Selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclics. Reports have suggested that SSRIs are cost-effective because they are better tolerated and safer in overdose.

A systematic review of all randomised controlled trials (RCTs), meta-analyses, and cost-effectiveness studies comparing SSRIs and tricyclic antidepressants (TCAs).

None of the RCTs provided an economic analysis and there were methodological problems in the majority which would preclude this approach. Meta-analyses suggest that clinical efficacy is equivalent but slightly fewer patients prescribed SSRIs drop out of RCTs. Cost-effectiveness studies have been based on crude ‘modelling’ approaches and over-estimate the difference in attrition rates and the cost of treatment failure. It appears impossible to evaluate the economic aspects of suicide because of its rarity.

There is no evidence to suggest that SSRIs are more cost-effective than TCAs. The debate will only be concluded when a prospective cost-effectiveness study is done in the setting of a large primary care based RCT.

The development of appropriate community care requires knowledge of the characteristics of the severely mentally ill.

All patients with a broad diagnosis of schizophrenia (n=528) were identified via key informants within an inner London health district; Feighner and DSM–III–R criteria for schizophrenia were applied. Clinical and social status, psychopathology (Manchester Scale) and problem behaviours (Social Behaviour Schedule) were assessed in a 4:5 representative sample.

Fifty-seven per cent had experienced at least one compulsory admission. Forty-five per cent (excluding long-stay in-patients) had marked positive psychotic symptoms; social isolation and lack of daytime activity was more common than among comparable populations elsewhere. One hundred and eleven (25%) of the non-hospitalised patients were not in contact with specialist services.

Difficulties in establishing and maintaining a therapeutic alliance between patients and professionals present a challenge to services in inner London. Many social and occupational needs were not being met by existing community provision.

Investigation of the geographical distribution of schizophrenia and its relationship to socio-demographic factors is useful for planning services.

Individuals with schizophrenia (n=980) were identified by key informants within an inner London borough and point prevalence calculated for broad, Feighner and DSM–III–R schizophrenia. The distribution of cases was tested for significant variation using the Poisson process model. Regression models using the Jarman-8 score and its component variables were tested for their ability to predict the prevalence of schizophrenia.

A high point prevalence of schizophrenia (5.3 per 1000 resident population) was demonstrated. Case distribution showed a marked and significant variation associated with socio-demographic factors. The prediction of prevalence was more accurate for broad than for narrower definitions of schizophrenia; unemployment rate performed best.

Unemployment rates and Jarman-8 scores may provide crude estimates for resource allocation in planning mental health services, highlighting the need for additional services in deprived inner city areas.

The context memory deficit hypothesis of schizophrenia postulates that the long-term deficit associated with this disorder is related to a memory impairment for contextual information.

To test this hypothesis, memory for temporal context was assessed in 33 patients with schizophrenia and 33 normal subjects, using a recency discrimination task.

Whereas patients were able to recall and recognise target items, they were unable to recognise from among the target items those which had been most recently learned.

Schizophrenia is associated with a temporal context memory deficit.

This confirmatory investigation examined the underlying structure of schizophrenia phenomenology through examination of the fit of several prominent dimensional models to observed symptom data.

Confirmatory factor analysis was conducted on a correlation matrix of schizophrenia signs and symptoms derived from case history ratings of 192 individuals with schizophrenia who were the subjects in the major twin studies of schizophrenia.

Schizophrenia phenomenology appears best described by four underlying factors, namely negative symptoms, premorbid social adjustment deficits, reality distortion, and disorganisation. Of interest, the premorbid deficit dimension was directly associated with negative symptoms and disorganisation, but was inversely associated with reality distortion.

These data clearly support the multidimensionality of schizophrenia phenomenology and provide objective support for a four-factor model over other models. This four-factor model may be useful in organising existing and future data concerning the genetic, neurobiological, neurological, and psychosocial features of schizophrenia.

The findings from a controlled study of the effect of a public education campaign on community attitudes to mentally ill people are presented.

A census of neighbours' attitudes toward mental illness was conducted in two areas before the opening of supported houses for the mentally ill. In one area an educational campaign was conducted The attitude survey was then repeated in both areas and patients' social contact with neighbours was recorded.

Respondents exposed to the didactic component of the campaign showed only a small increase in knowledge about mental illness but there was a lessening of fearful and rejecting attitudes in the experimental area and not in the control area Neighbours in the experimental area were more likely to make social contact with both staff and patients. It was social contact which was directly associated with improved attitudes rather than education per se. Patients in the experimental area made contact and even friendships with neighbours whereas those in the control area did not.

The public education campaign did not lead to significant changes in neighbours' knowledge of mental illness. However, their attitudes improved and patients' social integration was enhanced.

The reduction of beds in long-stay hospitals has led to concerns over the quality of care offered to the remaining residents as well as that provided in the community. This study seeks to compare the quality of care and quality of life (reported satisfaction) from residents in both types of setting.

