We assess the evidence that psychiatric patients are at increased risk of infection with HIV and discuss some of the clinical implications.

Surveys of HIV seroprevalence and risk behaviours among psychiatric patients were obtained from a manual and computer search (Medline and AIDSline).

Most studies report an increased prevalence of HIV infection among psychiatric patients compared to the general population. Risk behaviours, and obstacles to risk reduction, are identified.

There is a strong case for investigating the seroprevalence of HIV in psychiatric settings in the UK. Issues relating to HIV and AIDS are likely to assume increasing importance in general psychiatric practice.

Factors that determine geographical differences in incidence rates of ‘probable’ presenile Alzheimer's disease (AD PSD) may help to clarify the possible role of the environment in its aetiology.

We have ascertained the treated incidence of AD PSD in Scotland by scrutiny of hospital casenotes and searched for cases outside hospital settings. Small area geographical analysis compared the observed distribution of cases (each allocated to one of Scotland's 898 postcode sectors) with the estimated random distribution of cases.

There was non-random geographical distribution of AD PSD but not of the comparison conditions (vascular dementia (VaD), motor neurone disease, prostatic or ovarian cancers). Substantial differences between Scottish regions were probably not attributable to methodological artefact, as other techniques of case finding showed the same regional differences.

The observed differences in incidence of AD PSD between Scotland's regions are real and some localities have a higher incidence, mostly in central Scotland.

We related geographical variation of ‘probable’ presenile Alzheimer's disease (AD PSD) to exposures to possible risk factors for AD PSD and vascular dementia (VaD) and to geographical differences in survival times after presentation with AD PSD.

We found that an ecological measure of socio-economic deprivation was related to VaD but not to AD PSD. Among men with AD PSD and VaD, specific occupations conveyed no altered risk but having fathers who were coal miners was associated with AD PSD and VaD in offspring. Increased paternal age was associated with AD PSD but only in men. These factors acted independently of one another and did not distinguish between geographical areas of high and low incidence.

The length of survival after presentation with AD PSD distinguished between these areas, and when migration between these areas was taken into account, a plausible multifactorial model of the harmful effects of environment emerged, which acted independently of risk factors acting earlier in life.

We examined the differences in volume of the ventricular and extracerebral cerebrospinal fluid spaces in normal ageing and in probable Alzheimer's disease (AD) and we tried to investigate the effects of the severity of illness on the morphometric differentiation of AD and ageing, the principal components underlying brain atrophy in both conditions, and the correlations of these measurements with clinical findings.

Forty patients with probable AD were matched with 40 non-demented elderly controls. Both groups underwent standardised clinical tests and unenhanced cranial computed tomography for post hoc volumetric analysis.

The lateral and third ventricles and the anterior and lateral fissures were significantly larger in AD than in normal ageing. The volumes of the lateral ventricle and lateral fissure permitted a highly efficient differentiation between normal ageing and AD even at the mild stage of dementia, and this differentiation was improved further in the more severe stages of illness. We identified one principal component underlying brain atrophy in normal ageing and two components in AD: a ‘grey matter’ component accounting for sulcal and third ventricular enlargement, and a ‘white matter’ component for lateral ventricular enlargement. In AD, most of the volumetric measurements were significantly correlated with cognitive impairment, but in the group of non-demented elderly controls they were correlated with age.

Volumetric indices of brain atrophy permit a highly efficient differentiation between normal ageing and AD even in the mild stages of illness and this demonstrates that substantial structural brain changes have developed in the preclinical phase of illness. We suggest that there is an uncoupling between lateral ventricular enlargement and cortical brain atrophy in AD.

The study objective was to investigate the age-related variation of social factors in suicide.

Age-related variations in marital status, living arrangements, employment and social interaction were investigated in an entire 12-month suicide population in Finland (n = 1067); these findings were compared with appropriate census data.

Several social factors varied across age groups among suicides, with some age-related sex differences. Compared with the general population, the suicides were more commonly never married (especially men aged 30–39 years), divorced, and widowed (especially women aged 60–69 years); living alone was more frequent among the suicides, as was living with parents among male suicides aged 25–39 years. A history of psychiatric admission was especially common among young male suicides who had never married or were living with parents. Living alone was particularly frequent among middle-aged male suicides who had misused alcohol.

While most of the age-related variation in social factors found in suicide seems to parallel the natural variation of these factors in the general population, some social findings in suicide might be related to the victims' psychopathology and excessive alcohol use.

Paracetamol self-poisoning, which carries a significant risk of fatal liver damage, is increasing in the UK, especially among adolescents. There is concern that media portrayal of suicidal behaviour may influence its occurrence. We have investigated the effects of two broadcasts of a television drama showing a teenage girl's overdose of paracetamol.

