Diagnostic and conceptual issues relating to psychopathy are widely debated, but advances in our understanding of the aetiology are limited.

A PSYCHLIT computerised database search of publications covering five decades was supplemented by tracing back through references from existing review work.

Over 200 articles were extracted, and 95 were selected for review.

It is timely to evaluate the rôle of brain dysfunction. Biological determinants are under-researched and the lack of consistency in operational definitions in published research precludes anything more than tentative conclusions about the genetic, biochemical or electrophysiological correlates of psychopathy and antisocial behaviour. A multi-modal research programme is required in the search for a comprehensive model of psychopathy that can guide both research efforts and clinical interventions.

This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort.

Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18–64 on admission, who had been in hospital for between six months and three years.

Two particular sub-groups were observed. Younger NLS patients (aged 18–34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55–67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm.

Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.

This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital.

Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements.

The average point prevalence was 6.1 per 100 000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100 000 population per year. Many English services had very few non-acute psychiatric beds and 31 % of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61 % of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available.

Many NLS patients remain in hospital because their residential needs are not met by existing community provision.

A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London.

Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.)

It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

The Daily Living Programme (DLP) offered problem-oriented, home-based care for people aged 17–64 with severe mental illness facing emergency admission to the Bethlem–Maudsley Hospital. The multidisciplinary DLP team acted as direct provider and link with other services. Each patient had a key worker. Cost-effectiveness was assessed.

The comprehensive costs of DLP and standard in-patient care were compared within a randomised controlled trial. Cost measures ranged over all service inputs and living expenses. The costs of informal care and lost employment were also considered. Assessments of service use, costs and outcomes were conducted at referral, 4, 11 and 20 months.

The DLP was significantly less costly than standard treatment in both short and medium term (P = 0.000). Cost savings accrued almost exclusively to the NHS, with no other agency's costs being higher.

Coupled with mildly encouraging outcome results over the 20 month period, the DLP was clearly cost-effective in this medium term.

The effect of a randomised controlled withdrawal of home-based care was studied for half of a sample of seriously mentally ill (SMI) patients from an inner London catchment area, compared with the effects of continuing home-based care.

Patients, aged 18–64, had entered the trial at month 0 when facing emergency admission for SMI. After at least 20 months home-based care (Phase I), patients were randomised at month 30 into Phase II (months 30–45) to have either further home-based care (DLPII, n = 33) or be transferred to out-/in-patient care (DLP-control, n = 33). They were assessed at 30, 34, and 45 months. Phase I control patients (n = 10) were assessed again at month 45. Measures used were number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

The slim clinical and social gains from home-based v. out-/in-patient care during Phase I were largely lost in Phase II. Duration of crisis admissions increased from Phase I to Phase II in both DLPII and DLP-control patients. During Phase II, patients' and relatives' satisfaction remained greater for home-based than out-/in-patient care patients. At 45 months, compared with the Phase I controls, DLPII patients and relatives were more satisfied with care. Such satisfaction was independent of clinical/social gains.

The loss of Phase I gains were perhaps due to attenuation of home-based care quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls. The Phase II home-based care team suffered from low morale.

This study evaluated whether a community psychiatric nurse (CPN) team providing a comprehensive aftercare service, using a case management approach, improves psychopathology and social functioning of the long-term mentally ill, and reduces hospital use compared with a generic CPN team.

Patients suffering from severe and persistent mental health problems were randomised to intensive aftercare or generic care after referral to the CPN manager. Each group contained 41 patients who were assessed at baseline and at 6, 12 and 18 months by an independent research psychologist. Outcome measures included the GAS, PSE, SAS, patient and relatives' satisfaction, number of admissions, and length of stay.

No difference between the groups was found on any of the outcome measures, despite the much higher number of contacts of the intensive (n = 52) versus generic CPNs (n = 13) and the much greater range of interventions.

Intensive aftercare for people with persistent mental health problems was not found to be of greater benefit than generic CPN care. Many factors need to be considered for aftercare to be effective, including community resources, process of care, and staff training.

Part of the community psychiatric nurse (CPN) service was reorganised into a community support team (CST), with staff acting as case managers. An economic evaluation ran parallel to the comparison with generic CPN care.

Eighty-two clients were randomly allocated to experimental and control groups. Costs were comprehensively measured over a pre-referral period (three months), and then at 6, 12, and 18 months.

The economic evaluation found a cost difference between the groups. Generic group costs averaged £89 per patient per week more than CST group costs. The difference was only significant for the first six months. Changes in the burden of cost across agencies were observed.

Although CPN inputs and costs were higher for the CST group, there was a significant short-term reduction in total cost. Beyond the short term, the CST did not confer cost or cost-effectiveness advantages.

