The relationship between midline structural defects and schizophrenia remains unclear, although a number of neuroradiological studies have reported an association between schizophrenia and a range of anomalies.

Three patients are reported, each diagnosed with schizophrenia and neuroradiological evidence of midline structural anomalies. MRI scans are reported in conjunction with performance over a range of neuropsychological tests designed to assess frontal and lateralised cognitive functions.

Evidence of anterior dysfunction was present in all three cases, while on an individual basis patients displayed varying patterns of preserved and dysfunctional cognitive processing.

The reported findings raise a number of interesting issues regarding the nature of hemispheric involvement in schizophrenia.

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.

The effectiveness of anti-psychotic drugs against positive psychotic symptoms has been demonstrated in many studies, but their effects on quality of life have yet to be clarified. The impact of different neuroleptic therapies on the subjective quality of life of schizophrenic patients is evaluated in a cross-sectional open study.

During a four-month period a standardised quality of life interview for schizophrenic patients was applied on day 10 after admission; 33 patients on atypical neuroleptics (AAP) were compared with 31 matched patients on conventional neuroleptics (CAP).

The AAP group had significantly higher scores in general quality of life as well as in different life domains: physical well-being, social life and everyday life. In separate comparisons of the AAP group, patients on clozapine and risperidone were found to have a higher quality of life score than patients on CAP or zotepine.

The pharmacological profile of clozapine and risperidone may provide a basis for explaining the higher subjective quality of life found in this study. The lower quality of life of the CAP group may possibly be related to intrinsic effects of the conventional antipsychotics.

Converging evidence has suggested that the abnormalities in brain morphology observed in schizophrenia are similar to those seen in temporal lobe epilepsy (TLE). The purpose ofthis study was to compare the features of these groups directly with measures of the brain using magnetic resonance (MR) morphometry.

Morphometric measures of ventricular and hippocampal volumes obtained from FLASH MR images were studied in 32 patients with first-episode schizophrenia (FES), 39 patients withTLE (21 left, 18 right), and 42 healthy controls.

Ventricular volumes in the FES and TLE groups were both significantly larger than those seen in controls and did not differ from each other. The FES group showed significantly larger temporal horns, while theTLE group had relatively larger frontal horns. Analyses of hippocampal volumes revealed a significant group by hemisphere effect. The FES group showed relative reductions in left hippocampal volume that were comparable only toTLE patients with seizures originating from the left hemisphere.

The results indicate that FES and TLE groups both show evidence of ventricular enlargement. Lateralised morphological abnormalities of the hippocampal formation in FES and left TLE are comparable, and may be specific to temporolimbic regions.

The present study examines the effects of independent, single pre- and perinatal risk factors and rates of obstetric complications upon the subsequent development of schizophrenia.

This study was based on prospectively recorded birth records of 107 cases (82 with schizophrenic disorders and 25 with other psychotic reactions) and 214 controls, individually matched by gender and time and place of birth. Variables univariately associated with significantly elevated risk were entered in a logistic regression model.

A high non-optimality summary score (> or = 7 complications of 34 possible) was a significant risk estimate for the total index group (OR 4.58, 95% CI 1.74–12.03) and the 82 schizophrenic patients (OR 3.67, CI 1.30–10.36). Patients with 2–6 complications also had an increased, although lower, risk (OR 1.67, CI 1.02–2.75). A disproportionate birth weight for body length (OR 3.57, CI 1.77–7.19) and a small head circumference (OR 3.93, CI 1.32–11.71) were the strongest independent risk factors.

A contribution of obstetric complications to the risk of schizophrenia was confirmed. Only aberrations in physical size remained as individual independent risk factors.

Although modern psychiatric services seek alternatives to hospitalisation wherever appropriate, the national trend toward higher bed occupancies on acute psychiatric wards has refocused attention on community-based alternatives and methods of assessing reed for acute care.

We surveyed key decision makers in a community-oriented district service with a low acute psychiatric bed to population ratio, in order to examine alternatives to hospitalisation in a cohort of consecutive admissions over a six-month period.

Alternatives to acute ward hospitalisation were identified for 29% of admissions, and for 42% of those with an admission duration of more than 60 days. Residential options were chosen more often than intensive community support. Simulated bed day savings were considerable.

In a community-oriented service, key decision-makers could identify further alternatives to acute ward hospitalisation, although relatively few non-residential, community support options were chosen. Although this methodology has limitations, data based upon keyworker judgements probably have greater local ‘ownership’, and the option appraisal process itself may challenge stereotyped patterns of resource use.

