Concern has been growing about a cyclical pattern or ‘periodicity’ in mental health care over the past 300 years, in which large-scale policy decisions have been made, and then reversed, paying little attention to the particular needs of differing patient groups. Turner (1985) drew attention to the reckless course followed by psychiatry, and how the “discipline that has lost its way” (Lancet, 1985) may have done so owing to a poor grasp of its past history. In the movement towards community care, ‘difficult’ or the so-called ‘unrewarding’ (to use Scott's (1970) term) patients are a particularly vulnerable group (Aviram & Segal, 1973; Bachrach, 1980). Increasingly, community services are compelled to cater for less disturbed patients through being selective about whom they will accept. To a degree, forensic services on both sides of the Atlantic have partially filled the gap so created in service provision. For this and other reasons, it is difficult to make a general statement about the effectiveness of deinstitutionalisation and community care. To be more specific, there are basic conceptual difficulties in defining continuity of care and identifying subgroups for which it has different implications (Bachrach, 1981), and there are major methodological difficulties impeding an analysis of such a diffuse and fragmented provision. Scull's (1984) description of the overnight abolition of state facilities for juvenile offenders in Massachusetts in the US between 1969 and 1973 points to the impossibility of making a comparison ‘before and after’, when so much dissolution and decentralisation of services has occurred (see also Jones, 1982). A few model alternatives were described soon after the closures, and Bachrach (1980) has written about the dangers of generalising from model programmes, highlighting the differences between demonstration efforts and reality. It is proposed here that the difficult and offender population might act as a ‘litmus paper’ for the efficiency, or otherwise, of community care in general.

Considerable attention has been paid, both by regulatory authorities and clinicians, to the side-effects of antidepressants, but despite the known high suicide risk in depression, toxicity in overdosage has been largely ignored. On the basis of the evidence currently available, ‘older’ antidepressants appear to be more toxic than ‘newer’ agents. A case can be made for limiting the use of some of the older tricyclic antidepressants, especially in patients who remain in the community, when continuous supervision is lacking, in favour of newer, safer drugs.

Genetic factors in the aetiology of Alzheimer's disease (AD), are now being intensively investigated. The homogeneity of AD is under investigation. There are a few large kindreds with early onset of AD in whom transmission appears to be typically autosomal dominant, and 65% or more of the remaining cases at any age may have genetic aetiology. Both multifactorial and autosomal dominant inheritance with age-dependent expression have been proposed, but the late onset and death of unaffected relatives from competing causes make it difficult to choose between them. Lifetime risk gives the best estimate of incidence in family studies, but clinical and pathological criteria are not clear enough for confident diagnosis of AD in late old age. A role for external factors is indicated by twin studies, and the role of aluminium is currently under investigation. Molecular genetics promises to resolve many questions. The clinicians' role will be to provide well documented families for interdisciplinary research and to help in clarifying diagnosis in late old age.

Depression appears to be common after stroke, and therefore may have a bearing upon rehabilitation. To examine whether the depression is due to a specific brain lesion, or is reactive to the consequent disability, this study looked at the frequency and associations of depressed mood in a stroke rehabilitation unit in-patient population, unselected for site of lesion. Depression affected 50% of the patients; history of previous psychiatric disorder and cerebrovascular accident appeared to be important risk factors. There were hemispheric differences in the relationships between measures, with both the site-of-lesion and reactive viewpoints being upheld.

To assess the future requirements for long-stay psychiatric beds, every consultant psychiatrist in Glasgow was asked to consider whether long-stay patients in his or her wards would be fit for rehabilitation and return to the community. For the purposes of the survey, long stay was defined as a single admission of at least six months, but patients with an organic diagnosis who were aged over 65 were excluded. It was estimated that, with rehabilitation, almost a third of the patients surveyed could return to the community, and that, with more participation in self-care, over 15% might be able to manage in a ward or hostel within the hospital. Patients judged fit to return to the community were preponderantly younger patients with a shorter period of inpatient care, and those suffering from a functional psychotic illness.