Data from the Oxford Monitoring System for Attempted Suicide were used to examine changes in the number of overdoses and the use of paracetamol in the three week period before and after both broadcasts. An analysis of log-linear models was carried out, using additional data from two previous years, in order to control for the effects of gender, age group, time period, season, year and drug. A questionnaire was used to ascertain whether the programme had influenced patients' decisions to take an overdose or their choice of drug.

An increase in paracetamol overdoses occurred following the first broadcast, but when data from the two previous years were examined and the log-linear analysis was used there was no evidence of significant effects attributable to the broadcasts. The questionnaire study revealed that very few people had seen either episode, and only two claimed that it had influenced them (one in terms of getting help).

It is important to use sound methodology to avoid interpreting chance fluctuations as a media effect. The potential positive benefits of such programmes should also be investigated.

Clozapine's effectiveness in reducing symptoms and facilitating discharge among patients with chronic schizophrenia who were resistant to neuroleptics was studied.

All 169 such patients in a public psychiatric hospital were given clozapine. BPRS ratings (0–5 scale) were completed before treatment and 21 months later. Patients were followed for about 2.5 years.

Clozapine was discontinued in 37.8% of cases due to non-compliance, non-response, or side-effects. At follow-up 41 % of clozapine recipients and 25.9% of the drop-outs were discharged and remained so, and 33% of recipients and 24.1% of drop-outs were being prepared for discharge. Longer treatment was associated with more improvement. Decline in average BPRS total scores of recipients was significantly more than drop-outs (32.7, s.d. 16.8 v. 12.1, s.d. 14.1, d.f. = 155, t = 7.5, P = 0.000).

Clozapine appears to be effective for treating some chronic neuroleptic non-responding schizophrenic patients.

This study was carried out to measure bed occupancy in Greater London's psychiatric units, in response to the apparent shortage of admission beds.

The bed occupancy of London's 54 National Health Service (NHS) acute psychiatric units within 29 districts was ascertained by telephone on 16 bank holidays covering the period 1990–93.

The mean occupancy level for all London over the 4 years was 97.54% (95% CI = ±0.94%). The number of beds occupied in inner London was significantly greater (99.79 ± 1.11%) than in outer London (95.1 ± 1.49%) (t = 3.85, d.f. = 462, P < 0.001). Bed occupancy for inner London units was ≥ 100% on over 49% of occasions. There has been a steady decline in the number of beds over the four-year period. There was a clear correlation between occupancy levels and the Jarman UPA8 Underprivilege Score (r = 0.504) and between bed provision and the UPA8 (r = 0.67).

Occupancy rates have become unacceptably high and require careful monitoring. Corrective action may be required in order to prevent a breakdown in services.

It is reported that patients from ethnic minority groups, in particular Afro-Caribbeans, are more likely to enter less desirable pathways to psychiatric care. We aimed to determine whether ethnicity significantly affected time to presentation, type of first contact, rates of compulsory admission and police and primary care involvement, in patients with their first episode of psychosis.

As part of a prospective epidemiological study, patients and their carers were interviewed using a semi-structured questionnaire to trace the various persons and agencies seen en route to their first contact with psychiatric services.

While compulsory admission was more likely for Black patients, the excess was less striking than in previous studies. Black patients were no more likely than other patients to have police involvement. The most important factors in avoiding an adverse pathway were having a supportive family member or friend and the presence of a general practitioner to assist in gaining access to psychiatric services.

The routes to psychiatric services for first onset patients are different to those for chronic patients. Variables associated with social support were more important than ethnicity in determining pathways to care. Police involvement and compulsory admissions were strongly associated with the absence of GP involvement and the absence of help-seeking by a friend or relative. It may be that ethnicity becomes an important variable after the patient has come into contact with psychiatric services.

Several studies have suggested a declining first-admission rate for schizophrenia. This study examines the care-based incidence of schizophrenia in a Dutch register area.

Data from Groningen psychiatric case register were used to compare first-admission rates for schizophrenia over 1976–90 with those of other functional psychoses, and to consider various potential biases.

Diagnostic habits probably affected time trends in incidence rates. Using a broader definition of schizophrenia, no evidence was found for a decrease in the incidence of schizophrenia. Although first admissions to intramural services showed a (non-significant) decrease, this effect seemed to be neutralised when all mental health services were taken into account.

Care-based studies of time trends in psychiatric disorders should embrace all mental health services. Furthermore, unless a diagnostic classification system with univocal criteria is used, bias caused by changing diagnostic habits cannot be ruled out.

To assess quarterly fluctuations in schizophrenia births in a southern hemisphere data set, and to compare the quarterly birth distributions of patients born in the northern and southern hemisphere.

The month and place of birth of patients with schizophrenia (n = 9348) were extracted from a mental health register.

