We report a randomised controlled trial, in both the acute and maintenance stage of treatment, in 75 outpatients with recurrent major depression.

Patients were allocated to three groups: 16 weeks of acute treatment and two years' maintenance treatment in the following way: antidepressants and maintenance antidepressants; cognitive therapy and maintenance cognitive therapy: antidepressants and maintenance cognitive therapy. Both completers' and end-point data were analysed.

In the acute phase of treatment, all patients improved significantly and there was no significant difference among treatments, or in the pattern of improvement over time. In the maintenance stage of treatment, patients kept improving over time in all three groups and there was no significant difference among treatments. Cognitive therapy was consistently superior to medication.

The results indicate that maintenance cognitive therapy has a similar prophylactic effect to maintenance medication and is a viable option for maintenance after acute treatment with medication in recurrent depression.

The social origins of depression in people of Pakistani origin in the UK are not fully understood; they may not be the same as for the indigenous White population.

Patients attending a GP's surgery were screened with the Personal Health Questionnaire to detect depressive illness, which was confirmed using the Psychiatric Assessment Schedule; the estimated prevalence of major depression was 42%. Forty-four people with depression and 33 non-depressed comparison subjects were successfully interviewed using the Life Event and Difficulty Schedule, either in Urdu or English.

Seventy-five per cent of the sample were Pakistani born; 57% of cases and 33% of non-cases spoke English with difficulty. Seventy-five per cent of the cases and 36% of the non-cases had experienced an independent severe event and/or a major difficulty (P=0.0015). Difficulties associated with depression were most commonly in the marital, health and housing categories; overt racial harassment and discrimination were rare.

This is a preliminary study because of the small sample of GP attenders. The somatic presentation of depression in this population is clear. Acceptable forms of social support and help with marital, housing and employment problems will be needed to help relieve the depression in this population.

General psychiatrists have recently been encouraged to provide treatment to heroin addicts, including in-patient detoxification. No comparison has previously been made of specialist versus general psychiatric in-patient care.

During a randomised study of cue exposure, 186 opiate addicts were also randomised to either specialist in-patient (DDU; n=115) or general psychiatric (GEN; n=71) wards in the same hospital.

From pre-treatment (post-randomisation) onwards, patient outcomes differed across the two in-patient settings. Of the original randomised sample, significantly more DDU than GEN subjects accepted their randomisation (100 v. 77%), were subsequently admitted (60 v. 42%), and completed in-patient detoxification (45 v. 18%). Of patients admitted, more DDU than GEN patients completed detoxification (75 v. 43%). During seven-month follow-up, of those 43 patients who reached the end of treatment, significantly more ex-DDU than ex-GEN subjects were opiate-free.

From pre-treatment onwards, significant differences in process and outcome were found after allocation to treatment on either DDU or GEN. Further randomised studies are required to replicate and explain these findings.

Several reports have documented the presence of motor abnormalities in schizophrenic patients.

Thirty schizophrenics and 28 healthy controls were included in the study. Scalp-recorded bereitschaftpotentials (BPs) generated prior to voluntary movements were recorded in all subjects.

The early (NSI) and late components of BP and peak negativity were reduced in all schizophrenic patients. In particular, the NSI was reduced in patients with positive symptoms, and the late component in patients with negative symptoms.

These findings provide further support for the involvement of frontal cortex, subcortical structures and their connections in schizophrenia, and highlight some differences between positive and negative symptom clusters.

The consensus statement on the treatment of depression (Paykel & Priest, 1992) advocates the use of cognitive therapy techniques as an adjunct to medication.

This paper describes a randomised controlled trial of brief cognitive therapy (BCT) plus ‘treatment as usual’ versus treatment as usual in the management of 48 patients with major depressive disorder presenting in primary care.

At the end of the acute phase, significantly more subjects (P < 0.05) met recovery criteria in the intervention group (n=15) compared with the control group (n=8). When initial neuroticism scores were controlled for, reductions in Beck Depression Inventory and Hamilton Rating Scale for Depression scores favoured the BCT group throughout the 12 months of follow-up.