A psychosocial intervention is described geared to the needs of carers of the long-term mentally ill, which is feasible for a busy clinical team to implement: relatives were not selected for the group by patient diagnosis or motivation and little extra staff input was required. An interactive education session at home was followed by a monthly relatives group which aimed to reduce components of expressed emotion (EE) and to alleviate burden. The group facilitators adopted a directive but non-judgemental style, and constructive coping efforts were encouraged. The intervention was effective at reducing EE and improving family relationships. The study offers a realistic model of how to offer support to people providing long-term care for the severely mentally ill.

The literature on parricide is reviewed with special reference to women. Seventeen female parricides (14 matricides, 3 patricides) were identified: in a remand prison (11), a Special Hospital (5), and a Regional Secure Unit (1). Six were schizophrenic, five had psychotic depression, three had personality disorders, and one was alcoholic. Two of the patricides had no psychiatric disorder but retaliated against violent fathers. Regardless of psychiatric diagnosis, matricides were mostly single, socially isolated women in mid-life, living alone with a domineering mother in a mutually dependent but hostile relationship. Similar characteristics are found in male matricides, who are predominantly schizophrenic. It is suggested that these features are of greater significance in matricide than the specific form of psychiatric disorder. Compared with filicides, matricides were significantly older, were single, and more often suffered from mental illness and substance abuse. Attention is drawn to the possible homicidal risk associated with delusions of poisoning and hypochondriacal delusions.

The majority of patients with bipolar affective disorder relapse at least once during their lifetime, most several times, often with disastrous consequences. In this review we examine those factors which appear to play a facilitatory and in some cases, a causal role in determining whether a relapse will occur and, if so, when. Such factors include: the season of the year, with most admissions for mania in the British Isles occurring in the summer months; change in endocrine status, as after childbirth or when there is impaired thyroid function; treatment with drugs affecting central monoamine, particularly dopamine, neurotransmission; untoward life events. We evaluate the relative efficacy of treatments for the prevention of relapse, such as lithium, carbamazepine and antipsychotics, in the context of social and psychological support systems.

The current characterisation of dementia as a state of global cognitive failure (DSM-III-R, 1987) cannot differentiate it reliably, in cross-sectional diagnosis, from other states of compromised cognition. This is likely to contribute to both the over- and under-diagnosis of dementia in clinical practice (Marsden & Harrison, 1972; Fleminger, 1975; Ron et al, 1979; Smith & Kiloh, 1981; Garcia et al, 1984; Klein et al, 1985). However, diagnostic discrimination between true dementia and its behavioural phenocopies (e.g. depressive pseudo-dementia, quiet delirium, etc.) can be improved in a number of ways. One such is the longitudinal assessment of symptom-clusters (e.g. those related to memory, personality, and cortical syndromes); another is the inclusion of new symptoms into the definition of dementia. The first of these strategies has been given more attention than the second.

In a prospective study, 153 consecutive new referrals to a psychogeriatrician in Oxfordshire in 1973 were followed up for 15 years. The percentage of the over-65 population at risk was 0.27 and, of those aged over 80, 0.6. Alzheimer's dementia and depressive illness comprised over two-thirds of referrals. A quarter became permanent admissions, half of them with Alzheimer's dementia, 19% of whom were alive five years later. Depressive illness, at ten years, had a mortality 1.2–1.6 times that of the population at risk. The distinction between Alzheimer's dementia and depressive illness, based on their natural history and causes of death, was reinforced.

The basic unit of study for psychiatric investigation is the individual human being in interaction with the environment. The psychological understanding of human biography provided by psychodynamic observation is now being supplemented by knowledge derived from phenomenological and neurobiological research. Phenomenology and neurobiology are at present primarily concerned with detecting correlations between clinical syndromes and pathological brain states; they are static rather than dynamic in approach. However, currently emerging techniques of brain imaging aimed at elucidating neurophysiological processes provide the basis for going beyond structural neuropathology to neuropathophysiology. It is suggested that the observations derived from the psychodynamic study of patients constitute markers of underlying brain function, and that the future investigation of psychiatric illness must include a correlative study of both psychodynamic and neurobiological processes.

