelic association are encouraging.

There is no evidence to support current advice not to use benzodiazepines after bereavement.

To determine the role of benzodiazepines in the management of bereavement.

We conducted a randomised, double-blind, placebo-controlled evaluation of the use of diazepam after recent bereavement. Participants were randomised to either 2 mg diazepam or identically packaged placebo up to three times daily. The primary outcome measure was the Bereavement Phenomenology Questionnaire.

Thirty subjects were randomised. No evidence was found of an effect of benzodiazepines on the course of the first 6 months of bereavement (estimated mean difference of combined follow-up assessments=0.3 in favour of placebo; 95% CI –6.2 to +6.7).

We found no evidence of a positive or negative effect of benzodiazepines on the course of bereavement.

Erectile dysfunction is a common, multi-factorial disorder.

To evaluate the efficacy, tolerability and frequency of use of sildenafil citrate in men with mild to moderate erectile dysfunction of no established organic cause.

This double-blind, randomised, placebo-controlled, flexible-dose, two-way crossover study was conducted at four centres in the UK in 44 men with mild to moderate erectile dysfunction of no clinically obvious organic cause. The study included two 28-day treatment periods, during which time sildenafil or placebo (25–75 mg, based on efficacy) was taken as required.

Compared with placebo, sildenafil was associated with increases in frequency of use, erections adequate for sexual intercourse and level of sexual satisfaction (P < 0.0001). More patients receiving sildenafil stated they would use the treatment again compared with those receiving placebo (P < 0.0001). There were no discontinuations due to sildenafil treatment.

Sildenafil is effective and well tolerated in men with mild to moderate erectile dysfunction of no clinically identifiable organic cause.

Psychiatric patients have a higher suicide risk following hospital discharge.

To identify social, clinical and health-care delivery factors in recently discharged patients.

Retrospective case-control study of 234 patients who died within 1 year of hospital discharge, matched for age, gender, diagnosis and admission period with 431 controls. Odds ratios for identified risk factors were calculated using conditional multiple logistic regression.

Independent increased-risk factors were: not being White; living alone; history of deliberate self-harm (DSH); suicidal ideation precipitating admission; hopelessness; admission under different consultant; onset of relationship difficulties; loss of job; in-patient DSH; unplanned discharge; significant care professional leaving/on leave. Reduced-risk factors were: shared accommodation; delusions at admission; misuse of non-prescribed substances; and continuity of contact.

Continuity of contact may reduce suicide risk. Discontinuity of care from a significant professional is associated with increased risk of suicide.

Velo-cardio-facial syndrome (VCFS) is associated with deletions in the q11 band of chromosome 22, learning disability and psychosis, but the neurobiological basis is poorly understood.

To investigate brain anatomy in adults with VCFS.

Magnetic resonance imaging was used to study 10 patients with VCFS and 13 matched controls. We carried out three analyses: qualitative; traced regional brain volume; and measurement of grey and white matter volume.

The subjects with VCFS had: a high prevalence of white matter hyperintensities and abnormalities of the septum pellucidum; a significantly smaller volume of cerebellum; and widespread differences in white matter bilaterally and regional specific differences in grey matter in the left cerebellum, insula, and frontal and right temporal lobes.

Deletion at chromosome 22q11 is associated with brain abnormalities that are most likely neurodevelopmental and may partially explain the high prevalence of learning disability and psychiatric disorder in VCFS.

Health planning should be based on data about prevalence, disability and services used.

To determine the prevalence of ICD–10 disorders and associated comorbidity, disability and service utilisation.

We surveyed a national probability sample of Australian households using the Composite International Diagnostic Interview and other measures.

The sample size was 10 641 adults, response rate 78%. Close to 23% reported at least one disorder in the past 12 months and 14% a current disorder. Comorbidity was associated with disability and service use. Only 35% of people with a mental disorder in the 12 months prior to the survey had consulted for a mental problem during that year, and most had seen a general practitioner. Only half of those who were disabled or had multiple comorbidity had consulted and of those who had not, more than half said they did not need treatment.

The high rate of not consulting among those with disability and comorbidity is an important public health problem. As Australia has a universal health insurance scheme, the barriers to effective care must be patient knowledge and physician competence.

During the development of a new treatment for bipolar disorder, maintenance studies are used to evaluate the ability of the putative mood stabiliser to prevent relapse and recurrence of further episodes. Comparisons with the early bipolar disorder maintenance studies indicate that the methodologies of recent trials have evolved substantially.