A cross-sectional comparison was made of community residential homes and hospital wards drawn randomly from lists provided by local authorities in the outer London area. Samples were drawn from all the main provider types (local authority, housing association, private and joint NHS/voluntary sector). Measures were taken of the quality of the physical environment, staff and resident characteristics, external management arrangements and internal management regimes, resident satisfaction and staff stress. Direct observations were also made of the amount and quality of staff-resident interactions.

In general, the most disabled residents were found to be still living in hospital in the worst conditions and receiving the poorest quality of care. Although there were some problems with missing data, hospital residents also seemed most dissatisfied with their living situation. There were few differences between community providers regarding either the quality of care provided or the levels of reported satisfaction. Quality of care in the community homes seemed to be much more determined by the personality and orientation of project leaders.

Purchasers and providers still need to give attention to the problems of selectively discharging the most able residents to the community, leaving the most disabled being looked after in progressively deteriorating conditions. All residential providers need to review their internal management practices and try to ensure that residents are offered, as far as possible, the opportunity to make basic choices about where and how they will live. Staff training and quality assurance practices need to be reviewed in order to improve the direct quality of care offered to the most disabled individuals.

The possibility that treatment with tricyclic antidepressants, in the form of dothiepin, might attenuate benzodiazepine withdrawal symptoms was investigated in a double-blind trial.

Eighty-seven non-depressed psychiatric out-patients with putative normal dose benzodiazepine dependence had their benzodiazepines reduced in stepwise amounts of 20% of the original dose for eight weeks. The patients were randomised to receive dothiepin (with dosage increasing to 150 mg/day) or placebo as an aid to withdrawal before benzodiazepine reduction and these drugs were taken for four further weeks before being stopped.

Fewer patients entered and completed the study than expected and a Type II error was possible in the results. Although there was some evidence of withdrawal symptoms being less marked in those patients allocated to dothiepin this was independent of any antidepressant effect as depression scores were lower in the placebo group in the early phase of withdrawal (P<0.01). Of those completing the study, greater satisfaction (P=0.03) was recorded by those who had received dothiepin; no other differences reached statistical significance.

Dothiepin (and by implication other tricyclic antidepressants) might have some value in reducing benzodiazepine withdrawal symptoms but does not aid drug withdrawal.

The aim was to evaluate long-term outcome of DSM–III–R panic disorder at a mean of 5.3 years following a controlled trial of treatment that included antidepressants and behavioural counselling.

Sixty-eight (86%) subjects were evaluated by lengthy research interview.

Thirty-four per cent recovered and remained well, 46% were minimally impaired and 20% had persistent panic disorder of whom half remained significantly impaired. Anxious–fearful personality dysfunction was the most important predictor of poor outcome, followed by poor clinical status at discharge and inability at baseline to recall vividly the initial panic attack. Those who dropped out from the original trial did badly.

Complete recovery can occur even after many years of severe illness in a large minority of subjects who receive both antidepressants and behavioural counselling in the acute stage of treatment. The comparative prognostic value of personality, severity and chronicity need to be more fully addressed in future studies.

Cognitive impairment without dementia is commonly observed in ageing populations. The present study aims to describe types of impairment and evolution over a one-year period.

Three hundred and ninety-seven normal French elderly persons demonstrating recent, observable change in cognitive performance were examined annually using a computerised cognitive examination.

Five subtypes were differentiated by cluster analysis. Two of the groups were predicted by logistic regression to be at high risk of senile dementia. Of 16 incident cases of senile dementia diagnosed in the following year, 13 were found to have derived from these two groups. The typology was also found to be useful in the description of age-associated memory impairment.

Subclinical cognitive impairment was found to not constitute a unitary phenomenon and heterogeneous subgroups could be differentiated. The concept of ‘normality’ in elderly cohorts is reconsidered in the light of these findings.

White matter changes, as revealed by magnetic resonance imaging (MRI), may occur in depression and Alzheimer's disease.

T2-weighted MRI scans were performed in 39 control subjects, 61 subjects with NINCDS/ADRDA Alzheimer's disease and 60 subjects with DSM–III–R major depression. Deep white matter lesions (DWML) and periventricular lesions (PVL) were rated on a standard 0–3 scale by two radiologists blind to clinical diagnosis.

After controlling for differences in vascular risk factors and current blood pressure, DWML were significantly more common in depressed subjects and PVL in Alzheimer's disease subjects compared to controls. DWML were most common in those presenting in late life with their first ever depression and 50% of such subjects had severe (grade 3) DWML.

An association between DWML and depression and PVL and Alzheimer's disease is supported. The increase with DWML that occurs with ageing may predispose some elderly subjects to depression.

This study was undertaken to examine the validity of different diagnostic definitions of hyperactivity in a Chinese population. Estimates of the prevalence of hyperactivity were made according to these different diagnostic definitions.

In a two-stage epidemiological study of hyperactivity in Hong Kong, 3069 Chinese schoolboys were screened by questionnaires; and a stratified sample of 611 of them entered a second stage for more detailed diagnostic assessment.

