A point prevalence study al schizophrenia was carried out in 1986 in the former Hampstead Health District using a key informant method to identify cases. The point prevalence al broadly defined schizophrenia was 4.7 per 1000.

A repeat census al people with schizophrenia, using the same method, was carried out in 1991 and the point prevalence calculated. The accuracy al the census method was estimated. Contact with services, social and occupational activity, and medication usage in the 1986 and 1991 samples were compared.

The point prevalence rate al broadly defined schizophrenia in 1991 was 5.1 per 1000. The results al both censuses showed we underestimated the number of individuals with DSM-III-R positive schizophrenia by about 14%. The level of contact with specialist services was greater in 1991 than 1986. Patients in 1991 were discharged on higher doses of medication, and their most recent admission was more likely to be due to non-compliance, than the 1986 group.

The point prevalence confirmed the high rate reported in 1986. The accuracy of the census was within acceptable limits for service planning. Contact with specialist services increased between 1986 and 1991.

The previous paper reports a high prevalence of schizophrenia (broad definition) in an inner London area. In this paper we test hypotheses for this finding and examine the characteristics of people with schizophrenia who move frequently.

People with schizophrenia in the Hampstead area were identified by key informant methodology, at two censuses five years apart. This allowed identification of incident cases during these five years and identification of people who had moved into and out of the area.

The incidence of DSM-III-R schizophrenia in Hampstead between 1986 and 1991 was at least 0.21 per 1000 of the population aged 15 to 54. There was a significant movement of people with schizophrenia to this inner London area from outer London between 1986 and 1991. People with schizophrenia who were relatively mobile were significantly more likely to be male, to suffer with prominent hallucinations, and to have no contact with a GP.

The high prevalence of broad schizophrenia in this inner London area is, in part, due to geographical drift. A significant excess of the people with schizophrenia who move frequently are men with positive symptoms.

Needs for mental health care are likely to be high in urban areas. Purchasers must assess the extent to which these are being met. The pathways to care model provides a framework for this purpose.

Epidemiological surveys of adults living in deprived multi-ethnic innercity catchment area were undertaken in psychiatric services, primary care and community settings. Estimated prevalence rates were calculated and the association between clinical and demographic factors and the use of psychiatric services examined.

Around a third of people with mental health problems did not consult a GP. and half failed to have their problems recognised by their doctor. Access to psychiatric services and especially to inpatient care was highly restricted. Diagnosis and ethnicity had a marked influence on the use of specialist services.

Many people with psychiatric morbidity are not receiving treatment either from primary care or specialist services. High levels of severe morbidity and compulsory admissions highlight the pressures placed on inner-city psychiatric services.

In addition to clinical and service factors, planners need to take account of the influence of demographic variables, especially ethnicity, on access to mental health care.

Estimated prevalence rates were calculated from epidemiological surveys undertaken in three settings: psychiatric services, primary care and the general population. Associations between demographic factors and service use were examined using the pathways to care model.

Considerable differences in access to mental health care were found, particularly according to ethnicity. The major impediment to Asians accessing care occurred at the interface between primary and secondary care, whereas the most striking feature for Blacks was the poor level of case recognition by GPs.

In order to improve the uptake of mental health care, new initiatives should target those who are most likely to be unwell but least likely to access services. Purchasers and providers need to address differential patterns of use when developing and reviewing services.

Outcome is important in the validation of psychiatric diagnosis, as most disorders lack clinicopathological correlates. We describe the predictive validity of four definitions of schizophrenia (DSM-III-R, ICD-10, ICD-9 and CATEGO S+), in a representative cohort of patients selected during their first episode of psychosis.

Each definition of schizophrenia was applied to 99 patients. Their respective ability to predict 13-year outcome (Global Assessment of Functioning scales) was assessed.

DSM-III-Rand ICD-10 diagnoses of schizophrenia have high predictive validity for long-term outcome, and both provide relatively stable diagnoses. ICD-9 is reasonably good at predicting disability, but not symptoms, and CATEGO S+ showed no predictive validity. Adding six-month duration criteria to ICD-10, ICD-9 and CATEGO S+ improved their predictive validity, and removing the six-month duration criterion from DSM-III-R commensurately reduced predictive validity.

