This paper reports the results of the first systematic study of the reaction of people with learning disabilities to bereavement.

A sample of 5O parent-bereaved people with learning disabilities was compared with a matched control group of 50 non-bereaved people. A semi-structured bereavement questionnaire was used along with the following instruments: the Aberrant Behaviour Checklist (ABC), the Psychopathology Instrument for Mentally Retarded Adults (PIMRA) and the Life Events Checklist.

Highly significant differences are demonstrated between bereaved and non-bereaved samples on both the total scores and most of the subscores of the ABC and PIMRA. Staff and carers did not usually attribute behaviour problems to the bereavement and its concomitant life events, nor was there a recognition of psychopathology due to bereavement.

The impact in terms of psychiatric and behavioural morbidity of loss of a parent, with its concomitant life events, in adults with learning disabilities has been underestimated.

Symptoms in schizophrenia duster into syndromes, each of which may be associated with a particular pattern of cerebral blood flow. We sought to investigate whether these syndromes are also related to neuroanatomical changes.

A semi-automated method was used to examine structural magnetic resonance images in 12 patients with schizophrenia. The relationship between the relative regional grey matter volume and ratings of the syndromes of psychomotor poverty, disorganisation and reality distortion was investigated.

There was a significant negative correlation between psychomotor poverty score and the relative volume of the left ventro-medial prefrontal grey matter, and a significant positive correlation between disorganisation and the relative volumes of the hippocampus, and the parahippocampal/fusiform gyrus bilaterally.

The correlation between psychomotor poverty and left prefrontal grey matter volume resembles that previously seen with prefrontal blood flow in the same patients, suggesting that this functional abnormality is related to an underlying anatomical change.

Although many adults with learning disabilities show features of autistic syndrome, there have been very few population-based studies. We explored the prevalence of autistic traits and their association with maladaptive behaviours in a geographically defined population of adults with learning disabilities.

The carers of 220l adults with learning disabilities were interviewed, and information was sought concerning aspects of their behaviour and ability. Individuals were scored according to the number of core autistic traits displayed. The prevalence of autistic traits was examined in respect of aspects of behaviour and ability.

Autistic traits were common among adults with learning disabilities. Those with a higher number of autistic traits were more likely to be profoundly learning disabled and demonstrate awide range of challenging behaviours.

Many adults with learning disabilities demonstrate autistic traits. The relationship of autistic traits with challenging behaviour has major implications in service planning and delivery.

Data on the two-year pattern of course of illness have been collected in the WHO study of the Determinants of Outcomes of Severe Mental Disorder (DOSMD). These data are reanalysed using recursive partitioning, a method not yet applied to psychiatric data to test the hypothesis that subjects from participating centres in developing countries had better outcomes than those in developed countries.

Subjects were those from the DOSMD study for whom two-year follow-up data were available (n = 1056). The classification and regression trees recursive partitioning technique was used to examine the predictor variables associated with the outcome variable two year pattern of course.

Pattern of course was best predicted by centre, but two developed centres (Prague and Nottingham) grouped with the developing country centres excluding Cali, having better outcomes than in the remaining developed country centres and Cali. Type of onset (insidious v. non-insidious) was the next strongest predictor, but its effect differed across these two centre groupings. Effects for some groups were modified by other predictor variables, including age, child and/or adolescent problems, and gender.

The predominant predictor effects on two-year pattern of course continued to be centre and type of onset, but complex interactions between these variables and other predictor variables are seen in specific centre groupings not strictly defined by ‘developing’ and ‘developed’.

The previous paper reports a high prevalence of schizophrenia (broad definition) in an inner London area. In this paper we test hypotheses for this finding and examine the characteristics of people with schizophrenia who move frequently.

People with schizophrenia in the Hampstead area were identified by key informant methodology, at two censuses five years apart. This allowed identification of incident cases during these five years and identification of people who had moved into and out of the area.