To review the methods used in the first- and second-generation maintenance studies, highlighting the differences of the various designs.

Literature review.

Methods that have evolved the most include patient enrolment, randomisation schemes and the use of outcome measures and statistical analyses. In addition, regulatory and commercial issues have also influenced study design.

There is little consensus on the methodology of bipolar disorder maintenance studies. As the integration of newer therapies into routine clinical practice is dependent on the evidence from controlled studies, it is essential that future maintenance trials in bipolar disorder achieve adequate methodological rigour without sacrificing overall feasibility.

There have been relatively few surveys in Latin America that have attempted to estimate the prevalence of psychiatric morbidity in private households.

To determine the prevalence of common mental disorders and socio-demographic correlates among adults from Santiago, Chile.

Cross-sectional survey of private households with a probabilistic sampling design was used. Common mental disorders were measured using the Clinical Interview Schedule–Revised (CIS–R).

Three thousand eight hundred and seventy adults were interviewed. Twenty-five per cent were CIS–R cases and 13% met criteria for an ICD–10 diagnosis. Low education, female gender, unemployment, separation, low social status and lone parenthood were associated with a higher prevalence.

Prevalence rates were higher than those found in urban areas of Great Britain, both for ICD–10 diagnoses and ‘non-specific neurotic disorders’. Similar socio-demographic factors were associated with an increased prevalence of common mental disorders in Chile as in the UK. There is a need to unify methodologies to be able to compare results internationally.

A number of studies have questioned whether the natural course of schizophrenia is more favourable in ‘developing’ than ‘developed’ societies and whether culture is a factor in producing a favourable course.

This prospective study tests the hypothesis that the natural outcome of schizophrenia would be favourable in a Chinese rural area.

We investigated all patients with schizophrenia, including patients who had not received any treatment, among 149 231 rural community population in Xinjin County, Sichuan in 1994. Those patients who had never received treatment were followed up for two years.

Three-quarters of patients with schizophrenia who had not been treated remained symptomatic. As the duration of illness increased, the illness became more serious. The clinical outcome of the drug-treatment group was significantly better than for patients who had not received any treatment.

The natural clinical outcome of schizophrenia in the Chinese rural community was poor, and occupational functioning of patients with schizophrenia was comparatively better. Schizophrenia itself has a specific natural course – antipsychotic drug treatment and psychosocial treatment will produce an improvement in prognosis.

It had been suggested that the antidepressant venlafaxine, which inhibits reuptake of both serotonin and (at higher doses) noradrenaline, may result in better outcomes than treatment with selective serotonin reuptake inhibitors (SSRIs).

To compare remission rates during treatment with SSRIs or venlafaxine.

Data from eight comparable randomised, double-blind studies of major depressive disorder were pooled to compare remission rates (Hamilton Rating Scale for Depression score ≤ 7) during treatment with venlafaxine (n=851), SSRIs (fluoxetine, paroxetine, fluvoxamine; n=748) or placebo (four studies; n=446).

Remission rates were: venlafaxine, 45% (382/851); SSRIs, 35% (260/748); placebo, 25% (110/446) (P < 0.001; odds ratio for remission is 1.50 (1.3–1.9), favouring venlafaxine v. SSRIs). The difference between venlafaxine and the SSRIs was significant at week 2, whereas the difference between SSRIs and placebo reached significance at week 4. Results were not dependent on any one study or the definition of remission.

Remission rates were significantly higher with venlafaxine than with an SSRI.

From 1978 to 1979, a group of people in Taiwan were exposed to high levels of heat-degraded polychlorinated biphenyls (PCBs) owing to accidental ingestion of contaminated rice oil. Children born to mothers following the exposure (‘Yucheng’ children) were known to have hyperpigmented skin and other dysmorphology after birth.

To determine the effect of prenatal exposure to PCBs on cognitive development in Yucheng children.

One hundred and eighteen Yucheng children prenatally exposed to PCBs and degradation products, and community-matched control children who were exposed to background levels only, were followed from 1985 to 1998. The Bayley Scale for Infant Development, Chinese version of the Stanford – Binet IQTest, Raven's Coloured Progressive Matrices and Raven's Standardised Progressive Matrices were used to assess the cognitive development of these children.

The Yucheng children scored lower than control children on each of these methods of measurement between the ages of 2 and 12 years.