Outcome is important in the validation of psychiatric diagnosis, as most disorders lack clinicopathological correlates. We describe the predictive validity of four definitions of schizophrenia (DSM-III-R, ICD-10, ICD-9 and CATEGO S+), in a representative cohort of patients selected during their first episode of psychosis.

Each definition of schizophrenia was applied to 99 patients. Their respective ability to predict 13-year outcome (Global Assessment of Functioning scales) was assessed.

DSM-III-Rand ICD-10 diagnoses of schizophrenia have high predictive validity for long-term outcome, and both provide relatively stable diagnoses. ICD-9 is reasonably good at predicting disability, but not symptoms, and CATEGO S+ showed no predictive validity. Adding six-month duration criteria to ICD-10, ICD-9 and CATEGO S+ improved their predictive validity, and removing the six-month duration criterion from DSM-III-R commensurately reduced predictive validity.

Modern diagnostic systems (DSM-III-Rand ICD-10) have high predictive validity, and are superior to ICD-9. The six-month duration criterion of DSM-III-R schizophrenia accounts for its predictive validity and stability over 13 years, but restricts its use in first-episode studies. The one-month duration criterion of ICD-10 is less restrictive, without major compromises in predictive validity or stability.

The dopamine D3 receptor gene (DRD3) is a meaningful candidate gene because it unifies the dopamine and the limbic hypotheses for schizophrenia. We tested for an allelic association between schizophrenia and the DRD3 Mscl alleles, hypothesising heterogeneity between childhood/early adolescence-onset schizophrenia (CO-SZ) and adult-onset schizophrenia (A-SZ).

The frequencies of the DRD3 alleles were compared between 70 DSM-III-R schizophrenics (35 CO-SZ and 35 A-SZ) and 79 controls.

Compared with the controls, the subsample of A-SZ, but not CO-SZ, showed an over-proportion (P = 0.025) of allele 1. The association was not found in the total sample, combining the two subsamples.

Consistently with former studies, our data suggest an aetiological heterogeneity between CO-SZ and A-SZ and a possible specificity of the excess of allele 1 to the familial form of schizophrenia and to schizophrenia with a better outcome.

Early manic relapse following lithium discontinuation offers an important opportunity to investigate the relationship between symptoms, effects of treatment and regional brain activation in bipolar affective disorder.

Fourteen stable bipolar patients on lithium were examined with neuropsychological measures, clinical ratings and single photon emission computed tomography (SPECT) before and after acute double-blind withdrawal of lithium. Brain perfusion maps were spatially transformed into standard stereotactic space and compared pixel-by-pixel. A parametric analysis was used to examine the change in brain perfusion on lithium withdrawal, and the relationship between symptom severity and brain perfusion separately both between and within subjects.

Lithium withdrawal was associated with an important redistribution of brain perfusion, with increases in inferior posterior regions and decreases in limbic areas, particularly anterior cingulate cortex. Seven of the 14 patients developed manic symptoms during the placebo phase, correlating with relative increases in perfusion of superior anterior cingulate and possibly left orbito-frontal cortex.

The important effect of lithium withdrawal on brain perfusion implies that after withdrawal of lithium, the brain develops an abnormal state of activity in limbic cortex. The structures involved did not co-localise with those apparently modulated by manic symptoms.

The prevalence of schizophrenia is known to be greater in urban than in rural areas. Less studied are differences between the patients themselves and, more specifically, their use of psychiatric services.

The prevalence of schizophrenia was determined in rural Nithsdale in Scotland and urban Nunhead and Norwood in South London. Information about patients' psychiatric history, use of services during the study year and global assessment of functioning were obtained from case records and staff.

There were no significant differences in prevalence rates between Nithsdale patients, all White (2.78 per 1000 general population), Nunhead (3.46 per 1000) and Norwood (2.24 per 1000) Whites; rates were significantly higher among the non-Whites in Nunhead (7.36 per 1000) and Norwood (5.53 per 1000), who were mainly Black Caribbeans. Nithsdale patients were at a higher level of functioning and made substantially more use of psychiatric services. During the study year, 42% of Nithsdale patients used more than one of three principal community services, namely day, out-patient and community psychiatric nursing care.

The prevalence of schizophrenia is no different in rural Nithsdale and inner-city Nunhead and Norwood, when only White patients are considered. Nithsdale patients were at a higher level of functioning and made more use of available psychiatric services.

On the basis of Liddle's three-syndrome model of schizophrenia, it was predicted that: (1) symptoms of psychomotor poverty would be particularly correlated with impaired performance on neuropsychological tests likely to reflect functioning of the dorsolateral prefrontal cortex; (2) disorganisation would be particularly correlated with impaired performance on tests sensitive to medio-basal prefrontal functioning; and (3) reality distortion would be particularly correlated with measures sensitive to temporal lobe functioning.