The incidence of DSM-III-R schizophrenia in Hampstead between 1986 and 1991 was at least 0.21 per 1000 of the population aged 15 to 54. There was a significant movement of people with schizophrenia to this inner London area from outer London between 1986 and 1991. People with schizophrenia who were relatively mobile were significantly more likely to be male, to suffer with prominent hallucinations, and to have no contact with a GP.

The high prevalence of broad schizophrenia in this inner London area is, in part, due to geographical drift. A significant excess of the people with schizophrenia who move frequently are men with positive symptoms.

We examined citation data for the British Journal of Psychiatry (BJP) and four other general psychiatry journals to assess their impact on the scientific community.

Data on three measures of citations (total number of citations, impact factor and ranking by impact factor) were obtained from Journal Citation Reports for 1985–1994. Rank correlations from year to year were calculated.

The BJP currently ranks sixth of all psychiatry journals when journals are ranked by impact factor. The journal's impact factor fell between 1985 and 1990 and this was followed by a rise in impact factor after 1991. The BJP did not rank in the top 10 psychiatry journals between 1991 and 1993. Archives of General Psychiatry is cited more frequently than any other psychiatry journal, with the American Journal of Psychiatry usually ranking second. Psychopharmacology journals are replacing more general journals in the top rankings. Rankings of most journals have become less stable in recent years.

The BJP would have to change the nature and number of papers published to improve its impact factor. There are a number of limitations to citation data and such data are only one of several factors useful in evaluating the importance of a journal's contribution to scientific and clinical communities.

These condauthor is Editor of the British Journal of Psychiatry.

This paper examines the social and psychological impact on victims of stalking.

A group of 100 victims of stalking completed a 50-item questionnaire on their experiences.

The majority of the victims were subjected to multiple forms of harassment including being followed, repeatedly approached and bombarded with letters and telephone calls for periods varying from a month to 20 years. Threats were received by 58 subjects, and 34 were physically or sexually assaulted. All but six victims made major changes in their social and work lives, with 53% changing or ceasing employment and 39% moving home. Increased levels of anxiety were reported by 83%, intrusive recollections and flashbacks by 55%, with nightmares, appetite disturbances and depressed mood also being commonly reported. Suicidal ruminations were acknowledged by 24% of victims. The criteria for a diagnosis of post-traumatic stress disorder were fulfilled in 37% of subjects, with a further 18% having the clinical features but not qualifying for a stressor involving threatened or actual physical harm.

The study indicates the extent of the social and psychological damage sustained by those subjected to persistent stalking, and underlines the inadequacy of the current legal and medical responses to the needs of these victims.

Needs for mental health care are likely to be high in urban areas. Purchasers must assess the extent to which these are being met. The pathways to care model provides a framework for this purpose.

Epidemiological surveys of adults living in deprived multi-ethnic innercity catchment area were undertaken in psychiatric services, primary care and community settings. Estimated prevalence rates were calculated and the association between clinical and demographic factors and the use of psychiatric services examined.

Around a third of people with mental health problems did not consult a GP. and half failed to have their problems recognised by their doctor. Access to psychiatric services and especially to inpatient care was highly restricted. Diagnosis and ethnicity had a marked influence on the use of specialist services.

Many people with psychiatric morbidity are not receiving treatment either from primary care or specialist services. High levels of severe morbidity and compulsory admissions highlight the pressures placed on inner-city psychiatric services.

The finding of an earlier age at onset of schizophrenia in males compared with females, replicated across a number of studies, appears to be so robust as to support hypotheses about gender differences in the aetiology of the disorder. However, the possibility that this observed gender effect might reflect other confounding variables has not been adequately explored.

We analysed data on 778 men and 653 women, in three developing countries and in seven developed countries, who had been assessed in the WHO 10-country study of schizophrenia. We applied a generalised linear modelling strategy to estimate the unconfounded contributions of gender, family history, premorbid personality and marital status to age at onset.

The model that explained the highest percentage of the total variance indicated strong main effects (P < 0.001) for marital status and premorbid personality, a weak effect for family history, and an attenuated effect for gender. Two independent verification procedures suggested an independent onset-delaying effect for marital status (married), more marked in males.