Symptoms of depression were quantitatively recorded using a rating scale, for 239 men and 260 women. The frequency of the various symptoms were similar for the sexes, with a high frequency for anxiety, both psychic and somatic. The results show that the symptoms of depressive patients differ from those found in the classic descriptions.

The psychopathology of a series of patients referred to a combined psychiatric-toxicological assessment service with the specific complaint of being, or having been, poisoned is described, and related to the nature of their exposure to incriminated agents. The need for and value of this service are discussed.

The relapse and readmission rates of schizophrenic patients who participated in a controlled trial of a nine-month behavioural family intervention trial based on the EE status of their relatives are presented at two years. The patients who received the behavioural family intervention had lower rates of relapse and readmission than patients from high-EE homes who had received a short educational programme or routine treatment. The relapse rate of the behavioural family intervention group (33%) was the same as that of the low-EE group (33%), and significantly lower than that of the non-intervention high-EE group (59%).

One hundred and eighty-three patients suffering from functional psychoses were diagnosed according to ICD–8, RDC, and DSM–III criteria, and the concordance rates for the diagnoses compared. The heterogeneity of the diagnosis 'schizoaffective psychosis' as defined by these systems became clear. With respect to prognosis, the DSM–III diagnosis of schizophrenia was most closely related to poor outcome. Affective psychoses and schizoaffective psychoses, as well as DSM–III 'schizophreniform disorders', demonstrated a favourable prognosis.

DSM-III diagnoses and responses to the Beck Depression Inventory (BDI) were examined in 71 consecutive admissions to an inpatient psychiatric crisis service following deliberate self-harm. Although 80% of the admitted patients were moderately or severely depressed according to BDI scores, only 31 % were diagnosed with a major depressive episode. While all of the self-harm patients may be viewed as experiencing severe subjective distress, only a minority were shown to suffer from DSM-III depressive illness. The high depression scores on the BDI may be related to the patients' extreme distress preceding a crisis admission and to the high prevalence of personality disorders in this group of patients.

Obsessive-compulsive disorders (OCDs) (ICD-9 = 300.3) (ICD-9, 1978) remain an obscure, heterogeneous, and often unmanageable collection of interfering and repetitive experiences and actions which may interrupt, and occasionally obliterate the flow of behaviour (Beech, 1974; Rachman & Hodgson, 1980; Berrios, 1985; Jenike et al, 1986). Considered during the 19th century as a form of psychosis, OCDs were incorporated at the turn of the century into the psychodynamically redefined class of the ‘neuroses’ (Berrios, 1985). However, this newly gained identity has proved to be heuristically sterile as well as delaying research.

Ventricular size was measured from CT scans in 48 patients meeting RDC for schizophrenia who had a first-degree relative with a history of treatment for major psychiatric disorder, in 48 age- and sex-matched schizophrenic patients with no such history in first- or second-degree relatives, and in 48 matched, healthy controls. There was no difference in ventricular size between those with and without a positive family history, although both groups showed ventricular enlargement with respect to normal controls. Ventricular enlargement was demonstrated in the subgroup of 23 patients with a family history of schizophrenia, but not in the subgroup of 18 patients with a family history of affective disorder. These observations provide further evidence that schizophrenics with a family history of affective disorder may constitute an aetiologically distinct subgroup.

The cerebral vascular transit time of 17 patients with presenile dementia of the Alzheimer type (ATD), nine abstinent patients with alcoholic Korsakoff's psychosis (KOR), and ten age-matched controls was determined by the bolus intravenous injection of pertechnetate. A gamma camera was used to estimate the median transit time (MTT) of the radioactive bolus in a planar (non-tomographic) projection normal to the vertex. The spread of the bolus arriving at the aortic arch was measured independently by a single external detector over the chest, and correction made for the transit time of this input function in calculating the net MTT for the head. Both ATD and KOR groups showed lengthened net MTTs, compatible with reduced cerebral blood flow, and which were correlated with reduced cognitive function. It is concluded that the method employed gives a simple, inexpensive estimate of function-related blood flow to the brain in presenile dementia.