The above hypotheses were tested on 87 subjects with a confirmed diagnosis of schizophrenia. Patients' symptoms were scored for each of the three syndromes. Patients completed six neuropsychological tests designed to measure impairment in specific areas of the brain.

There was no support for the first two hypotheses. There was, however, evidence of a specific relationship between reality distortion and neuropsychological performance usually considered to be related to left temporal lobe functioning.

Although not directly supporting the first two hypotheses; the results are, in general, consistent with there being different cortical-subcortical circuits associated with each of psychomotor poverty and disorganisation. Temporal lobe functioning appears to have particular significance for the reality distortion syndrome.

Mental health legislation allows for treatment needs to override civil liberty. Mental health review tribunals act as a counterbalance. This study examines the long-term outcome of patients reviewed by a tribunal, and in particular whether the tribunal, in its concern for civil liberty, might be discharging patients prematurely.

All non-offender patients from a defined catchment area reviewed by the tribunal between the inception of the 1983 Mental Health Act and 31 December 1991 were followed-up until 31 May 1993.

Those discharged by the tribunal did not differ significantly from those refused discharge in subsequent survival period in the community, in readmission rate or in final outcome.

Within the limitations of a non-experimental study, the main hypothesis was not supported. An intensive study of family and personal life in the three months after discharge would cast useful additional light on the soundness of tribunal decisions.

The Level of Expressed Emotion scale (LEE) is a questionnaire designed to measure the perception of expressed emotion, an important predictor of the course of several psychiatric disorders.

In this study, the scales predictive and construct validity were examined in a sample of 26 clinically depressed out-patients and their partners, and in a sample of 40 couples from the general community

In the sample of depressed out-patients, the LEE was predictive of depression improvement at six-month follow-up. With regard to the construct validity, results in both samples showed quite strong relationships between the LEE and depressive symptomatology, relational dissatisfaction, and coping styles.

The LEE may be a useful tool in the study of interpersonal processes and depression, both in clinical and research settings.

Loss or reversal of the normal asymmetry of the planum temporale (PT) has been reported in schizophrenia, and may be due to aberrations in the gene(s) controlling the development of brain asymmetries. We tested this hypothesis in a sample of schizophrenics and their relatives from families multiply affected with the disorder.

We compared 32 schizophrenics and 55 of their non-schizophrenic first-degree relatives with 39 matched community controls. Volumetric measurements of the cortical volume beneath the PT were obtained using the Cavalieri method from three-dimensionally reconstructed magnetic resonance imaging images.

PT volume asymmetry coefficients from patients and their relatives did not differ significantly from those of the controls. Gender-specific analysis did not reveal any differences.

Abnormalities in PT volume asymmetry are not present in familial schizophrenia, where genetic factors appear to predominate.

The suppression of melatonin by light at 00.30 hours has been shown to be greater in winter than in summer in patients with seasonal affective disorder (SAD) but not in matched normal controls.

In this study 12 patients with SAD and 12 matched normal controls were exposed to morning light therapy in the winter. Melatonin profiles and sensitivity to light were measured before and after treatment.

The SAD but not the normal group showed a phase advance of melatonin rhythms in response to phototherapy. There was an association between phase position and phase shift in the SAD but not in the normal group.

There may be instability of circadian rhythms in SAD mediated by a high-amplitude phase response curve, rather than a fixed phase abnormality as had been previously suggested. This instability may be secondary to impaired serotoninergic function in the afferent pathways to the suprachiasmatic nuclei.

There is compelling evidence for the existence of susceptibility genes for bipolar disorder. Association studies using functional DNA variations are an important approach for identifying these genes. The enzyme catechol-O-methyltransferase (COMT) plays a key role in the degradation of catecholamine neurotransmitters and is a candidate for involvement in bipolar disorder. Recently a common functional genetic polymorphism that underlies population variation in COM Tactivity has been elucidated and a simple assay developed.

In a collaboration involving seven European centres, we have undertaken an association study of this functional polymorphism in 412 unrelated West European caucasian DSM - III-R bipolar patients and 368 ethnically matched controls.

We found no evidence of allelic or genotypic association.

We can conclude that variation at this functional polymorphism does not make an important contribution to bipolar disorder in the Western European population. Future studies using this powerful experimental approach can be expected to contribute to identification of bipolar susceptibility genes.

Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary.

As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs.

Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts.

The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.