The gender difference in the age at onset of schizophrenia is not a robust biological characteristic of the disorder. Failure to control for marital status and premorbid personality in male/ female comparisons of age at onset may explain a large part of the differences reported previously.

Amisulpride is a substituted benzamide with high selectivity for dopamine D2 and D3 receptors. The purpose of the study was to evaluate the effect of 100 mg amisulpride in patients with predominantly negative symptoms of schizophrenia.

This was a multi-centre, randomised, parallel-group, double-blind study. Patients received either amisulpride (100 mg/day) or placebo over a six-month treatment period.

A total of 141 patients were included, 69 received amisulpride, 72 placebo. Fifty-eight patients (41%) had received neuroleptic treatment prior to inclusion. The percentage of amisulpride patients completing the study (55%) was significantly higher than that with placebo (32%), and drop-out rates due to lack of efficacy were 27% with amisulpride and 47% with placebo. All efficacy assessments were statistically in favour of amisulpride compared with placebo. The overall incidence of extrapyramidal symptoms was comparable in both groups; only five patients started anti-Parkinsonian treatment during the study (one in the placebo and four in the amisulpride group).

Amisulpride is effective in the medium-term treatment schizophrenic patients with predominantly negative symptoms.

Studies performed with schizophrenic adults who were resistant to classical neuroleptics showed improvement in 30% of the patients when treated with clozapine. Very early onset schizophrenic patients benefit only partially from conventional antipsychotics and are at increased risk of developing extrapyramidal symptoms; clozapine may offer an alternative treatment for these patients.

Eleven neuroleptic-resistant children (< 13 years) with schizophrenia were treated with clozapine. Improvement was monitored during the first 16 weeks using the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale and Clinical Global Impression. The mean clozapine dosage was 227.3 (s.d. 34.4) mg/day at the end of the 16 weeks.

There was an overall statistically significant reduction in all parameters, especially positive symptoms, implying a favourable outcome. Most of the improvement occurred during the first 6 to 8 weeks. The major side-effects were somnolence and drooling (no agranulocytosis).

Clozapine may be a promising drug for the treatment of resistant childhood-onset schizophrenia.

We set out to investigate whether community nurses could be trained in problem-solving therapy and, once trained, how effective they would be in treating emotional disorders in primary care.

Seventy patients with an emotional disorder in primary care were randomly allocated to receive either problem-solving therapy from a trained community nurse or treatment as usual from their general practitioner. Interview and self-rated assessments of clinical and economic outcome were made pre-treatment, at eight weeks and at 26 weeks after treatment.

There was no difference in clinical outcome between patients who received problem-solving treatment and patients who received the general practitioner's usual treatment. However, patients who received problem-solving treatment had fewer disability days and fewer days off work. The health care cost of problem-solving was greater than that of the general practitioner's usual treatment but this was more than offset by savings in the cost of days off work.

Problem-solving treatment can be given by trained community nurses. The clinical effectiveness and cost-benefit of the treatment will depend on the selection of appropriate patients.

Frith et al (1995) and others have hypothesised that disruptions in the connection between left frontal and temporal areas of the brain are a central deficit in schizophrenia. In this paper we examine whether such connectivity as assessed by EEG coherence is related to level of symptoms in patients with schizophrenia.

For 73 patients with schizophrenia, assessments of the EEG coherence between frontal and temporal regions were carried out under conditions of activation by a mathematical task, and between frontal and occipital regions when performing a visuo-spatial task. We then examined the relationship between these coherence measures and the reality distortion, disorganisation and psychomotor poverty dimensions of symptomatology.

Only left frontal -temporal connectivity was found to have a significant negative relationship to symptomatology. This relationship was, however, specific to reality distortion rather than to symptoms of disorganisation or psychomotor poverty, and may be more characteristic of males than females.

Disruption of frontaltemporal connectivity appears to have a specific relationship to reality distortion symptoms in schizophrenia.

