Decreased expression of proteins such as synaptophysin in the hippocampus and prefrontal cortex in schizophrenia is suggestive of synaptic pathology. However, the overall profile of changes is unclear.

To investigate synaptophysin gene expression in the cerebral cortex in schizophrenia.

The dorsolateral prefrontal (Brodmann area [BA] 9/46), anterior cingulate (BA 24), superior temporal (BA 22) and occipital (BA 17) cortex were studied in two series of brains, totalling 19 cases and 19 controls. Synaptophysin was measured by immunoautoradiography and immunoblotting. Synaptophysin messenger RNA (m RNA) was measured using in situ hybridisation.

Synaptophysin was unchanged in schizophrenia, except for a reduction in BA 17 of one brain series. Synaptophysin mRNA was decreased in BA 17, and in BA 22 in the women with schizophrenia. No alterations were seen in BA 9/46.

Synaptophysin expression is decreased in some cortical areas in schizophrenia. The alterations affect the mRNA more than the protein, and have an unexpected regional distribution. The characteristics of the implied synaptic pathology remain to be determined.

Lithium treatment is claimed to reduce mortality in patients with affective disorder, but the evidence is conflicting.

To estimate mortality rates from a cohort of patients with affective disorder commenced on lithium with an observation period of two years and a follow-up after 16 years.

The mortality rates of patients were compared with those of the general Danish population, standardised for age, gender and calendar time with respect to death from all causes, suicide and death from cardiovascular disease.

Forty of the study's 133 patients died during the 16-year observation period (11 from suicide). Mortality among patients commenced on lithium was twice that of the general population. The statistically significantly elevated mortality was due largely to an excess of suicides; mortality from all other causes was similar to the background populations. Thirty-two patients died after the first two years of observation and were included in the analysis of the association between death and treatment compliance. Suicide occurred more frequently among those patients not complying with treatment.

Mortality, especially suicide, was significantly increased in unselected patients with affective disorder commenced on lithium relative to the general population.

We know little about how people with a learning disability access secondary health care.

To describe the epidemiology of learning disability, the influence of deprivation on prevalence and the pattern of secondary care uptake, including the effect of institutionalisation.

A record-linkage study of secondary care contacts of 434 000 people between 1991 and 1997. A population with learning disability was identified; their secondary care contact was calculated and compared with the general population's.

The distribution of people with a learning disability (n = 1595) correlated significantly with deprivation. The presence of a learning disability hospital significantly affected care uptake. Place of residence also affected acute admission to the learning disability hospital. Former institution residents generated 212 admissions per 1000 patients; community patients generated 18 per 1000. The admission rate with any psychiatric diagnosis to any setting was 26.3 per 1000 people with a learning disability; 16.5% of such patients had a dual diagnosis.

Health provision for people with a learning disability is affected by institutional provision.

Current concepts and measures of personality disorder are in many respects unsatisfactory.

To establish agreement between two contrasting measures of personality disorder, and to compare subject–informant agreement on each. To examine the extent to which trait abnormality can be separated from interpersonal and social role dysfunction.

Fifty-six subjects and their closest informants were interviewed and rated independently. Personality functioning was assessed using a modified Personality Assessment Schedule (M–PAS), and the Adult Personality Functioning Assessment (APFA).

Subject–informant agreement on the M–PAS was moderately good, and agreement between the M–PAS and the APFA, across and within subjects and informants, was comparable to that for the M–PAS. This was equally the case when M–PAS trait plus impairment scores and trait abnormality scores were used.

The M–PAS and the APFA are probably assessing similar constructs. Trait abnormalities occur predominantly in an interpersonal context and could be assessed within that context.

Controversy continues regarding an association between obstetric complications and risk of schizophrenia in early adult life.

To compare the rate of labour and delivery complications among persons who developed schizophrenia with controls; to establish whether any complication is associated with later schizophrenia.

We located the labour ward records of 431 individuals with schizophrenia and of same-gender controls from the same hospital birth series. Mothers were matched by age, socio-economic group and parity. Individual complications were evaluated blindly using two obstetric complication scales.

Overall, the rate of labour and delivery complications for those who developed schizophrenia did not differ from that of controls. Males who had presented to psychiatric services before the age of 30 had a greater frequency of and more severe labour/delivery complications than their matched controls.

Other than among young-onset males we found no increase in labour and delivery complications among cases.

