It has been suggested that there is frontal lobe involvement in schizophrenia, and that it may be lateralised and gender-specific.

To clarify the structure of the frontal lobes in schizophrenia in a postmortem series.

The volume of white matter and cortical components of the frontal lobes was measured in brains of controls and patients with schizophrenia using planimetry and the Cavalieri principle. The components measured were: superior frontal gyrus, middle frontal gyrus, a composite of inferior frontal gyrus and orbito-frontal cortex, as well as total frontal lobe cortex and white matter. In addition, the anterior cingulate gyrus was measured.

No diagnosis, gender, diagnosis × side, diagnosis × gender or diagnosis × gender × side interactions were observed in the volume of any of the components, the grey matter as a whole or the white matter. No evidence for volumetric inter-group differences was found for the anterior cingulate gyrus.

Such structural abnormalities as are present in the frontal lobes are more subtle than straightforward alterations in tissue volume; they may include changes in shape and the pattern of gyral folding.

Alzheimer's disease (AD) is a common, complex, age-related disorder in which both genetic and environmental factors are important.

To integrate recent studies on genetic and environmental factors in AD into a multi-factorial disease model.

Disease models to explain gene-environment interaction in cardiovascular disease are related to observations on AD.

Informative, community-based studies on the genetic epidemiology of AD are rare. Putative risk factors from the Scottish studies include increased paternal age in AD men and coal mining as paternal occupation in both AD and vascular dementia. Migration effects suggest that environmental factors in high-incidence AD areas are important during adult life.

The studies summarised do not provide sufficient data to support a single comprehensive disease model of gene-environment interaction in AD. Future studies will require very large (≥600) sample sizes, molecular genetic analysis, and environmental data that span neurodevelopment and the period between disease onset and appearance of clinical symptoms.

Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide.

To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients.

A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12–16 months later.

ICD–10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%.

Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.

The Stanley Foundation Bipolar Network (SFBN) was created to address the paucity of help studies in bipolar illness.

To describe the rationale and methods of the SFBN.

The SFBN includes five core sites and a number of affiliated sites that have adopted consistent methodology for continuous longitudinal monitoring of patients. Open and controlled studies are performed as patients' symptomatology dictates.

The reliability of SFBN raters and the validity of the rating instruments have been established. More than 500 patients are in continuous daily longitudinal follow-up. More than 125 have been randomised to one of three of the newer antidepressants (bupropion, sertraline and venlafaxine) as adjuncts in a study of mood stabilisers and 93 to omega-3 fatty acids. A number of open clinical case series have been published.

Well-characterised patients are followed in a detailed continuous longitudinal fashion in both opportunistic case series and double-blind, randomised controlled trials with reliable and validated measures.

It is not known whether mothers with psychotic disorders are clinically and socially distinct from women with psychoses who have not had children.

To determine the proportion of mothers in an epidemiologically representative population of women with psychotic disorders, to examine the factors associated with having children, and to examine the factors associated with having children ‘looked after’ by social services.

Descriptive analysis and two case–control studies.

Sixty-three per cent of women with psychotic disorders were mothers. There were no clinical differences between women with or without children, but mothers were more likely to be older and live in unsupported accommodation. Having had a ‘looked after’ child was associated with Mental Health Act detention, younger age, a forensic history and being Black African.

Many women with psychoses are mothers. Mothers with psychoses are as disabled and have as many needs as women with psychoses without children.

Psychiatric casualties are recognised as an important and inevitable feature of modern warfare. At the beginning of the 20th century they were scarcely acknowledged and still less treated. Today, as a result of lessons learned in the First and Second World Wars, numbers can be predicted on the basis of battle intensity and effective clinical interventions applied.

To discover more about the factors that cause psychiatric casualties and their relationship to total battle casualties.

A survey of historical War Office reports and the papers of Royal Army Medical Corps psychiatrists has provided both statistics and treatment strategies.

Reported psychiatric casualties were low in the Boer War, influenced, in part, by the misdiagnosis of psychosomatic disorders. Their incidence rose appreciably in the First World War with the identification of shell-shock and neurasthenia. The Second World War saw the collection of accurate data, and combat stress was treated efficiently, although few soldiers returned to fighting units.

A constant relationship exists between the incidence of the total killed and wounded and the number of psychiatric casualties, mediated by the nature of the fighting and quality of the troops involved.

Long-term follow-up has rarely been reported after self-exposure therapy for phobias.

Completion of such a follow-up.

Two-year follow-up was achieved in 68 (85%) of 80 patients with phobias who had completed a previous 14-week randomised controlled trial comparing therapist-accompanied self-exposure, self-exposure or self-relaxation. Measures were self-reported ratings of symptoms, satisfaction and use of other treatment.

Improvement at week 14 was maintained 2 years later. Clinician-accompanied exposure and self-exposure did not differ on any measure. Compliance with self-exposure homework during weeks 0–8 predicted more improvement 2 years later. Patients who failed to improve with relaxation by week 14 improved after subsequent crossover to exposure. A need for more treatment for their phobias was still felt by 33 patients (49%).