Modern diagnostic systems (DSM-III-Rand ICD-10) have high predictive validity, and are superior to ICD-9. The six-month duration criterion of DSM-III-R schizophrenia accounts for its predictive validity and stability over 13 years, but restricts its use in first-episode studies. The one-month duration criterion of ICD-10 is less restrictive, without major compromises in predictive validity or stability.

Loss or reversal of the normal asymmetry of the planum temporale (PT) has been reported in schizophrenia, and may be due to aberrations in the gene(s) controlling the development of brain asymmetries. We tested this hypothesis in a sample of schizophrenics and their relatives from families multiply affected with the disorder.

We compared 32 schizophrenics and 55 of their non-schizophrenic first-degree relatives with 39 matched community controls. Volumetric measurements of the cortical volume beneath the PT were obtained using the Cavalieri method from three-dimensionally reconstructed magnetic resonance imaging images.

PT volume asymmetry coefficients from patients and their relatives did not differ significantly from those of the controls. Gender-specific analysis did not reveal any differences.

Abnormalities in PT volume asymmetry are not present in familial schizophrenia, where genetic factors appear to predominate.

Schizophrenia may in some cases be a neurodevelopmental disorder. Breast milk is important to the developing brain. Might a lack of breast milk be an environmental risk factor in schizophrenia?

Mothers of 45 schizophrenic patients in Nithsdale, southwest Scotland, completed a questionnaire about whether or not their offspring had been breast-fed.

The incidence of breast-feeding in patients was 29% and in sibs 38%. Most patients were born in the 1940s and 1950s. The incidence in patients born in these two decades, 33 and 26%, respectively, was significantly lower than in Scottish surveys in 1946 (81%) and 1958 (51%). Those patients who had not been breast-fed had more schizoid and schizotypal personality traits in childhood and a poorer social adjustment than their sibs; breast-fed patients did not differ from their sibs.

Fewer schizophrenic patients than normal were breast-fed. Lack of breast milk may be a risk factor in the neurodevelopmental form of schizophrenia.

Models of sex therapy for sexual dysfunction in single men are available, but their value is not well established. This controlled study compared three approaches to the treatment of sexually dysfunctional single men.

Sixty-nine single men diagnosed as sexually dysfunctional were randomly assigned to treatments focusing on either their sexual dysfunction, their interpersonal problems, a combination of both or a waiting list; 51 completed treatment and 50 the one-year follow-up. Treatment was administered in small groups in 15 weekly sessions and four six-weekly sessions during the first six months of a year-long follow-up.

No clinically meaningful change was observed during the waiting period. In contrast, a significant and equivalent improvement was observed in all treatment groups by the end of treatment. However, differences between them were in evidence at 6 and 12 months' follow-up.

Both treatments paying attention to the patients' interpersonal difficulties resulted in significantly better outcomes overall than the approach that concentrated on problems in sexual functioning alone.

There have been very few controlled studies of antidepressants in dysthymia, particularly in samples diagnosed reliably and with an adequate length of follow-up. In this investigation, we measured the long-term outcome in a large group of patients meeting DSM – III -R criteria for dysthymia. This study was designed to investigate whether fluoxetine is effective in the treatment of dysthymia.

This randomised study, including 140 patients, compared fluoxetine (91 patients) and placebo (49 patients) on a double-blind basis in two distinct phases: a short-term end-point (3 months with 20 mg/day fluoxetine) and a medium-term end-point (6 months) where the initial responders continued double-blind treatment unchanged and non-responders received an additional treatment of 20 mg/day fluoxetine.

After three months of treatment, response was seen more frequently in the fluoxetine group (42/72) than in the placebo group (14/39, P <0.0001). Improved patients at 3 months were still improved at 6 months. Furthermore, 50% of the non-responders at 3 months improved and rated as responders at 6 months, after fluoxetine was increased to 40 mg daily.

This study showed the significant and persistent action of fluoxetine on dysthymia. The finding that 50% of the non-responders at 3 months were improved at 6 months, after fluoxetine dosage was increased to 40 mg daily, argues in favour of treating dysthymic patients for at least 6 months, and with a higher dosage if the initial doses are ineffective.

Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.

Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.

Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced atraumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

Although based on correlational data derived from a convenient'sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

Although road traffic accidents are a major cause of injury and death in children and adolescents, research into their psychological consequences consists mainly of case reports.