Neighbourhood characteristics may influence the risk of psychosis, independently of their individual-level equivalents.

To examine these issues in a multi-level model of schizophrenia incidence.

Cases of schizophrenia, incident between 1986 and 1997, were identified from the Maastricht Mental Health Case Register. A multi-level analysis was conducted to examine the independent effects of individual-level and neighbourhood-level variables in 35 neighbourhoods.

Independent of individual-level single and divorced marital status, an effect of the proportion of single persons and proportion of divorced persons in a neighbourhood was apparent (per 1% increase respectively: RR=1.02; 95% CI 1.00–1.03; and RR=1.12, 95% CI 1.04–1.2.1). Single marital status interacted with the neighbourhood proportion of single persons, the effect being stronger in neighbourhoods with fewer single-person households.

The neighbourhood environment modifies the individual risk for schizophrenia. Premorbid vulnerability resulting in single marital status may be more likely to progress to overt disease in an environment with a higher perceived level of social isolation.

Owing to the lack of controlled trials of treatment setting in adolescent anorexia nervosa, the benefits and costs of in-patient treatment are not established.

To clarify the relationship between a range of presenting features, treatment received and medium- to long-term outcome in adolescent anorexia nervosa.

A range of presenting variables were rated for 75 cases of DSM – III – R anorexia nervosa at presentation to an adolescent service, including the Morgan–Russell Global Assessment Score. Cases were followed up at 2–7 years and outcome rated according to reliable methods. Setting of treatment received was also recorded.

Two out of 75 cases had died by the time of follow-up. Adequate data for 72 enabled an outcome category to be assigned. The 21 who had received in-patient treatment had a significantly worse outcome than the 51 never admitted to hospital. Multivariate analysis suggests admission to be the major predictor of poor outcome.

The benefits and costs of admission to hospital require further investigation, ideally in a randomised-controlled trial. The negative consequences of in-patient treatment are neglected in research.

Cross-sectional studies give no indication of the changes that may occur in the mental health status of a community in course of times. Studies should be designed to assess these changes.

To assess the changes, if any, in the prevalence of mental disorders in a rural community after an interval of 20 years in the context of its changing socioeconomic conditions.

A door-to-door survey of the prevalence of psychiatric morbidity in two villages was conducted by a team of psychiatrists. The survey was repeated after 20 years by the same team and by the same method. Changes in the mental health status of the community were compared.

Total morbidity per 1000 fell from 116.8 to 105.2. Morbidity in men fell from 86.9 to 73.5 per 1000 and in women from 146.8 to 138.3 per 1000. Rates of anxiety, hysteria and phobia had fallen dramatically and those of depression and mania had risen significantly.

The level of psychiatric morbidity showed no statistically significant change. The morbidity pattern (relative proportion of type of morbidity), however, showed some interesting changes. Similar studies should be done on a larger sample.

The use of antipsychotic drugs in people with learning disabilities is currently receiving intensified scrutiny and attempts are being made to reduce it.

A randomised controlled trial was designed to investigate factors influencing antipsychotic drug reduction among people with learning disabilities prescribed such medication for behavioural problems.

Thirty-six participants randomly allocated to the experimental group underwent four, monthly 25% drug reduction stages. There were no planned drug changes for the control group (n = 20).

Twelve participants (33%) completed full withdrawal; afurther seven (19%) achieved and maintained at least a 50% reduction. Drug reduction was associated with increased dyskinesia and higher activity engagement but not increased maladaptive behaviour. Some setting characteristics were associated with drug reinstatement.

A substantial proportion of people with learning disability prescribed antipsychotic medications for behavioural purposes rather than for treating psychotic illness can have their drugs reduced or withdrawn.

The clinical pictures of autistic spectrum disorders include features described in catatonia.

To examine the severe exacerbation of the catatonic features of autistic disorders in adolescence or early adult life, which occurs in some individuals.

A semi-structured interview schedule was used to collect information from parents or other care-givers concerning 506 referrals to a specialist clinic for autistic spectrum disorders. Individuals with severe exacerbation of catatonic features were compared with a same-age group of referrals without this type of deterioration in skills and behaviour.

Seventeen per cent of referrals aged 15 or over had severe exacerbation of catatonic features. They were significantly more likely than the comparison group to have had, before the onset of the change in behaviour, impaired language and passivity in social interaction.