Children with hyperkinetic disorder (ICD–10) or ADDH (DSM–III) both displayed significant hyperactive symptoms, but with somewhat different external correlates; hyperkinetic disorder tended to show more neurodevelopmental impairments, ADDH more cognitive and educational difficulties. These findings raise the possibility of heterogeneity in the disorders present with hyperactivity. The DSM–III–R category of ADHD was more common, and those extra cases, that did not overlap with ADDH or hyperkinetic disorder, included children with no obvious behavioural, cognitive or neurodevelopmental impairments. Hence ADHD may be an over-inclusive category. Prevalence rates for hyperkinetic disorder, ADDH and ADHD were respectively 0.78%, 6.1% and 8.9%.

A disorder of hyperactivity does exist in the Chinese culture, displaying the same kinds of symptomatology and external correlates as in the West. The prevalence rates of hyperkinetic disorder and ADDH in Chinese schoolboys are on the low side when compared to those reported in Western studies.

The Fear Questionnaire is an internationally popular measure in anxiety disorder research, but its validity with social phobia patients has not been clearly demonstrated.

A confirmatory factor analysis was conducted using the Fear Questionnaire responses of 122 social phobia patients.

The results indicated that the proposed three-factor model of the scale (agoraphobia, social phobia, and Wood/injury dimensions) provided a good fit to the data.

These data provide strong support for the validity of the scale and for the multidimensional view of fears proposed by Arrindell.

This study compares the characteristics of women with anorexia nervosa with those of women who have all the diagnostic features of that disorder except amenorrhoea.

The study uses data from a large community epidemiological survey of the mental health status of household residents in Ontario, Canada. A multi-stage stratified sampling design generated a sample of 4285 females aged 15–64. DSM–III–R diagnoses were made using the Composite International Diagnostic Interview.

Eighty-four out of 4285 female respondents met full or partial-syndrome criteria for anorexia nervosa. Comparison of these two groups revealed few statistically significant differences in terms of demographics, psychiatric comorbidity, family history or early experiences.

Amenorrhoea did not discriminate between women with anorexia nervosa and women with all the features except amenorrhoea across a number of relevant variables. The authors question the utility of amenorrhoea as a diagnostic criterion.

The retina contains high concentrations of dopamine. We previously reported that recently withdrawn cocaine-dependent patients had significantly reduced blue cone b wave amplitude responses on the electroretinogram (ERG). In this study we wished to examine if there was a relationship between cocaine craving and reduced blue cone b wave ERG responses.

A series of 14 recently withdrawn cocaine-dependent patients completed a 45-item cocaine craving questionnaire shortly before the ERG.

Cocaine dependent patients who had a reduced (<0.5 microvolts) blue cone b wave ERG response had significantly higher cocaine craving scores than patients without a reduced blue cone ERG response. There was also a significant negative correlation between blue cone b wave amplitude responses and scores on the cocaine craving questionnaire.

A reduced blue cone b wave ERG response may identify recently withdrawn cocaine-dependent patients with biological dysregulation and increased cocaine craving.

This paper examines the pattern and frequency of implementation of environmental strategies and the use of psychotropic medication in the management of patients with delirium in an acute hospital setting.

The study involved 46 consecutive referrals to a consultation psychiatry service each of whom met ICD–10 criteria for delirium. Patients were subdivided into hyperactive, hypoactive and mixed subtypes of delirium and assessed regarding severity of delirium, the use of psychotropic medication prior to consultation and the implementation of environmental measures in their management.

Mean age was 60.1 years. Thirty per cent of patients were of the hyperactive subtype, 24% hypoactive and 46% mixed. Psychotropic medication was given to 56.5% prior to consultation and this is significantly associated with severity of delirium and in particular, with hyperactive delirium subtype. Of eight environmental strategies only four were instituted in over 50% of the patients prior to consultation. The application of these strategies was associated with overall severity of delirium, agitation, mood lability and sleep-wake cycle disturbance. It was not significantly associated with severity of disorientation or with disturbed perception/thinking.

Simple environmental strategies such as limiting changes in staff, minimising noise levels and involving relatives in re-orientation are frequently overlooked in the management of patients with delirium. Our study suggests that the implementation of environmental strategies occurs primarily in response to behavioural challenges rather than to limit the core features of delirium.

Tardive dystonia is an uncommon complication of neuroleptic treatment which is frequently disabling and poorly responsive to treatment.

The case is reported of a 28-year-old patient with schizophrenia who developed severe, generalised tardive dystonia after five years of neuroleptic treatment. Stopping neuroleptic medication and treatment with tetrabenazine, an anticholinergic and a benzodiazepine were ineffective. Treatment with clozapine and then the novel combination of clozapine plus clonazepam was instituted.

Treatment with clozapine alone brought about limited improvement. Addition of clonazepam resulted in virtually complete disappearance of all abnormal movements. This remission has been sustained for nearly two years.

This report adds to two other cases suggesting that the combination of clozapine and clonazepam may be an effective treatment for tardive dystonia.