A prospective quasi-experimental design was used to evaluate the effect of training CPNs to undertake psychosocial intervention with families caring for a relative with schizophrenia.

Patients meeting predetermined criteria were allocated to either an initial waiting-list control group or a delayed intervention group. The CPNs were trained to offer family interventions to a total target group of 48. Treatment was eventually accepted by 85%, of whom 81 % (n = 34) were followed-up for 12 months. Families received a weekly mean session of 47 minutes (compared with 33 minutes in the controls). The main outcome measures are frequency and severity of symptoms (KGV), social functioning (SFS) and days in hospital. Carers' minor psychiatric morbidity (GHQ) and knowledge (KASI) are also reported.

In the patient group both the positive and negative symptoms of schizophrenia improved significantly (P ≤ 0.001 and P ≤ 0.01 respectively) to 12-month follow-up, as did a global measure of social functioning (P ≤ 0.001). Tentative evidence was also collected that family intervention reduced in-patient episodes. Benefits for relatives included a decrease in minor psychiatric morbidity (P ≤ 0.05) and an increase in knowledge about neuroleptic drugs (P ≤ 0.001).

The study offers some evidence that CPNs can be taught to improve the outcome for families who care for a relative with schizophrenia.

Community psychiatric nurses (CPNs) are increasingly working in primary health care with non-psychotic patients. This study was designed to test the efficacy of this work.

The study was carried out in six health centres in north London with a total of 36 participating general practitioners (GPs) and 11 CPNs. Using a randomised controlled trial, 177 patients were referred by their GP and randomly allocated to continuing GP care, immediate community psychiatric nursing intervention, or placed on a 12-week waiting-list, after which time the patient was offered CPN intervention. A range of measures of symptoms and social function were used, and ratings were carried out at assessment and at 24 weeks.

Patients improved on all measures over time (P < 0.001 for all measures). However, there was no difference between the group of patients receiving GP care and patients seen by the CPN. Improvements seemed to be independent of the amount of contact. Drop-out rates from CPN intervention were high (50%). CPN drop-outs were more disabled to start with, but did as well as CPN treatment completers. Patients were more likely to drop out with trained than untrained CPNs. There was no evidence that referral to a CPN saved GP time.

The results add weight to the argument that CPNs should refocus their activity on people with serious mental health problems, and indicate that CPN education should focus on skill acquisition and interventions of proven effectiveness.

We developed and evaluated a comprehensive, ongoing intervention for families of schizophrenic patients appropriate for China's complex family relationships and unique social environment.

Sixty-three DSM–III–R schizophrenic patients living with family members were enrolled when admitted to hospital and randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counselling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention.

At 6, 12, and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalised was lower, the duration of rehospitalisation was shorter, and the duration of employment was longer in the experimental group than in the control group; these differences were statistically significant at the 12 and 18-month follow-ups and were not explained by differences in drug compliance. Family intervention was associated with significantly lower levels of family burden.

This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system.

A study of the influence of life-event stress on the onset and course of acute somatisation in primary care.

Forty-four somatisers were compared with 11 subjects who had psychiatric disorder but complained only of psychological symptoms, 39 patients who had ‘mixed’ conditions involving independent physical and psychiatric illness, 90 patients who had physical illness, and 123 healthy members of the general population.

Severely threatening life events were more common among all subjects with psychiatric disorder. A novel contextual rating of the potential of stressors to produce symptoms for ‘secondary gain’ was developed. In the 38 weeks before symptom onset, somatisers and psychologisers were more likely to have experienced at least one event which had this potential. Somatisers were also less likely to adopt neutralising coping efforts when faced with such a crisis.

The likelihood of adopting neutralising efforts was closely related to the presence of a joint index of parental problems in care and exposure to physical illness in the subject's childhood. In a two-year follow-up, subsequent functional illnesses were also associated with experiences which had secondary-gain potential, and subjects with childhood risk factors continued to have higher rates of crises with secondary-gain potential and to fail to adopt neutralising coping strategies.

Although depression in childhood appears to be familial, transmission of symptoms could be genetic or environmental. Twin studies enable us to separate these effects. Our aim was to assess the importance of genetic and environmental factors on depressive symptoms during childhood and adolescence in an epidemiological sample of twins.

Questionnaires (including the Mood and Feelings questionnaire) were mailed to a systematically ascertained sample (411 twin pairs) aged between 8 and 16 years. The overall response rate was 77%.

Data for the whole sample were best explained by an additive genetic model, with heritability of depressive symptom scores estimated at 79%. However, on splitting the sample, symptoms in children (aged 8 to 11) could be explained by shared environmental factors only, while symptoms in adolescents (aged 11 to 16) remained highly heritable.

The results suggest that although depressive symptoms appear to be largely heritable, the influence of genetic and environmental factors may vary with age.