The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

The clinical features of patients who satisfy a variety of criteria for the negative syndrome can be arranged in five groups of phenomena: (a) poverty of thought and speech, (b) blunted affect, (c) decreased motor activity, (d) apathy and avolition, and (e) diminished interpersonal interaction. We have shown that depressed mood and depressive cognition are not related to the negative syndrome, but there is some overlap between the specific phenomena of depressive illness and negative symptoms in schizophrenia. Items measuring cognitive impairment have a moderate correlation with the negative syndrome, but the negative syndrome accounts for less than half of the variance of cognitive performance. These items that define the negative syndrome can be as reliably measured as depressive and positive symptoms.

Economists in the UK have developed a particular view of ethical choice which puts the main focus on short-term, static decisions. As resources are scarce, decisions have to compete (O'Donnell et al, 1988). Although economists have also stressed the moral imperative of improving efficiency, the theme of choice as inexorable has come through much more strongly. Economists in the UK have been more hesitant about giving any clear advice on how to deal with the special problems of supply efficiencies and professional monopoly in health services.

A sample of 26 HIV seronegative, 59 HIV seropositive asymptomatic and 7 HIV seropositive symptomatic homosexual and bisexual men were assessed over two visits, a mean of 11 months apart, using the BDI, STAI, and CIS. Significant differences emerged between the symptomatic group and the other two groups. Past psychiatric history and the somatic items in the assessments accounted for some of these differences. The seropositive asymptomatic and the seronegative groups did not differ on any of the mood or psychiatric assessments, suggesting minimal effect on psychological well-being of seroconversion in the absence of symptoms.

Two hundred and one referrals to a psychiatric assessment scheme based at two inner-London magistrates' courts were followed up to assess the effect of the scheme on hospital and prison resources. Of the 65 hospital admissions, 50 (77%) derived some or marked benefit from psychiatric treatment. Those who did badly were more likely to be of no fixed abode, and had higher rates of criminality and previous compulsory admission to hospital. Absconding was the largest management problem; 30 (46%) of those admitted did so. Twelve months after admission, all patients except one had been discharged; 10 (15%) had been readmitted to hospital. The scheme generated an extra 21 (64%) hospital admissions per annum from the two courts, compared with the three years before its introduction. The saving in remand time to the prison was approximately double the increased admission time to hospital. However, the overall effect of early diversion on hospital and prison resources was small.

Research on the relationship between stress and schizophrenia is fraught with conceptual and methodological problems. These problems include issues related to the nature and measurement of stress, the likelihood of reciprocal influences between stress and symptoms, and the adequate assessment of symptoms. Several recommendations are made regarding future research in this area. These include using multiple and broadly based measures of different types of stressors and symptoms, greater use of truly prospective research designs, and the evaluation of the effects of interventions specifically designed to reduce stress in patients who suffer from schizophrenia.

Various techniques have been used to assess the results of ‘deinstitutionalisation’. This paper reviews these outcome studies, most of which have concluded that a new long-stay group will replace the old long-stay patients, and that a residual group of ageing patients, mostly with organic syndromes, is difficult to accommodate in the community.

A postal questionnaire was sent to 195 senior British psychiatrists who were asked about their attitudes towards the DSM-III-R diagnosis of somatisation disorder (SD) and the ICD-10 diagnosis of multiple somatisation disorder. Of the 148 respondents, 98 (66%) had experience of liaison psychiatry, and these psychiatrists used the diagnosis significantly more often than those without liaison sessions. More than half the respondents perceived SD as both a personality disorder and a mental state disorder, although 27% thought that patients with SD had an undiagnosed physical disease. The marked discrepancy between British and North American psychiatrists in diagnostic practices was perceived to be a consequence of both the difference in health care systems and the interest shown in the disorder by North American psychiatrists, rather than a reflection of genuine differences in prevalence.

Of 219 elderly patients with a major depressive disorder (meeting RDC), 69 recovered sufficiently and consented to enter a two-year double-blind placebo-controlled trial of dothiepin. Survival analysis revealed that dothiepin reduced the relative risk of relapse by two and a half times. Past but not current serious physical illness was also associated with a favourable outcome, whereas a prolonged index depressive illness trebled the relative risk of relapse. In the light of previous research on prognosis it is suggested that elderly persons who recover from a major depressive illness should continue with antidepressant medication for at least two years, if not indefinitely.

Liaison psychiatrists need to interview somatising patients in a way which allows a full assessment of the problem. This can best be achieved if the psychiatrist has already discussed with the referring physician the reason for referral and what the patient has been told about it. The medical notes should always be reviewed in detail and independent data obtained from a relative or other informant. During the interview itself the psychiatrist must be prepared to use techniques which deepen rapport with the patient, who may be initially wary or hostile. The psychiatrist should attempt to establish early a treatment alliance. Special aspects of the mental state need to be noted, including the patient's attitude to his/her symptoms and the strength with which somatic beliefs are held. Different approaches may be used according to the nature of the problem and the therapeutic style of the doctor. An awareness of these interview techniques would greatly reduce the chances of fruitless interviews with a hostile patient who believes the symptoms are being dismissed as being ‘all in the mind’.

The study tested Bowlby's hypothesis that experiencing the poor relating of parents in childhood predisposes the individual to poor relating in adult life. Data were drawn from two community samples: a younger sample of 25–34-year-old married women, and an older one of 40–49-year-old women. Data were also drawn from the husbands of the women in the younger sample. It focused on the single childhood variable of the recollection of poor maternal care. To avoid the effect of this on depression or other psychopathology, groups who were depressed and not depressed, or who were at different levels of psychopathology, were examined separately. Recollection of poor early care was associated with poor relating, lower age at marriage, poor-quality marriage and divorce from first marriage. There was a suggestion that the effects of the recollection of poor early care of marital partners summate.