Patients with phobias maintained their improvement to 2-year follow-up after the end of self-exposure therapy.

Regional medium secure developments have proceeded unevenly, with wide variations in resources to deliver services.

To compare patients admitted to seven (pre-reorganisation) regional services and styles of service delivery.

A record survey of a complete sample of 2608 patients admitted on 3403 occasions between 1 January 1988 and 31 December 1994.

Services differed according to location of patients before admission, their legal basis for detention, criminal and antisocial behaviour, diagnosis, security needs and length of stay. Regions with more resources and lower demand provided a wider range of services. Thames services were relatively under-provided during the study period, with North East Thames substantially reliant on admissions to private hospitals.

Uncoordinated development led to under-provision despite high demand. Certain regions prioritised offender patients and did not support local psychiatric services. New standards are required for service specification and resource allocation to redress inequality. Traditional performance measures were of limited usefulness in comparing services.

The isolation experienced by many patients with severe psychotic disorders is generally assumed to be due to their social withdrawal. An alternative possibility is that relatives avoid frequent contact with patients because they find the situation distressing.

To examine the predictors of frequent patient-relative contact, in particular the role of relatives' experience.

UK700 trial data were used to determine baseline predictors of frequent contact and establish whether relatives' experience at baseline predicted continued frequent contact 2 years later.

Neither characteristics associated in the literature with relatives' ‘burden’ nor relatives' experience predicted patient-relative contact frequency. Instead, the predictors were mainly demographic.

Many relatives experience considerable distress, but the evidence does not suggest that they avoid frequent contact with the patient as a consequence.

The Stanley Foundation Bipolar Network (SFBN) evaluates treatments, course and clinical and neurobiological markers of response in bipolar illness.

To give a preliminary summary of emerging findings in these areas.

Studies with established and potentially antimanic, antidepressant and mood-stabilising agents range from open case series to double-blind randomised clinical trials, and use the same core assessment methodology, thereby optimising the comparability of the outcomes. The National Institute of Mental Health Life Chart Method is the core instrument for retrospective and prospective longitudinal illness description.

The first groups of patients enrolled show a considerable degree of past and present symptomatology, psychiatric comorbidity and functional impairment. There are associations of both genetic and early environmental factors with more severe courses of illness. Open case series with add-on olanzapine, lamotrigine, gabapentin or topiramate show a differential spectrum of effectiveness in refractory patients.

The SFBN provides important new data for the understanding and treatment of bipolar disorder.

Increased rates of schizophrenia continue to be reported among the African–Caribbean population in England.

To evaluate the competing biological, psychological and social explanations that have been proposed.

Literature review.

The African–Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African–Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings.

More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

Cerebral lateralisation appears to be decreased in schizophrenia. Results of studies investigating this, however, are equivocal.

To review quantitatively the literature on decreased lateralisation in schizophrenia.

Meta-analyses were conducted on 19 studies on handedness, 10 dichotic listening studies and 39 studies investigating anatomical asymmetry in schizophrenia.

The prevalence of mixed- and left-handedness (‘non-right-handedness’) was significantly higher in patients with schizophrenia as compared to healthy controls, and also as compared to psychiatric controls. The analysis of dichotic listening studies revealed no significant difference in lateralisation in schizophrenia. However, when analysis was restricted to studies using consonant-vowel or fused word tasks, significantly decreased lateralisation in schizophrenia emerged. Asymmetry of the planum temporale and the Sylvian fissure was significantly decreased in schizophrenia, while asymmetry of the temporal horn of the lateral ventricle was not.

Strong evidence is provided for decreased cerebral lateralisation in schizophrenia.

The comparative outcome of psychosis in British Whites and UK African-Caribbeans is unclear. Some report that African-Caribbeans have worse outcome, whereas others claim better symptomatic outcome and a more benign course.

To compare the course, outcome and treatment of psychosis in African-Caribbeans and British Whites in a large multi-centre sample.

A secondary analysis of 708 patients with research diagnostic criteria-defined psychosis from a 2-year, randomised controlled trial of case management. Outcome measures (hospitalisation, illness course, self-harm, social disability and treatment received) were adjusted for socio-economic and clinical differences between groups at baseline using regression analysis.

African–Caribbeans were less likely to have a continuous illness and to receive treatment with antidepressants or psychotherapy.

The outcome of psychosis is complex but differs between UK African–Caribbeans and British Whites. This may reflect risk factors that increase the rate of psychosis in UK African–Caribbeans. Treatment differences require further investigation.

Recent research has reported increased risk of aggressive incidents by individuals with psychotic illness.

To examine acts of aggression in first-episode psychosis.

Subjects with a first-episode psychosis were ascertained from a defined catchment area (Nottingham, UK) and reassessed at 3 years (n=166) using clinical interview, informants, health care and forensic records.

