The objective is to estimate parameters of the natural history of panic disorder, including its prodrome, incidence, recovery and recurrence.

In 1981 the Baltimore Epidemiologic Catchment Area Study interviewed 3481 individuals probabilistically selected from the household population. During 1993–1996, 1920 of these individuals (73% of survivors) were interviewed again. Baseline and follow-up interviews included the National Institute of Mental Health Diagnostic Interview Schedule. During the follow-up, a subsample was assessed by psychiatrists using the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry (SCAN).

There were 35 new cases of panic disorder in 24 475 person years of exposure, yielding an annual incidence of 1.43 per 1000 per year. Data from the SCAN assessments suggest the incidence estimate is conservative. Incidence is greater in females and declines with age. About one-third of the new cases arise without agoraphobia, but about half have anxiety of some sort present for many years prior to meeting criteria for diagnosis. People with agoraphobia have less intense onsets but slower recoveries than those without agoraphobia.

Panic is heterogeneous in its pattern of onset and recovery. Some of the heterogeneity is associated with the presence of other anxiety over a long period of the life.

Although increased mortality is one of the most consistent and accepted epidemiological findings in schizophrenia, a high rate of suicide appears unable to account fully for this burden which remains poorly understood.

A cohort of 88 in-patients was followed prospectively over a 10-year period and predictors of survival sought among demographic, clinical and treatment variables.

Over the decade, 39 of the 88 patients (44%) died, with no instances of suicide. Reduced survival was predicted by increasing age, male gender, edentulousness and time since pre-terminal withdrawal of antipsychotics; additionally, two indices of polypharmacy predicted reduced survival: maximum number of antipsychotics given concurrently (relative risk 2.46, 95% C1 1.10-5.47; P=0.03) and absence of co-treatment with an anticholinergic (relative risk 3.33, 95% C1 0.99-11.11; P=0.05).

Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotic polypharmacy. Conversely, over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.

This paper presents 15-year outcome data on place of residence, clinical and social morbidity and carer distress in a cohort of 179 people with schizophrenia who were living with their families in 1981–1982

Data on morbidity and carer distress were derived from replicated patient and informant interviews using standardised research instruments. Details of residence came from patient and informant interviews corroborated by case note information.

Thirty-nine (22%) of the original 179 patients were dead and six (3%) lost to follow-up. Of the remaining 134 patients, 74 (55%) still lived with their families, 31 (23%) lived in institutional accommodation, 26 (19%) lived alone and 3 (2%) were homeless. There was little change in the level of clinical or social morbidity or carer distress.

These findings suggest that most people with schizophrenia who live with their families remain significantly disabled by their illness, while their carers suffer ongoing distress. Mental health services should seek to support families who want to care for relatives with schizophrenia. Appropriate alternative accommodation must be provided when family care is not possible.

Measurement of the impact of different types of service provision on the views of service users is important in planning mental health services.

Needs (met and unmet) and satisfaction with services, were assessed. People with psychosis (n=131) were interviewed before (Time 1) and after (Time 2) the introduction of two community mental health services in south London. One was intensive, with two specialist teams, the other standard. Outcomes were compared at Time 2, controlling for the Time 1 values.

Overall, 70% of needs were met and mean satisfaction was between ‘mixed’ and ‘mainly satisfied’. There was evidence for higher met needs in the intensive sector, but no evidence for lower unmet needs in the intensive sector or for differences in satisfaction. The additional needs met by the intensive service were associated with aspects of basic living situation. Satisfaction was negatively correlated with both unmet and met needs.

Both services were reasonably successful, with little difference from the user perspective. The intensive service provided benefits in terms of met needs, but this has to be balanced against a possible increase in unmet needs.

5-HT2A receptor antagonism may be crucial to the action of atypical antipsychotics. Previous work has related 5-HT2A receptor blockade to clinical efficacy and protection from extrapyramidal side-effects.

We developed a SPET imaging protocol for assessing 5-HT2A receptor binding using the selective ligand 1231-5-1-R91150. Six healthy volunteers, five clozapine- and five risperidone-treated subjects with DSM–IV schizophrenia were studied. Multi-slice SPET was performed on each subject.

Cortex: cerebellum ratios were significantly lower in both clozapine-and risperidone-treated subjects compared with the healthy volunteers in all cortical regions. There was no difference in occupancy between the two drug-treated groups. No correlation was found between the percentage change in the Global Assessment Scale (GAS) and 5-HT2A receptor binding indices in the drug-treated groups.

Clozapine and risperidone potently block 5-HT2A receptors in vivo. The lack of relationship between receptor binding indices and change in GAS suggests that 5-HT2A receptor blockade may be unrelated to clinical improvement. Future studies will substantiate this finding by studying 5-HT2A receptor binding in large groups of patients treated with both typical and novel atypical antipsychotics.

Little is known about psychiatric disorders in adolescents who attend primary care.

Prospective study of 13- to 16-year-olds consecutively attending general practice. Information was obtained from adolescents, parents and general practitioners, using questionnaires and research interviews.

136/200 (68%) of adolescent attenders took part. Two per cent presented with psychiatric complaints. From research interviews with adolescents, psychiatric disorder in the previous year was found in 38%, with moderate impairment of functioning in over half (according to Children's Global Assessment Scale scores). Most disorders (42/50, 84%) were emotional (‘internalising’) disorders. Psychiatric disorders were significantly associated with high levels and intensity of physical symptoms and with increased health risks. General practitioner assessment of psychiatric disorders was low on sensitivity (20.8%) but high on specificity (90.7%). Doctors identified most severely affected adolescents.

