There are many practical psychiatric, social, and ethical problems which accompany heart transplantation. These include pre- and postoperative anxiety and depressive conditions, postoperative delirium, and social and family dysfunctional syndromes. This paper reviews the literature critically in the following five areas: pre-transplant evaluation, coping with surgery, postoperative sequelae, rehabilitation, and management. Although most recipients have a good outcome from the physical and psychiatric points of view, a substantial minority experience family conflicts and sexual dysfunction after surgery. An average of 45% of patients from all studies returned to full-time employment. The distinctive role and contribution of the psychiatrist on the transplant team is discussed and important areas for future research are outlined.

The advent of new imaging techniques is broadening our understanding of the major psychiatric illnesses. The increased knowledge of brain function will have consequences for the expert medical witness who has to give evidence in court. Both the insanity defence and the defence of automatism depend on disorders of the mind. Psychiatry is now able in many cases to produce evidence that these are consequent upon disorders of the brain. In presenting evidence in court there is an apparent conflict between ‘brain words' and ‘mind words'.

The usual phenomena of cannabis intoxication include experiences which in a non-intoxicated state would be considered as psychiatric symptoms. These can be distinguished from adverse reactions to cannabis, the commonest of which is an acute anxiety state. Acute psychotic episodes can also follow ingestion of the drug but are infrequent. These can be classified as acute confusional states and episodes occurring in clear consciousness. Neither presentation consistently shows enough specific features to warrant the diagnosis of ‘cannabis psychosis' as a distinct clinical entity. The evidence that cannabis has a causative role in chronic psychotic or affective disorders is not convincing, although the drug may modify the course of an already established illness. Further controlled studies would be required to clarify the aetiological significance of the drug in these conditions.

The subversion of psychiatric intervention for political purposes in the USSR during the 1970s and 1980s resulted in both intra-psychic and subsequent adaptational dysfunction in those dissidents who physically survived it. Incarceration in special psychiatric hospitals subjected the inmates to a sense of helplessness under the control of a malevolent power, futility, despair, danger from close and contentious contact with hardened criminals and the violently insane, overdosage with mind-altering and body-distorting neuroleptic drugs, and a Kafkaesque ambiguity concerning the specific terms of institutionalisation. Discharge did not bring release from continued threats and the eroded social networks to which the inmates returned subjected them to a new set of stressors. While some families remained intact and provided necessary support during the re-entry period, many families had been destroyed either by the circumstances of the family member's incarceration or by the length of the victim's stay in the psychiatric hospital. Wives left, people died, friends deserted, jobs evaporated, and often there was not even a home to accept them. Social agencies were either hostile or indifferent to their plight. Many felt like they had been thrown overboard from a prison ship without a life preserver. It was the proverbial transition from the frying pan into the fire.

A large number of rating scales have been devised to assess the clinical construct of ‘depression’. These scales have been universally used in research with little consideration of their content, or how they relate to accepted definitions of depressive disorder. The scales are often arbitrarily selected and used for the study on the assumption that all measure the same construct. The item analysis of a number of the most widely used depression scales reveals a variation in the areas of psychopathology they cover; some scales place greater emphasis upon the assessment of anxiety than upon depressed mood. Since disturbance in neurobiological systems is manifest by specific aspects of affective and behavioural malfunction, and since psychodynamic factors lead to particular cognitive sets, the advancement of research will depend upon the construction and validation of more refined measures than are provided by the present approach.

In order to assess the safety and some efficacy aspects of clozapine under UK conditions, 54 in-patients with severe treatment-resistant schizophrenic disorders were evaluated using several scales before and during treatment. Of the 54 evaluated, 26 completed the 26-week study. Of these patients, 20 showed improvement in psychopathology, often to a marked degree, involving both positive and negative symptoms. Some oral-facial extrapyramidal side-effects decreased as well. Two patients developed neutropenia, but recovered on discontinuation of clozapine. The most frequent adverse event was hypersalivation, and five patients suffered from seizures. It is concluded that clozapine is worth considering for the treatment of severe treatment-resistant patients in the UK.

Over the past three years, progress in the molecular genetics of familial Alzheimer's disease has been fast and fundamental. The seminal finding that some cases are due to a mutation in the β-amyloid precursor protein (APP) gene has been followed by the discovery of a major additional locus for the disease on chromosome 14. The combined data suggest that the genetic sites accounting for most early-onset familial Alzheimer's disease cases have now been located. In addition, research is revealing the mechanisms by which the genes exert their pathogenicity. This promises to provide the explanatory link between the genes and the clinicopathological syndrome. The ultimate goal, an understanding in similar terms of the much commoner senile, sporadic form of Alzheimer's disease, is now a realistic target.