Prenatal exposure to PCBs and their derivatives has long-term adverse effects on cognitive development in humans.

Exposure to external phobic cues is an effective therapy for panic/agoraphobia but the value of exposure to interoceptive cues is unclear.

Randomised controlled comparison in panic/agoraphobia of the effects of (a) external, (b) interoceptive or (c) combined external and interoceptive self-exposure to (d) control subjects.

Eighty out-patients were randomised to a control group or to one of three forms of self-exposure treatment (external, interoceptive, or combined). Each treatment included seven sessions over 10 weeks and daily self-exposure homework. Assessments were at pre- and post-treatment and up to 1 year post-entry. Assessors remained blind during treatment.

The three self-exposure groups improved significantly and similarly at post-treatment and up to 1-year follow-up, and significantly more than did the control subjects. Rates of improvement on main outcome measures averaged 60% at post-treatment and 77% at follow-up.

The three methods of self-exposure were equally effective in reducing panic and agoraphobic symptoms in the short- and long-term.

Schizophrenia has been linked with psychological problems in childhood but there is little information on precursors of affective psychosis.

To compare childhood psychological antecedents of adult schizophrenia and affective psychosis.

Childhood item sheets, which give standardised information on signs and symptoms of mental illness in the year preceding assessment are completed for all attendees at the children's department of the Maudsley and Bethlem Royal Hospital. We examined item sheet data on individuals with an adult diagnosis of schizophrenia (n=59) or affective psychosis (n=27) and a comparison group with no adult mental illness (n=86) (all had attended the department).

Abnormal suspiciousness or sensitivity and relationship difficulties with peers are associated with later schizophrenia. In contrast, affective psychosis is associated with childhood hysterical symptoms and disturbances in eating.

Childhood psychological precursors for schizophrenia and affective psychosis differ and do not simply reflect non-specific psychiatric disturbance in adolescence.

Psychiatric patients have an elevated risk of suicide while in hospital.

To compare social, clinical and health-care delivery factors in in-patient and out-patient suicides and their controls.

Retrospective case-control study of 59 in-patients and 106 controls, matched for age, gender, diagnosis and admission date. Odds ratios were calculated using conditional multiple logistic regression.

There were seven independent increased-risk factors: history of deliberate self-harm, admission under the Mental Health Act, involvement of the police in admission, depressive symptoms, violence towards property, going absent without leave and a significant care professional being on leave. When compared with out-patient suicides, in-patients were more often female and male in-patients had a psychotic illness. Unlike the out-patient suicides, social factors were not found to be significant.

The characteristics of inpatient and out-patient suicides differ. Identified risk factors have relatively low sensitivity and specificity.

Little is known about suicide in England in the medieval period. Legal records provide the best source of post-mortem data about suicides.

Selected Eyre records from the reigns of Henry III (1216–1272), Edward I (1272–1307), Edward II (1307–1327) and Edward III (1327–1377) were translated and examined for details of self-killing.

One hundred and ninety-eight cases of self-killing were found, eight of which were found to be accidental, non-felonious deaths. Self-killing was more common in men. Hanging was the most common and drowning the second most common method of self-killing in both males and females. Self-killing with sharp objects was predominantly a male method. Other methods of self-killing were rare. There were no reports of deliberate self-poisoning. There is some evidence of underreporting of, and attempts to conceal, self-killing from royal officers.

Eyre records suggest that although some of the facts surrounding self-killing have changed, others have remained constant, particularly the higher proportion of men who kill themselves and the greater use by men than women of sharp instruments to kill themselves. We discuss the description and understanding of psychiatric states by medieval English Eyres, particularly in terms of the perception of the mental states that accompanied suicidal actions.

There is increasing support for the use of cognitive behaviour therapy as an adjunct to medication for patients with bipolar disorder.

To explore current psychological models of bipolar disorder, describing the clinical rationale for using cognitive therapy and providing a brief overview of the approach.

Results from outcome studies are discussed.

Preliminary findings indicate that cognitive therapy may be beneficial for patients with bipolar disorder. The collaborative, educational style of cognitive therapy, the use of a stepwise approach and of guided discovery is particularly suitable for patients who wish to take an equal and active role in their therapy.

Randomised, controlled trials of cognitive therapy in bipolar disorder are required to establish the short-term and long-term benefits of therapy, and whether any reported health gain exceeds that of treatment as usual.