This paper describes the origins of the TAPS project and the design of the prospective study of the long-stay patient populations of Friern and Claybury hospitals, two large mental hospitals in north-east London scheduled for reprovision and closure by the regional health authority.

A feature of the recent history of medicine has been the introduction of treatments whose costs are orders of magnitude higher than doctors are used to justifying. Having previously been left almost untouched by these developments, psychiatrists are beginning to find themselves in the position previously occupied by renal physicians, transplant surgeons, and oncologists – having to face uncomfortable decisions about costs versus benefits and the rationing of medical care. To a considerable extent this is a consequence of the launch of the new, ‘atypical’, and ‘superior’ neuroleptic, clozapine.

The quality of life of detained patients has not received adequate attention despite the responsibilities placed on hospital staff and the special problems faced by these patients. Legal principles to ensure quality of life have not been formalised, and the acceptable standards that a patient can expect have not been tested in the UK courts. Contemporary models of ensuring quality are being imposed with increasing pressure on health care professionals, but high-quality management has sometimes lagged behind. This has led to a poor quality of life for certain patients. It is important for future research to overcome difficulties in developing objective measurements and set the appropriate standards of quality of life that detained patients should expect. This would provide a basis against which both appropriate standards of care and the necessary resource allocation could be measured.

Thirty-nine chronic schizophrenic male out-patients and their relatives were interviewed separately to assess their perceptions of their current relationships. Two simple 5-point rating scales predicted the risk of psychotic exacerbation during a one-year follow-up: patients' perceptions of the relatives' attitudes towards them, and patients' own attitudes towards the relatives. Survival analysis of data in a 2 × 2 factorial - combining degree of contact with the key relatives and the patients' perceptions of their relatives - found that patients in frequent contact with a positively perceived relative had significantly better survival rates without psychotic exacerbation. Patients' perceptions of their relatives may help identify patients at risk of exacerbation of their illness.

To test the hypothesis that depressed and schizophrenic patients have a common pathophysiological mechanism for hypofunction of the prefrontal cortex (‘hypofrontality’), we measured regional cortical blood flow (rCBF) in ten depressed patients, ten patients with schizophrenia, and 20 age- and sex-matched normal controls. Blood flow was measured during three different cognitive conditions: a resting state, a simple number-matching sensorimotor control task, and the Wisconsin Card Sorting test (WCS). The schizophrenic patients had lower prefrontal rCBF during the WCS. There were no differences in global or regional flow between the depressed patients and the normal subjects during any testing condition. Analysis of rCBF lateralisation showed that during the WCS normal subjects had relatively more left parietal blood flow than depressed patients, who had more right parietal blood flow. Since the testing condition that has most consistently revealed hypofrontality in schizophrenia (i.e. the WCS) was not associated with abnormal rCBF in the depressed patients, these data suggest that the pathophysiological mechanisms underlying prefrontal hypofunction in depression and schizophrenia are different.

An analysis was conducted on the basis of available data to assess the economic consequences of clozapine therapy for people with moderate to severe schizophrenia in long-stay institutions or staffed group homes, with a view to providing an estimate of the likely costs and benefits of the drug. Data from a cost-effectiveness study conducted in the US, supplemented by other literature sources, were used to construct a clinical decision tree for likely clinical outcomes for such patients. A panel of UK psychiatrists provided consensus on how these patients would have been managed in the UK. The costs associated with each patient outcome were estimated, and a sensitivity analysis performed to test the assumptions made. For the patients themselves, clozapine would lead to a net gain of 5.87 years of life with no disability or only mild disability. The base case analysis showed that the direct costs of using clozapine were £91 less per annum (or £1333 per lifetime) than for standard neuroleptic therapy, when the effect on all health-care resources was taken into account. In addition, the sensitivity analysis showed that clozapine would be cost-saving or cost-neutral under many different assumptions. A prospective health economic study with clozapine in the management of schizophrenia would be desirable to confirm these results.

‘Somatisation’ is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the nonmonetary burden of physical and psychosocial disability on patients and their relatives.

A two-year follow-up study of 165 teenagers with conduct and emotional disorders treated as in-patients on a regional adolescent unit (YPU) is described. The target types of behaviour for each subject were scored independently by the teenager, the parent or guardian, and the professional referrer before admission and at one month, one year and two years after discharge. The significant overall improvement in behaviour observed at one month after discharge was sustained at one and two years. Thirty-three subjects who abandoned treatment within six weeks of admission had made significantly less progress than the fully treated group at one month after discharge, but there were no significant differences at the one- and two-year evaluations. Two years after treatment, between 69% and 79% of the 132 subjects who completed treatment were regarded as improved, depending on which respondent made the assessment. Adolescents who completed treatment had different characteristics from those who terminated treatment prematurely and were more likely to be girls in care referred by social services.

A random sample of 100 new patients referred consecutively to the psychiatric hospital was assessed using the Arabic translation of the PSE. An abstract form was designed to include all PSE scores as well as the necessary extra data to make ICD-9, ICD-10, and DSM-III-R diagnoses. Kappa correlation was calculated for inter-rater and intra-rater reliability. Overall reliability and reliability of each major psychiatric diagnosis were compared between the three systems. The use of the PSE helped in achieving good agreement between Arab psychiatrists for all the three systems, but ICD-10 was found to have the highest reliability figures both for three-digit and four-digit psychiatric diagnoses.