Psychopharmacology has revolutionised the practice of psychiatry and continues to evolve with developments in psychiatric nosology. It has provided the bridge for elucidating the biology of psychiatric disorders and has refined diagnostic distinctions with the introduction of highly specific agents such as lithium. Prediction in psychopharmacology has enhanced the clinical validity of psychiatric syndromes and has contributed to the delineation of meaningful subgroups, with implications for clinical practice.

Although both lithium and triiodothyronine (T3) augmentation strategies may be rapid, safe, and effective ways of treating patients who fail to respond to tricyclics, little is known about the clinical or biochemical correlates of response. We examined clinical and endocrine variables which distinguished T3 and lithium responders from each other and from non-responders in a post-hoc analysis of two studies involving 51 subjects who had received these augmentation strategies under double-blind conditions. Lithium non-responders were more severely depressed and had more insomnia and weight loss than responders. T3 responders could be distinguished from lithium responders by greater weight loss. There were no reliable clinical differences between T3 responders and non-responders. Thyroid function tests did not differ between any of the treatment or response groups. Our findings suggest that clinical but not endocrine variables may distinguish responders to these two augmentation strategies.

The relationship between childhood sexual abuse and mental health in adult life was investigated in a random community sample of women. There was a positive correlation between reporting abuse and greater levels of psychopathology on a range of measures. Substance abuse and suicidal behaviour were also more commonly reported by the abused group. Childhood sexual abuse was more frequent in women from disrupted homes as well as in those who had been exposed to inadequate parenting or physical abuse. While elements in the individual's childhood which increased the risks of sexual abuse were also directly associated to higher rates of adult psychopathology, abuse emerged from logistic regression as a direct contributor to adult psychopathology. Severity of abuse reported was related to the degree of adult psychopathology. The overlap between the possible effects of sexual abuse and the effects of the matrix of disadvantage from which it so often emerges were, however, so considerable as to raise doubts about how often, in practice, it operates as an independent causal element. Further, many of those reporting childhood sexual abuse did not show a measurable long-term impairment of their mental health. Abuse correlated with an increased risk for a range of mental health problems, but in most cases its effects could only be understood in relationship to the context from which it emerged.

John Bowlby bemoaned the separation between the biological and psychological approaches in psychiatry, and hoped that attachment theory, which brings together psychoanalysis and the science of ethology, would help bridge the rift between them. Recent findings in developmental psychology have delineated features of parent–infant interaction, especially responsiveness, attunement, and modulation of affect, which lead to either secure or insecure attachment. Similar principles can be applied to the relationship between psychotherapist and patient - the provision of a secure base, the emergence of a shared narrative (‘autobiographical competence’), the processing of affect, coping with loss - these are common to most effective psychotherapies and provide the basis for a new interpersonal paradigm within psychotherapy. Attachment theory suggests they rest on a sound ethological and hence biological foundation.

The history of psychiatric research on genotypes, phenotypes, and the brain reveals much about the role of these concepts in our past and current understanding of schizophrenia and other psychiatric illnesses. Although interest in each topic is old by the standards of our young science, all have waxed and waned in their influence during our brief history. By ‘genotype’ I mean the hereditary constitution consisting of the genetic code, and by ‘phenotype’ I mean the physical expression of those genes throughout the life cycle of the individual. The relevance of the genotype to our field was recognised during the time of Charles Darwin, and reflected in the views of Henry Maudsley. Early optimism about the role that genetics would play in our understanding of mental disorder was tempered by the failure to find patterns of inheritance that corresponded to those described by Mendel. Enthusiasm about the study of genetic influences on human attributes was further attenuated when pseudo-genetics was embraced as a rationale for the horror of genocide. There has been a long and honourable history of genetic research in psychiatry, sustained by individuals such as Dr Eliot Slater (the 35th Maudsley lecturer and then Director of the Medical Research Council Psychiatric Genetics Research Unit at the Maudsley Hospital), but a renewal of the early excitement about genetic research has been engendered largely by recent developments in molecular biology.

The thrust of development of new antipsychotic drugs has been to identify new compounds that have enhanced antipsychotic efficacy and have lesser side-effects than standard neuroleptic compounds. Drug development strategies no longer concentrate on D2 receptor antagonism but aim to produce novel compounds. The following have been pursued: (a) selective dopamine receptor antagonists; (b) serotonin receptor agonists and antagonists (5-HT1a,e, 5-HT2, 5-HT3) or mixed 5-HT2 - D2 receptor antagonist; (c) selective dopamine agonists or partial agonists; and (d) sigma-site and excitatory amino-acid antagonists. Such compounds are at various stages of development. The only drug which has truly distinguished itself as ‘atypical’ is clozapine. Its mechanism of action is unknown and the search for it, in large part, has been the impetus for development of the compounds listed above.