Catatonia is a later complication of autistic spectrum disorders, which adds considerably to the burden of caring. More research is needed to identify causes, neuropathology, and early signs of vulnerability.

There is little information on whether patterns of steroids precede and are associated with depressive onset.

To establish whether there is an association between salivary cortisol and/or dihydroepiandrosterone (DHEA) levels and depression independent of psychosocial risk.

Two subgroups of adolescents in the community at high (n=181) and low (n=65) risk for psychopathology were interviewed for recent psychiatric disorder at entry and again at 12 months. Salivary samples (08.00 and 20.00 h) for hormone estimations and self-reports on current mood and cognitive style were obtained at both assessments.

Neither hormone was associated with risk status, current mood or cognitive style at entry. Of 31 onsets of major depression that occurred over the next 12 months, 30 came from the high-risk group but were not associated with any particular pattern of risk. Increased negative mood and feelings and DHEA (08.00 h) hypersecretion at entry were associated with subsequent major depression.

Both negative mood and feelings and alterations in adrenal steroid function precede the onset of first-episode major depression in adolescents. Variation in levels of hormones may arise from more distal origins than recent life events and current ongoing difficulties.

There are no published studies concerning the depiction of mental illness in children's television programmes.

To determine whether mental illness was depicted in children's television.

Sample of one complete week of children's television (57 hours, 50 minutes; 128 series episodes: 69 cartoon animations, 12 non-cartoon animations, 47 real life) provided for children under the age of 10 years. Disclosure analysis of portrayals of mental illness through repeated viewings identified patterns in the use of linguistic, semiotic and rhetorical resources.

Of the 128 episodes, 59 (46%) contained one or more references to mental illness, predominantly in cartoons (n=47, 80%) compared with other episode types (χ2=17.1, d.f.=2, P<0.05). Commonly occurring terms such as ‘crazy’ (n=28), ‘mad’ (n=19) and ‘losing your mind’ (n=13) were employed to denote loss of control. The six consistently mentally ill characters were almost entirely devoid of admirable attributes.

Young viewers are being socialised into stigmatising conceptions of mental illness.

Intensive case management is commonly advocated for the care of the severely mentally ill, but evidence of its cost-effectiveness is lacking.

To investigate the cost-effectiveness of intensive compared with standard case management for patients with severe psychosis.

708 patients with psychosis and a history of repeated hospital admissions were randomly allocated to standard (case-loads 30–35) or intensive (case-loads 10–15) case management. Clinical and resource use data were assessed over two years.

No statistically significant difference was found between intensive and standard case management in the total two-year costs of care per patient (means £24 550 and £22 700, respectively, difference £1850, 95% Cl – £1600 to £5300). There was no evidence of differential effects in African–Caribbean patients or in the most disabled. Psychiatric in-patient hospital stay accounted for 47% of the total costs, but neither such hospitalisation nor other clinical outcomes differed between the randomised groups.

Reduced case-loads have no clear beneficial effect on costs, clinical outcome or cost-effectiveness. The policy of advocating intensive case management for patients with severe psychosis is not supported by these results.

A recent review suggested an association between using unpublished scales in clinical trials and finding significant results.

To determine whether such an association existed in schizophrenia trials.

Three hundred trials were randomly selected from the Cochrane Schizophrenia Group's Register. All comparisons between treatment groups and control groups using rating scales were identified. The publication status of each scale was determined and claims of a significant treatment effect were recorded.

Trials were more likely to report that a treatment was superior to control when an unpublished scale was used to make the comparison (relative risk 1.37 (95% C11.12–1.68)). This effect increased when a ‘gold-standard’ definition of treatment superiority was applied (RR 1.94 (95% C11.35–2.79)). In non-pharmacological trials, one-third of ‘gold-standard’ claims of treatment superiority would not have been made if published scales had been used.

Unpublished scales are a source of bias in schizophrenia trials.

Most scientific journals practise anonymous peer review. There is no evidence, however, that this is any better than an open system.

To evaluate the feasibility of an open peer review system.

Reviewers for the British Journal of Psychiatry were asked whether they would agree to have their name revealed to the authors whose papers they review; 408 manuscripts assigned to reviewers who agreed were randomised to signed or unsigned groups. We measured review quality, tone, recommendation for publication and time taken to complete each review.

A total of 245 reviewers (76%) agreed to sign. Signed reviews were of higher quality, were more courteous and took longer to complete than unsigned reviews. Reviewers who signed were more likely to recommend publication.