Of the subjects, 9.6% demonstrated at least one act of serious aggression (defined as weapon use, sexual assault or victim injury) during at least one psychotic episode and 23.5% demonstrated lesser acts of aggression (defined as all other acts of aggression). For all aggressive subjects (33.1%), unemployment (OR=3.6, 95%CI 1.6–8.0), comorbid substance misuse (OR=3.1, CI 1.1–8.8) and symptoms of overactivity at service contact (OR=6.9, CI 2.7–17.8) had independent effects on risk of aggression.

We confirmed some previously reported demographic and clinical associations with aggression in first-episode psychosis but no relationship with specific psychotic symptoms or diagnostic groups was observed.

The relationship between adversity and genetic risk factors in depression could be mediated by familial ‘hazard prone’ traits, as reflected in high levels of sensation-seeking.

To examine whether high sensation-seeking scores are associated with more adverse life events resulting in depression.

In a sib-pair design, 108 probands with depression and their siblings and 105 healthy control subjects and their siblings were compared for psychopathology, life events and scores on the Sensation-Seeking Questionnaire (SSQ).

The SSQ scores were correlated negatively with depression, were familial and were correlated positively with less severe events, but not the severe events typically associated with depressive onsets.

The SSQ measures a familial personality trait and depression is associated with lower scores. Although high sensation-seeking is associated with a higher rate of life events, these carry little threat.

Little research has been carried out on the benefits of intensive case management (ICM) for people with borderline IQ and severe mental illness.

To compare outcome and costs of care of patients with severe psychotic illness with borderline IQ to patients of normal IQ and to assess whether ICM is more beneficial for the former than for the latter.

The study utilises data from the UK700 multi-centre randomised controlled trial of case management. The main outcome measure was the number of days spent in hospital for psychiatric reasons. Secondary outcomes were costs of care and clinical outcome.

ICM was significantly more beneficial for borderline-IQ patients than those of normal IQ in terms of reductions in days spent in hospital, hospital admissions, total costs and needs and increased satisfaction.

ICM appears to be a cost-effective strategy for a subgroup of patients with severe psychosis with cognitive deficits.

The effectiveness of lithium is being questioned increasingly and requires clarification.

To assess the effectiveness of lithium treatment in depression and mania, syndromal types I and II, with predominantly mixed or psychotic episodes or rapid cycling, during treatment resumed following discontinuation, and across three decades.

The longitudinal course of 360 patients with bipolar disorder compliant with lithium treatment for at least 1 year and without comorbidity for substance use disorder was reviewed.

Risk of single-episode recurrences, a common index of treatment failure, was similar to that in other reports. Both episode frequency and ‘time ill’ improved more in type II than type I cases. Reduced morbidity during treatment was similar in patients with mixed or psychotic episodes, or rapid cycling, and in less complex cases. Retreatment yielded minor decrements in response, and there was no tendency for lesser responses in more recent years.

Based on overall affective morbidity, long-term lithium treatment in compliant patients without comorbid substance use disorder, though imperfect, remains effective, even in subgroups of supposedly poor prognosis.

Underprovision by the National Health Service (NHS) has led to an increase in medium secure psychiatric beds managed by the independent sector. Black people are overrepresented in medium secure care.

To describe those people from an inner-London health authority occupying all forms of medium secure provision. To compare those in NHS provision with those in the independent sector, and Black patients with White patients.

A census of those in medium secure care in August 1997.

The 90 patients in independent-sector units were similar to the 93 patients in NHS units except that they were more likely to have been referred from general psychiatric services (48% v. 19%) and less likely to have been referred from the criminal justice system or a high-security hospital (37% v. 63%). There were few differences between Black and White patients.

The NHS meets only part of the need for medium secure care of the population of this London health authority. This comparison of the characteristics of Black and White patients does not help to explain why Black people are overrepresented in medium secure settings.

Reduced serotonergic (5-HT) function and elevated testosterone have been reported in aggressive populations.

To investigate relationships between impulsivity, aggression, 5-HT function and testosterone in male offenders with personality disorders.

Sixty male offenders with DSM–III–R personality disorders and 27 healthy staff controls were assessed using the Special Hospital Assessment of Personality and Socialisation (SHAPS), impulsivity and aggression ratings, d-fenfluramine challenge and plasma hormone concentrations.

The SHAPS non-psychopaths and those with schizoid personality disorders had enhanced 5-HT function (prolactin response to d-fenfluramine). Reduced 5-HT function was found in offenders with DSM–III–R borderline personality disorders and those with a history of repeated self-harm or alcohol misuse. The 5-HT function was inversely correlated more strongly with impulsivity than with aggression. Plasma testosterone correlated positively with aggressive acts. The SHAPS primary psychopaths had lower initial cortisol and higher testosterone concentrations than controls.

Future studies are needed to investigate regional brain 5-HT function.