BCT may be beneficial, but given the time constraints, therapists need to be more rather than less skilled in cognitive therapy. This, plus methodological limitations, leads us to advise caution before applying this approach more widely in primary care.

In a follow-up survey from Oslo, 503 persons were re-interviewed using the same questionnaire after 10 years.

The questionnaire includes questions about social support, social characteristics of the neighbourhood and mental health. Information about the neighbourhood was also gathered from key informants.

Of the five types of neighbourhoods surveyed, only one showed marked change over time with respect to social characteristics. This was an initially poorly functioning neighbourhood with poor mental health among the residents, where substantial improvement took place as part of the further development of the area. Parallel with the improvement in social environment there was a significant improvement in mental health among those who continued to live in the same area, as opposed to those who continued to live in the other areas. Selective migration could not explain this finding.

The findings support the environment stress hypothesis, implying that the quality of a neighbourhood has an impact on mental health. The implications for psychiatric prevention are discussed.

Dress styles and forms of address vary among psychiatrists.

A semi-structured interview was administered to a sample of psychiatric in-patients, and a questionnaire was sent to junior and consultant psychiatrists, to identify preferences for dress styles and terms of address.

Forty-nine (71%) of the inpatient sample participated. A preference was found for smart attire and white coats. Of the 69 (80%) doctors returning questionnaires, the majority supported smart dress as the most appropriate attire. Most patients preferred to be called by their first name while addressing doctors by title and surname. Junior doctors preferred to use first names when talking to patients while almost all consultants used title and surname. Doctors of all grades liked to be called by their title and surname.

Paying more attention to the way we present ourselves and interact at work may help to facilitate the therapeutic alliance.

New methods of rapid opiate detoxification, under intravenous sedation, can detoxify heroin-addicted patients in 24 hours. Their clinical application has been limited by the lack of studies establishing both efficacy and safety.

In a randomised, controlled study, 300 treatment-refractory, heroin-addicted patients received rapid intravenous detoxification treatment (naloxone infusion, 0.06–0.08 mg/kg, then oral naltrexone 50 mg/day) under either monitored light intravenous sedation or unmonitored deep intravenous sedation.

All patients were successfully detoxified and 93% remained abstinent one month later. Severity of withdrawal, according to the Wang Scale modified by Loimer, was 4.9 (s.d. 3.0) points in the light sedation group and 4.8 (s.d. 2.9) in the deep sedation group (P=0.26). Two patients (1.3%) in the light sedation group and four (2.6%) in the deep sedation group required tracheal intubation (P=0.31). There was only one severe complication, a case of nosocomial aspirative pneumonia which improved with antibiotic treatment.

Successful rapid intravenous detoxification can be achieved using relatively light levels of sedation.

A randomised clinical trial was carried out in suicide attempters to assess clinical efficacy of an intensive psychosocial intervention compared with treatment as usual.

Two hundred and seventy-four suicide attempters presenting for medical treatment were randomly assigned to either intensive psychosocial treatment or ‘care as usual’. Intensive psychosocial treatment consisted of brief admission to a special crisis-intervention unit and problem-solving aftercare. ‘Care as usual’ included any form of treatment the assessing clinicians thought appropriate. Psychological well-being was evaluated by the SCL–90 and the Hopelessness Scale at 3, 6 and 12 months following entry in the study.

No differences in outcome were found. The probability of repeat suicide attempts in the 12-month follow-up was 0.17 for patients in the experimental group and 0.15 for the control group. There were no differences in ratings on the SCL–90 and the Hopelessness Scale. Patients in the experimental group attended significantly more out-patient treatment sessions.

General implementation of an intensive in-patient and community intervention programme for suicide attempters does not seem justified.

Previous studies show that criticism by relatives during acute depressive illness predicts relapse over nine months, but the course of criticism over time and its relation to the course of illness, have not been examined in depressed patients.

Thirty-nine depressed patients and their partners, were interviewed separately at three-monthly intervals over about one year. Illness was assessed by Research Diagnostic Criteria and Hamilton Depression Rating Scale. Criticism was measured by the Camberwell Family Interview.