Depressive and anxiety disorders are common among adolescent general practice attenders and linked to increased physical symptoms; general practitioner recognition is limited.

Suicides among people with schizophrenia are commonly believed to be impulsive and to occur unexpectedly.

As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, suicide victims with DSM-III-R schizophrenia (n=86; n=64 in the active illness phase) and others (n=1 109; n=666 without any evidence for psychosis) were compared for communication of suicidal intent (CSI), as well as previous suicide attempts known by the next of kin and/or an attending health care professional during the latest treatment relationship.

More victims with schizophrenia (84%) had a history of previous CSI, and/or had made previous suicide attempt(s) than others (70%). Also, victims with active illness schizophrenia (56%) had more CSI and/or had made suicide attempts during their last three months than victims with no psychosis (41%).

CSI and/or suicide attempts occur at least as often in people with schizophrenia as in those without schizophrenia, even in the active phase of the illness.

It is reported that people with mild learning disability have a higher point prevalence of schizophrenia than the normal population, the reasons for which are unclear.

Thirty-nine subjects with mild learning disability and schizophrenia, 34 control subjects with schizophrenia and 28 control subjects with mild learning disability were seen. Interviews with relatives and carers were also conducted. Assessments were made of clinical variables, psychopathology, neurological ‘soft'signs, IQ, memory and family history. Blood was taken for karyotypic analysis from comorbid subjects.

The comorbid group had more negative symptoms, episodic memory deficits, soft neurological signs, epilepsy and receive more community supports than control subjects with schizophrenia. Comorbid subjects had a tendency to belong to multiply affected families and show high rates of chromosomal variants on routine karyotypic testing.

Future work on the generality of schizophrenia should include people with premorbid learning disability, as a discrete subtype from whom valuable genetic aetiological clues may be obtained.

We report the impact on the quality of life (QOL) of people with psychosis of an intensive compared with a standard model of community care.

People with psychosis, in two sectors in south London, were interviewed with a variety of measures at baseline, and at two-year follow-up (n=138). After baseline, services within one sector were reorganised, and a more intensive model of community care was introduced. QOL was measured using the Lancashire Quality of Life Profile.

The two overall QOL measures, global QOL and the average of the domain-specific scores, were remarkably stable over time. There was weak evidence for an improvement in living situation domain in the intensive sector; this may be accounted for by a large drop in in-patient admissions. In both sectors objective QOL was poor, and there was little change in any of the objective indicators except in-patient admissions, and a suggestion of increased social activity in the intensive sector.

We failed to find an effect of intensive community care on QOL in people with psychosis. This may indicate an insensitivity to change in QOL measures, or that the intervention failed to produce the kind of changes in mental health and functioning which would be reflected in improved QOL.

In spite of the virtually ubiquitous nature of the initial 10-day placebo run-in period (IPR) in drug trials, there is little empirical data establishing its relevance.

Data from 593 subjects were examined retrospectively to determine whether or not the prognosis of subjects minimally improved during the IPR was different to those who were unimproved. The IPR period was single-blind and was followed by a six-week double-blind phase in all studies.

Twenty-six per cent of the subjects were minimally improved and 74% were unimproved. Approximately 10% of the subjects who were much improved were not followed systematically. Across a range of diagnosis, severity and chronicity subjects minimally improved (versus unimproved) after IPR had a more favourable prognosis whether assigned to drug or placebo.

Change during IPR appears to be a meaningful predictor. Stratification should be considered in future antidepressant studies.

Suicide rates have increased over the past three decades, especially in young men. Depression, conduct disorder, crime and substance misuse have also increased. This study tested hypotheses on the possible links between the secular increase in the rates of these behaviours.

A data set on 6091 subjects aged 8–18 years (58.4% boys) referred to psychiatric services over & 21-year period (1970–1990) was used. & detailed analysis of & random sample of 80 case notes was conducted.

Suicidal behaviours increased significantly among pubertal male adolescents only (n=1313). In this sub-sample, substance misuse accounted for the increase over time. The rates of both suicidal behaviours and of substance misuse almost doubled between 1979 and 1990 in this patient group. The case note analysis showed that solvent and alcohol misuse had also increased over the study period. Moreover, among the subjects misusing substances, alcohol was the only substance with & strong and positive association with suicidal behaviours. Substance misuse pre-dated suicidal behaviours in most patients.

A link has been found between the increase over time of suicidal behaviours in adolescent boys and & contemporaneous increase in substance misuse. The strength and direction of the association suggests that alcohol misuse is the causal factor.

The analysis of the costs of schizophrenia and its treatment under different mental health care structures will facilitate the improved allocation of the limited resources available for the treatment of schizophrenia. The research we present compares health service use and total health care costs of three cohorts of subjects with schizophrenia which are representative of three areas of Spain (Burlada in Navarra, Cantabria and the Eixample of Barcelona).

We selected first-time contacts with any psychiatric service who received a diagnosis of schizophrenia. Subjects were evaluated in the third year after onset.

The mean number of out-patient visits per patient per year was 10.7 and the mean in-patient days were 9.5. The mean direct cost per patient in the third year of treatment was US$2243. Costs were higher for single subjects and for people who had a relapse. Costs of subjects with better functioning were lower than costs of subjects with a worse state.

Direct costs of care in Spain were lower than the reported figures from other western European countries. Costs were greater in the two centres with greater community mental health service development. Some of the findings may be explained by service availability.