This study supports the feasibility of an open peer review system and identifies such a system's potential drawbacks.

An excess of both depression and undesirable life events in first-degree relatives of probands with depression as compared with controls has been reported. This association may have reflected a familial factor in common.

To examine the familiality of life events and depression and whether there may be a common familial factor influencing vulnerability to depression and the experiencing of life events.

In a sib-pairdesign, 108 probands with depression and their siblings were compared with 105 healthy controls and their siblings for psychopathology and life events.

The lifetime relative risk of depressive disorder in the siblings of depressed subjects as compared with siblings of controls was 9.74, although these groups did not differ in the life events measures. Several categories of events showed significant sibling correlations, but this was due to the same event affecting both members of the pair.

Although depressive disorder was strongly familial, the familial effects on life events were largely explained by shared experiences. There was no evidence for a common factor influencing both depression and life events.

Abrupt interruption of therapy with selective serotonin reuptake inhibitors (SSRIs) has been associated with somatic and psychological symptoms.

Systematically to assess symptoms and effects on daily functioning related to interruption of SSRI therapy.

Patients treated with fluoxetine, setraline or paroxetine underwent identical five-day periods of treatment interruption and continued active treatment under double-blind, order-randomised conditions, with regular assessment of new symptoms.

Placebo substitution for paroxetine was associated with increases in the number and severity of adverse events following the second missed dose, and increases in functional impairment at five days. Placebo substitution for sertraline resulted in less pronounced changes, while interruption of fluoxetine was not associated with any significant increase in symptomatology.

Abrupt interruption of SSRI treatment can result in a syndrome characterised by specific physical and psychological symptoms. Incidence, timing and severity of symptoms vary among SSRIs in a fashion that appears to be related to plasma elimination characteristics.

Special hospitals in England provide psychiatric care and treatment in high security. Their future is often questioned.

To test for variation in demand for high-security psychiatric services over one 10-year period.

This study was from the special hospitals' case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by health region; admission episodes; legal category of detention; admission source and type of offence.

Referrals to special hospitals showed no decrease during the 10 years; an apparent increase may reflect under-recording before 1992. Admissions fell by about 16% over the 10 years, but with regional variation. Women, civil cases, admissions under the MHA classifications of psychopathic disorder or mental impairment and directly from a court on a hospital order were most affected. There was an increase in admissions of pre-trial and sentenced male prisoners, and of transferred hospital order patients from other hospitals.

There is continuing demand from all parts of the country for high-security hospital beds. The smaller numbers admitted appear to include more demanding cases.

There exists no instrument specifically designed to measure comprehensively the needs of older people with mental disorders.

To develop such an instrument which would take account of patients', staff and carers' views on needs.

Following an extensive development process, the assessment instrument was subjected to a test–retest and interrater reliability study, while aspects of validity were addressed both during development and with data provided by sites in the UK, Sweden and the USA.

The Camberwell Assessment of Need for the Elderly (CANE) comprises 24 items (plus two items for carer needs), and records staff, carer and patient views. It has good content, construct and consensual validity. It also demonstrates appropriate criterion validity. Reliability is generally very high: κ > 0.85 for all staff ratings of interrater reliability. Correlations of interrater and test–retest reliability of total numbers of needs identified by staff were 0.99 and 0.93, respectively.

The psychometric properties of the CANE seem to be highly acceptable. It was easily used by a wide range of professionals without formal training.

Cross-sectional data show that generalised anxiety disorder (GAD) is a chronic condition with episodes lasting much longer than the six-month minimum required by DSM–III–R and DSM–IV. Although GAD is chronic, little is known about factors influencing illness duration.

To investigate variables that influence the clinical course of GAD.

A total of 167 patients with GAD participated in the Harvard–Brown Anxiety Research Program. Patients were assessed at intake and re-examined at six- to twelve-month intervals for five years. Kaplan–Meier curves were constructed to assess the likelihood of remission. Regression analysis was used to investigate factors predicting full or partial remission.

The rate of remission was 0.38 after five years. Diminished likelihood of remission was associated with low overall life satisfaction, poor spousal or family relationships, a concurrent cluster B or C personality disorder and a low global assessment score.

Full or partial remissions were less likely to occur in patients with poor relationships and personality disorders. These patients should be given more intensive and possibly multi-modal therapy.