Criticism when patients were most depressed predicted neither remission nor subsequent relapse. Patients who fully recovered, with or without later relapse, had partners who were consistently uncritical, or critical only at presentation. Patients with residual symptoms during remission had more persistently critical partners.

The nature of the association between criticism and depression could not be unequivocally established, although it appeared likely that continuing criticism was a result of continuing depression. Relatives' understanding of the illness may mediate between levels of criticism and the course of depression.

With few exceptions, evaluation of the capacity of general practitioners (GPs) to recognise psychiatric disorder in their patients has failed to consider the role of ethnic diversity in the consultation process and whether such knowledge can improve understanding of the degree to which psychiatric morbidity is recognised within GP settings.

This research was completed in five general practices representative of all those within an inner-city health district. Psychiatric morbidity in patients consecutively attending the practices was then assessed using the General Health Questionnaire; in addition, GPs were asked to complete a checklist of current problems identified during each consultation.

Analysis suggested that Asian and Black patients were less likely than White patients to have psychological problems identified; that social problems and a psychiatric history facilitated recognition; and that current physical illness hindered recognition.

GP recognition of psychological problems varies according to patient ethnicity but can be substantially masked by both the physical and social circumstances of patients at consultation.

Exposure and response prevention is considered a treatment of choice for obsessive–compulsive disorder (OCD). Yet there have been very few randomised controlled trials employing credible placebo conditions. This study compares exposure and response prevention with a general anxiety management intervention.

Eighteen patients meeting DSM–IV criteria for OCD were randomly assigned to either exposure and response prevention or anxiety management. Both treatments involved approximately 15 hours of therapy over a three-week period.

There was a significant reduction in obsessive–compulsive symptoms following treatment with exposure and response prevention, while no change occurred in the control group. This was found to be statistically significant using a composite measure of OCD symptom severity, patient ratings of interference and therapist ratings of symptom severity.

These findings suggest that the symptom reductions associated with behaviour therapy for OCD are a result of the specific techniques of exposure and response prevention, rather than non-specific aspects of the therapy process. General anxiety management techniques are not effective in the treatment of OCD.

The prevalence of the core ideational component of eating disorders among the at-risk population (11 – to 16-year-old girls) is not known.

A community survey of 11 – to 16-year-old girls was conducted to establish the prevalence of significant concerns about body weight and shape characteristics of eating disorders. A total of 1068 girls were screened and 368 interviewed using standardised measures.

Significant weight and/or shape concerns were estimated to be present in 14.5% of the 11-to 12-year-olds, 14.9% of the 13-to 14-year-olds and 18.9% of the 15-to 16-year-olds. Only among those aged 15 to 16 was the presence of such concerns associated with a significant level of concurrent behavioural and ideational disturbance.

Significant concerns about weight or shape are present in almost one in five 15-to 16-year-old girls, many of whom evidence high levels of ancillary disturbance.

The study aimed to compare the beliefs of health professionals about the potential helpfulness of various mental health interventions with those of the general public.

Surveys were carried out in Australia of 872 general practitioners, 1128 psychiatrists, 454 clinical psychologists and 2031 members of the public. Respondents were presented with a case vignette describing either a person with depression or one with schizophrenia. Respondents were asked to rate the likely helpfulness of various types of professional and nonprofessional help and of pharmacological and non-pharmacological interventions.

The professionals gave much higher ratings than the public to the helpfulness of antidepressants for depression, and of antipsychotics and admission to a psychiatric ward for schizophrenia. Conversely, the public tended to give much more favourable ratings to vitamins and minerals and special diets for both depression and schizophrenia, and to reading self-help books for schizophrenia.

The beliefs that health practitioners hold about mental disorders differ greatly from those of the general public. There is a need for mental health education campaigns to help close the gap between professional and public beliefs.

Several studies have reported a decline of up to 50% in the incidence of schizophrenia over recent decades. We aimed to measure changes in the incidence and diagnostic patterns of first-episode psychosis by comparing two Nottingham cohorts, identified in two equal periods separated by 14 years.