A prospective study was made of young road traffic accident victims; 57 subjects, aged 5–18 years, who had been injured in road traffic accidents, and their parents, were interviewed 2–16 days post-accident and re-examined after 12–15 weeks.

Post-accident stress symptoms occurred at both times. There was a decrease of symptom severity between the two interviews, but at the later time, 14% still suffered from moderate or severe post-traumatic stress disorder, 17% from serious traffic-related fears, and parents reported increased mood disturbance in their children compared with the pre-accident period. High levels of distress during and immediately after the accident were associated with severe post-traumatic stress symptoms.

There is an urgent need for healthcare staff working with children and adolescents involved in road traffic accidents to be aware of the potential psychological consequences and the importance of the immediate accident experience on subsequent coping.

Successive DSM versions struggle with the heterogeneity of the eating disorders. Criteria were mainly based on clinical impressions and on descriptive and inferential studies.

In a study of 55 eating-disordered adolescents, we investigated whether patients could be grouped on an empirical basis, using principal components analysis (PCA) with optimal scoring (scaling), i.e. PCA with no a priori assumptions. Clustering was based on Morgan-Russell subscales, each measured four times over the course of illness.

Contrary to DSM – IV criteria, patients did not cluster primarily on the basis of anorectic symptoms; the occurrence of bulimic symptoms was more dominant. Core symptomatology (preoccupation with food, disturbed body perception and inadequate sexual behaviour) did not differ between patients, either at referral or over time.

These results support the spectrum hypothesis of the eating disorders, which considers them as one syndrome with different manifestations.

Affective disorders typically have a better outcome than schizophrenia, although recent evidence suggests that some patients with affective disorder have a relatively poor outcome, with cognitive impairments and persistent symptomatology.

Fifty chronically hospitalised geriatric patients with mood disorders (major depression or bipolar disorder) were compared on the clinical symptoms and aspects of cognitive impairment with 308 geriatric schizophrenic patients who were hospitalised at the same institution. The two samples did not differ in current age or in premorbid education level, but the affective patients had a later age of onset and more females in the sample.

There were no overall differences in cognitive functioning between the groups, although the clinical symptom profiles resembled those seen in better outcome patients.

Cognitive impairment is present in poor-outcome patients with affective disorders as well as schizophrenia, suggesting that cognitive impairments predict poor outcome across psychiatric disorders and not just in schizophrenia.

The literature regarding psychiatric illness among elderly people with learning disabilities is limited and conflicting because of methodological differences. There have been no recent studies comparing psychiatric epidemiology between younger and older adults with learning disabilities, using the same methodology and definitions.

Comprehensive psychiatric examination using a semi-structured rating scale was undertaken on everyone with learning disabilities, aged 65 years or over (n= 134), living in a defined geographical area. Comparison was made with a randomly selected control group of adults with learning disabilities aged 20–65 years (n=73) drawn from the same geographical area.

Elderly people with learning disabilities have a greater prevalence of psychiatric morbidity than younger controls (68.7v. 47.9%). Rates for depression and anxiety disorders are high, and dementia is common: there are equal rates for schizophrenia/delusional disorders, autism and behaviour disorders in the two groups.

The higher psychiatric morbidity among elderly (compared with younger) people with learning disabilities has not previously received adequate recognition. This warrants further investigation by service planners and clinicians.

The study sought to investigate the form of the delusion in schizophrenia and the overvalued idea in anorexia, employing a range of belief characteristics to discover whether differences could be detected between them, and how they stood in general relationship to the religious beliefs of normals.

A belief rating scale was devised with 12 characteristics, and completed by 20 schizophrenics, 20 anorectics, and 20 normal controls. Comparisons were drawn between populations using the Mann-Whitney test, and different types of belief were contrasted within diagnostic groups using each subject as their own control by repeated-measures MANOVA.

The schizophrenic delusion was differentiated from the overvalued idea in anorexia by a number of variables, which also served to distinguish both phenomena from religious beliefs held by normals. The schizophrenic delusion exhibited many of the qualities of an initial (or observational) belief, when its content suggested that it should manifest those of a derived belief. The anorectic overvalued idea, although occasionally an initial belief in terms of its content, was typically held in the form of a derived belief.

A wider range of characteristics is required to define all the differences between delusion and the overvalued idea, and these have implications for belief modification programmes.