Patients' perspectives concerning impaired functioning provide important information.

To evaluate the reliability and validity of the Work and Social Adjustment Scale (WSAS).

Data from two studies were analysed. Reliability analyses included internal scale consistency, test – retest and parallel forms. Convergent and criterion validities were examined with respect to disorder severity.

Cronbach's α measure of internal scale consistency ranged from 0.70 to 0.94. Test – retest correlation was 0.73. Interactive voice response administrations of the WSAS gave correlations of 0.81 and 0.86 with clinician interviews. Correlations of WSAS with severity of depression and obsessive–compulsive disorder symptoms were 0.76 and 0.61, respectively. The scores were sensitive to patient differences in disorder severity and treatment-related change.

The WSAS is a simple, reliable and valid measure of impaired functioning. It is a sensitive and useful outcome measure offering the potential for readily interpretable comparisons across studies and disorders.

The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) is an established outcome measure for child and adolescent mental health. Little is known of adolescent views on outcome.

To develop and test the properties of an adolescent, self-rated version of the scale (HoNOSCA–SR) against the established clinician-rated version.

A comparison was made of 6-weekly clinician-rated and self-rated assessments of adolescents attending two services, using HoNOSCA and other mental health measures.

Adolescents found HoNOSCA–SR acceptable and easy to rate. They rated fewer difficulties than the clinicians and these difficulties were felt to improve less during treatment, although this varied with diagnosis and length of treatment. Although HoNOSCA–SR showed satisfactory reliability and validity, agreement between clinicians and users in individual cases was poor.

Routine outcome measurement can include adolescent self-rating with modest additional resources. The discrepancy between staff and adolescent views requires further evaluation.

Confusional states associated with medical and surgical conditions require more study and biochemical explanation.

To understand impairment of consciousness, cognition and memory.

A psychiatrist reports experience of his changing mental state over 5 days from notes made immediately on recovery.

A prodromal phase of declining consciousness, understanding and memory registration over perhaps 48 h was difficult to detect. During unconsciousness there were four brief partial reversals with arousal, and some mental functioning (memory, formation of beliefs) occurred.

Self-report can be a useful addition in clinical study and patients with renal failure require psychological and psychiatric study. Comparison with the mental effects of benzodiazepine or of an anaesthetic such as nitrous oxide might throw light on the pathology.

Growing evidence suggests that there may be a subtype of depression arising in later life that is characterised by a distinct clinical presentation and an association with cerebrovascular disease. This has been termed ‘vascular depression’.

To review the evidence for associations between cardiovascular disease and depression and between cerebrovascular disease and depression, and to examine implications for clinical practice and research.

The authors reviewed the medical literature covering the past 5 years.

There is strong evidence for an association between cardiovascular disease and depression, but this is not confined to older people. The causal pathway may be bi-directional. There is also a convergence of evidence suggesting a causal link between cerebrovascular disease and depression, especially that occurring later in life. The major focus has been on neuroradiological findings thought to be due to vascular disease, although the pathology may be heterogeneous.

Although there are gaps in the evidence there is strong support for the concept of vascular depression, characterised by reduced depression ideation, subcortical neurological dysfunction, apathy and psychomotor change. This has implications for both treatment and prevention.

Epidemiological studies of dementia subtypes have revealed widely varying distribution rates. There are almost no published community prevalence data for dementia with Lewy bodies (DLB) or the frontal lobe dementias (FLD).

To identify the distribution of dementia subtypes in a representative community population of older people.

People aged ⩾65 years in randomised enumeration districts in Islington, north London, were screened using a reliable and valid questionnaire. People screened as having dementia were assessed in detail and diagnoses were made according to standard diagnostic criteria.

Of 1085 people interviewed, 107 (9.86%) met screening criteria for dementia. Diagnoses were made for 72 people (67.3%). Distribution of subtypes varied according to the criteria used; the best-validated criteria yielding: Alzheimer's disease 31.3%; vascular dementia 21.9%; DLB 10.9%; and FLD 7.8%.

Alzheimer's disease is confirmed as the most common cause of dementia in older people, followed by vascular dementia. However, DLB and FLD occur sufficiently often to be seen frequently in clinical practice and should be incorporated into future editions of standard diagnostic criteria.

There is a vast array of scales available to assess all aspects of mental and physical health in older people which may be of relevance to the work of old age psychiatrists.

To summarise some of the scales that may be commonly used in clinical and research practice and to give the reader guidelines as to where further information can be obtained.

The scales were selected on the basis of the authors' own clinical and research knowledge and information was gathered from a comprehensive text on assessment scales in old age psychiatry.

The selected scales are described in brief and a table outlines the purposes for which they are most suitable.

Although many scales are available, the choice of the individual scale relies specifically on the question that is to be asked. The ideal scale does not exist.

A high rate of maternal depression and associated disturbance in the mother–infant relationship has been found in an indigent peri-urban South African community Khayelitsha. The question arises whether a community-based intervention could be beneficial.

To train community workers to deliver an intervention to mothers and infants in Khayelitsha, and to compare mothers and infants receiving this intervention with a sample receiving no such intervention.

Four Khayelitsha women were trained in a mother-infant intervention, which they delivered to 32 women recruited in late pregnancy. At 6 months post-partum, maternal mood, the mother–infant relationship and infant growth were assessed. The findings were compared with a matched group of 32 mothers and infants.

There was no reliable impact of the intervention on maternal mood. However, compared with the comparison sample, the quality of mother – infant engagement was significantly more positive for those who had received the intervention.

The pilot study produced preliminary evidence of a benefit of a community-based mother – infant intervention delivered by trained, but otherwise unqualified, community workers, sufficient to warrant a formal controlled evaluation of this treatment.

Social adversity may be a risk factor for depression, by increasing Cortisol secretion, which impairs serotonin (5-HT) neurotransmission.

To examine this causal pathway in a community setting.

Women who were currently ICD–10 depressed (n=94), vulnerable to depression but not depressed (n=166) and non-vulnerable controls (n=177) were recruited. We assessed social adversity and vulnerability (Life Eventsand Difficulties Schedule; Self Evaluation and Social Support Scales) and psychiatric state (Schedules for Clinical Assessment in Neuropsychiatry). Salivary cortisol concentrations were measured at 09.00 and 23.00 h. Serotonin function was assessed using prolactin responses to dexfenfluramine.

Cortisol concentrations were not increased in the depressed or vulnerable. Morning salivary and serum cortisol were reduced in depression. Evening cortisol was increased after recent life events. Life events and depression were associated with increased prolactin responses.

The hypothalamic–pituitary–adrenal axis is sensitive to social stress but does not mediate vulnerability to depression. Exaggerated 5-HT2 receptor responsiveness to stress may play a role in the evolution of depression.