Two prospectively ascertained cohorts of first-episode psychotic disorder were identified over the time periods 1978–80 and 1992–94. The earlier cohort was of the World Health Organization Determinants of Outcome of Severe Mental Disorder (DOSMD) ten-country study. The later cohort was obtained using similar methodology. Both groups were diagnosed using ICD-10 diagnostic criteria and age-standardised incidence rates were compared.

The standardised incidence rate for all psychotic disorders rose slightly from 2.49 to 2.87 per 10 000 population per year, but the F20 classification fell significantly by over a third (1.41 to 0.87 per 10 000 per year). The second study group (1992–1994) included a greater diversity of psychotic diagnoses compared with the first, in particular an increased proportion of acute and drug-related psychoses.

Methodological considerations call for caution in interpreting such data, but we conclude that the significant fall in the narrowly defined diagnostic category of schizophrenia reflects a real change in the syndromal presentation of psychotic disorders.

Serotonin receptors may play an important role in the pathophysiology of affective disorders. We studied type-2 serotonin (5-HT2) receptors in the brain of patients with major depression.

Using positron emission tomography (PET) and the selective radioligand [18F]altanserin, we investigated 5-HT2 receptor distribution in eight drug-free unipolar depressed patients and 22 healthy subjects. Data were analysed using Statistical Parametric Mapping 95.

In depressed patients, [18F]altanserin uptake was significantly reduced in a region of the right hemisphere including the posterolateral orbitofrontal cortex and the anterior insular cortex. A trend to similar changes was found in the left hemisphere. No correlation was found between the uptake and the Hamilton rating scale score.

Pathophysiology of depression may involve changes in 5-HT2 receptor in brain regions selectively implicated in mood regulation.

Despite the high suicide rate in the elderly, there is a relative lack of information on the longer-term outcome of elderly people who have attempted suicide, particularly their psychiatric and physical morbidity and mortality.

Comprehensive demographic and psychiatric data were available on 100 consecutive referrals to a liaison psychiatric service of patients over 65 years of age who attempted suicide between 1989 and 1992. Detailed follow-up in 1994 included the interviewing of survivors using GMS–AGECAT.

Of the 64 women and 36 men, with a mean age of 75.8 years, 42 subjects were dead at follow-up; 12 were suspected suicides, five having died as a delayed result of their index attempt. Twelve women made a further non-lethal suicide attempt. All five male repeat attempts proved fatal.

Elderly people who attempt suicide have a high mortality both from completed suicide and death from other causes. The completed suicide rate is at least 1.5% per year, and the repetition rate is 5.4% per year. Those at risk of further self-harm are likely to be in contact with psychiatric services and to be suffering from persistent depression.

We compared regional cerebral blood flow (rCBF) in three groups of patients with DSM–III–R anxiety disorders.

Fifteen patients with obsessive–compulsive disorder (OCD), 15 with panic disorder with agoraphobia (PA), and 16 with post-traumatic stress disorder (PTSD) and a similar group of healthy controls were assessed on brain-dedicated high-resolution SPET.

MANOVA revealed significant rCBF differences between diagnostic groups (F=4.4; d.f.=3, 57; P=0.007) and between cerebral regions (F=6.4; d.f.=1, 57; P=0.01) in OCD and PTSD compared with PA and healthy controls, limited to bilateral superior frontal cortices and right caudate nuclei. Whole brain blood flow correlated positively with anxiety (r=0.24, n=46, P=0.05). Beck depression scores correlated significantly negatively with left caudate rCBF (r= –0.24, n=46, P=0.05) and right caudate rCBF (r= –0.31, n=46, P=0.02). PTSD syndrome severity correlated significantly negatively with the left caudate (r=-0.49, n=16. P=0.03) and with right caudate rCBF (r=-0.7, n=16, P=0.001)

Functional rCBF differences in anxiety disorders could relate to repetitive, intrusive, distressing mental activity, prominent in both OCD and PTSD.