The relationship between those schizophrenia-like conditions that have their onset in late life and early-onset schizophrenia is unclear. Very few family history studies of patients with late-onset psychosis have been reported, and it is not known whether their relatives have an increased risk of psychosis.

Information was collected on the psychiatric morbidity of 269 first-degree relatives of patients with schizophrenia or delusional disorder with an onset after the age of 60 (late paraphrenia), and 272 first-degree relatives of healthy elderly control subjects, using a research diagnostic instrument.

With a narrow age range (15–50 years) at risk, the estimated lifetime risk of schizophrenia was 1.3% in the relatives of both cases and controls. With a wider age range (15–90 years) at risk, estimated lifetime risk of schizophrenia was 2.3% for the relatives of cases, and 2.2% for the relatives of controls. However, depression was significantly more common among the relatives of cases than controls.

Those schizophrenia-like psychoses with onset in late life are not genetically associated with schizophrenia.

In addition to clinical and service factors, planners need to take account of the influence of demographic variables, especially ethnicity, on access to mental health care.

Estimated prevalence rates were calculated from epidemiological surveys undertaken in three settings: psychiatric services, primary care and the general population. Associations between demographic factors and service use were examined using the pathways to care model.

Considerable differences in access to mental health care were found, particularly according to ethnicity. The major impediment to Asians accessing care occurred at the interface between primary and secondary care, whereas the most striking feature for Blacks was the poor level of case recognition by GPs.

In order to improve the uptake of mental health care, new initiatives should target those who are most likely to be unwell but least likely to access services. Purchasers and providers need to address differential patterns of use when developing and reviewing services.

Previous meta-analyses suggest that individuals treated with serotonin-specific reuptake inhibitors (SSRIs) in randomised controlled trials (RCTs) are less likely to discontinue treatment than those on tricyclic antidepressants. This metaanalysis investigates whether this is due to the frequent use in RCTs of older reference tricyclics (imipramine and amitriptyline), which may have worse side-effects than more recent compounds.

A meta-analysis of RCTs comparing tricyclic and heterocyclic antidepressants with SSRIs in the treatment of depression.

The overall odds ratio of discontinuation on tricyclic/heterocyclic antidepressants compared with SSRIs was 0.86 (95% CI 0.78–0.94). The odds ratio for reference tricyclics was 0.82 95% CI 0.72–0.23), newer tricyclics 0.89 (95% CI 0.74–1.06), and heterocyclics 1.02 (95% CI 0.78–1.35). The pooled advantage of SSRIs over tricyclics was maintained whether the population studied consisted of younger adults or only the elderly. No differences in discontinuation rates were detected between the SSRIs.

The lower rate of discontinuation in patients on SSRIs may be due to the use of old tricyclics (which have worse side-effects) as reference compounds. The SSRIs do not show a statistically significant difference in discontinuation rates when compared with newer tricyclics or heterocyclics.

Familial liability in the functional psychoses had traditionally been examined by comparing mutually exclusive diagnostic categories. This study examines overlapping psychopathological dimensions in relation to familial morbid risk of psychosis.

We tested for associations between seven factor-analysis derived psychopathological dimensions and familial morbid risk of psychosis, in a sample of 150 patients with recent-onset functional psychosis and 548 of their first-degree relatives.

A syndrome characterised by affective blunting and insidious and early onset of illness, non-specifically predicted psychosis in the first-degree relatives, whereas a manic syndrome specifically predicted affective psychosis in the relatives. No other main effects were observed, but there were interactions with proband diagnosis: a syndrome characterised by bizarre behaviour, inappropriate affect, catatonia and poor rapport predicted psychosis in relatives of schizophrenic probands, and a syndrome of depressive: symptoms predicted psychosis in relatives of schizoaffective probands. Positive symptoms were not associated with illness in the relatives.

Genetic effects in the functional psychoses may comprise non-specific components that canalise a general, early-onset, affective blunting phenotype and several other, more specific, influences on phenotypic variation.