The quarterly birth distribution of patients with schizophrenia differed significantly from the estimated general population distribution in SH-born patients. The quarterly distribution of patient births differed significantly when the two hemispheres were compared.

These data support the hypothesis that there is a risk for schizophrenia that is related to the time of birth, and which fluctuates across the year.

This systematic review of the association between schizophrenia and obstetric complications (OCs) was performed to assess the degree of heterogeneity between studies and to quantify the increased risk of schizophrenia in exposed subjects.

Twenty case-control, one prospective cohort and two historical cohort studies were identified using a medline search supplemented by a manual search and direct communication with other researchers. Individual odds ratios were calculated for each study and a pooled estimate produced. The effect of methodological variation between studies was further assessed by partitioning studies according to study characteristics.

Overall, there was no significant heterogeneity of effect between studies, and the pooled odds ratio for the exposure to OCs on subsequent development of schizophrenia was 2.0 (95% CI 1.6–2.4). However, partitioning according to study design revealed significant heterogeneity (z = –2.60, P < 0.01) between the pooled estimate from the case-control studies and that from the historical cohort studies. There was a gap on the funnel plot in the region of small studies finding no effect.

Although the result indicates that subjects exposed to OCs are twice as likely to develop schizophrenia, the analysis suggests that the observed association could be inflated by both selection and publication biases.

We examined whether expressed emotion (EE) influenced the course of schizophrenia in Japan.

We conducted a cohort study. Of 73 subjects with schizophrenia meeting the diagnostic criteria of ICD–9 or DSM–III–R, 52 participated in the study. The Camberwell Family Interview was conducted to evaluate EE. The subjects had been followed up for nine months and psychiatrists who were blind to the EE status evaluated their symptoms with the Brief Psychiatric Rating Scale.

The relapse rate in the high-EE group was 58% and that in the low-EE group 21 % (P < 0.01). Nine-month relapse risk ratio was 2.72 (95% CI 1.24 to 5.97).

In Japan, as elsewhere, EE is a good predictor of schizophrenic relapse.

The aetiology of miscarriage is poorly understood. The aim of this study is to determine whether women admitted to hospital with miscarriage have experienced more psychosocial stress in early pregnancy than women whose pregnancies progress to labour.

Interviews of 48 case-control pairs, matched for known predictors of miscarriage risk, using the Life Events and Difficulties Schedule.

The miscarriage group were more likely to have experienced a “severe life event” in the three months preceding miscarriage (35% v. 15%; P < 005); more likely to have been experiencing a “major social difficulty” (31% v. 4%; P < 0.002); and more likely to have experienced “life events of severe short-term threat” in the fortnight immediately beforehand (31% v. 4%; P < 0.002). Fifty-four per cent of the miscarriage group had experienced at least one of the above indicators of psychosocial stress before miscarrying, compared with 15% of controls (P = 0.0001). Other factors significantly associated with miscarriage included childhood maternal separation; non-UK European origin; poorer reported relationships with partners, and fewer social contacts.

Psychosocial stress may be a factor in the aetiology of miscarriage. Alternatively, there may be a common determinant (e.g. personality, lifestyle or environmental) predisposing to both stress and miscarriage.

Stress responses of bereaved parents (mothers 194, fathers 143) who experienced infant loss were compared with parents (mothers 203, fathers 157) with a live born child.

Psychological distress using scales of anxiety, depression and alcohol use was compared at 2, 8, 15 and 30 months post-loss.

Bereaved mothers showed significantly more anxiety/depression than controls at all four interviews. For bereaved fathers, anxiety/depression differed significantly from controls only at two months. Heavy alcohol use was significantly more prevalent at 2 and 30 months. Relative risks showed significant gender differences between bereaved parents at all four interviews for anxiety/depression. When this outcome was extended to include heavy drinking in addition to anxiety/depression, these differences diminished and were significant only at 2 and 8 months.

Female responses are longer lasting and reflected by elevated levels of anxiety/depression. Male responses equally involve anxiety, depression and heavy alcohol consumption.

The study sought to quantify psychiatric morbidity among survivors of a major air crash and to identify aetiological factors linked with post-traumatic stress disorder (PTSD).

Sixty-eight of the 79 survivors (86%) were assessed at a clinical interview within one year of the disaster. The majority also completed the General Health Questionnaire, the Impact of Events Scale (IES) and the Zung Anxiety and Depression Scales.

Fifty-four of the study group (79%) met DSM–III–R criteria for a psychiatric disorder within one year of the disaster, of whom 27 (50%) had PTSD. Those who saw injured or dead people at the scene, or had sustained less severe injuries as measured by their Injury Severity Scores, or were under 35 years old, were significantly more likely to develop PTSD.

High rates of psychiatric morbidity are found in survivors of transportation disasters. Further studies are needed to identify those at most risk and to evaluate the benefits of psychological intervention.