A series of small, mainly uncontrolled, studies have suggested that techniques adapted from cognitive–behavioural therapy (CBT) for depression can improve outcome in psychosis, but no large randomised controlled trial of intensive treatment for medication-resistant symptoms of psychosis has previously been published.

Sixty participants who each had at least one positive and distressing symptom of psychosis that was medication-resistant were randomly allocated between a CBT and standard care condition (n=28) and a standard care only control condition (n=32). Therapy was individualised, and lasted for nine months. Multiple assessments of outcome were used.

Over nine months, improvement was significant only in the treatment group, who showed a 25% reduction on the BPRS. No other clinical, symptomatic or functioning measure changed significantly. Participants had a low drop-out rate from therapy (11%), and expressed high levels of satisfaction with treatment (80%). Fifty per cent of the CBT group were treatment responders (one person became worse), compared with 31% of the control group (three people became worse and another committed suicide)

CBT for psychosis can improve overall symptomatology. The findings provide evidence that even a refractory group of clients with a long history of psychosis can engage in talking about psychotic symptoms and their meaning, and this can improve outcome.

We report a randomised controlled trial, in both the acute and maintenance stage of treatment, in 75 outpatients with recurrent major depression.

Patients were allocated to three groups: 16 weeks of acute treatment and two years' maintenance treatment in the following way: antidepressants and maintenance antidepressants; cognitive therapy and maintenance cognitive therapy: antidepressants and maintenance cognitive therapy. Both completers' and end-point data were analysed.

In the acute phase of treatment, all patients improved significantly and there was no significant difference among treatments, or in the pattern of improvement over time. In the maintenance stage of treatment, patients kept improving over time in all three groups and there was no significant difference among treatments. Cognitive therapy was consistently superior to medication.

The results indicate that maintenance cognitive therapy has a similar prophylactic effect to maintenance medication and is a viable option for maintenance after acute treatment with medication in recurrent depression.

General psychiatrists have recently been encouraged to provide treatment to heroin addicts, including in-patient detoxification. No comparison has previously been made of specialist versus general psychiatric in-patient care.

During a randomised study of cue exposure, 186 opiate addicts were also randomised to either specialist in-patient (DDU; n=115) or general psychiatric (GEN; n=71) wards in the same hospital.

From pre-treatment (post-randomisation) onwards, patient outcomes differed across the two in-patient settings. Of the original randomised sample, significantly more DDU than GEN subjects accepted their randomisation (100 v. 77%), were subsequently admitted (60 v. 42%), and completed in-patient detoxification (45 v. 18%). Of patients admitted, more DDU than GEN patients completed detoxification (75 v. 43%). During seven-month follow-up, of those 43 patients who reached the end of treatment, significantly more ex-DDU than ex-GEN subjects were opiate-free.

From pre-treatment onwards, significant differences in process and outcome were found after allocation to treatment on either DDU or GEN. Further randomised studies are required to replicate and explain these findings.

New methods of rapid opiate detoxification, under intravenous sedation, can detoxify heroin-addicted patients in 24 hours. Their clinical application has been limited by the lack of studies establishing both efficacy and safety.

In a randomised, controlled study, 300 treatment-refractory, heroin-addicted patients received rapid intravenous detoxification treatment (naloxone infusion, 0.06–0.08 mg/kg, then oral naltrexone 50 mg/day) under either monitored light intravenous sedation or unmonitored deep intravenous sedation.

All patients were successfully detoxified and 93% remained abstinent one month later. Severity of withdrawal, according to the Wang Scale modified by Loimer, was 4.9 (s.d. 3.0) points in the light sedation group and 4.8 (s.d. 2.9) in the deep sedation group (P=0.26). Two patients (1.3%) in the light sedation group and four (2.6%) in the deep sedation group required tracheal intubation (P=0.31). There was only one severe complication, a case of nosocomial aspirative pneumonia which improved with antibiotic treatment.

Successful rapid intravenous detoxification can be achieved using relatively light levels of sedation.

We compared regional cerebral blood flow (rCBF) in three groups of patients with DSM–III–R anxiety disorders.

Fifteen patients with obsessive–compulsive disorder (OCD), 15 with panic disorder with agoraphobia (PA), and 16 with post-traumatic stress disorder (PTSD) and a similar group of healthy controls were assessed on brain-dedicated high-resolution SPET.

MANOVA revealed significant rCBF differences between diagnostic groups (F=4.4; d.f.=3, 57; P=0.007) and between cerebral regions (F=6.4; d.f.=1, 57; P=0.01) in OCD and PTSD compared with PA and healthy controls, limited to bilateral superior frontal cortices and right caudate nuclei. Whole brain blood flow correlated positively with anxiety (r=0.24, n=46, P=0.05). Beck depression scores correlated significantly negatively with left caudate rCBF (r= –0.24, n=46, P=0.05) and right caudate rCBF (r= –0.31, n=46, P=0.02). PTSD syndrome severity correlated significantly negatively with the left caudate (r=-0.49, n=16. P=0.03) and with right caudate rCBF (r=-0.7, n=16, P=0.001)

Functional rCBF differences in anxiety disorders could relate to repetitive, intrusive, distressing mental activity, prominent in both OCD and PTSD.

The Health of the Nation includes a target for reducing population suicide rates. We have examined and quantified various high-risk and population-based strategies for prevention based upon a number of stated assumptions and hypothetical interventions.

The published literature was used to estimate the population attributable fractions for both high-risk and population-based strategies. The number needed to treat for the high-risk strategies was calculated, assuming an intervention that reduced suicide rates by 25%

Interventions that would reduce rates of suicide by 25% would reduce population rates by about 2.6% for those recently discharged from hospital and by up to 5.8% for those presenting to general hospital with deliberate self-harm. The population attributable fraction for unemployment was 10.9%

High-risk strategies will have only a modest effect on population suicide rates, even if effective interventions are developed. Evaluating interventions for deliberate self-harm patients seems worthwhile. The UK Government's target for suicide reduction is more likely to be achieved using population-based strategies. Reducing the availability of methods commonly used for committing suicide is the most practicable current policy, although more radical approaches, for example reducing unemployment, may also substantially reduce suicide rates.

Of 9156 patients admitted to psychiatric hospitals in Denmark between 1970 and 1987 and diagnosed for the first time as having schizophrenia, 508 committed suicide. The purpose of the study was to identify risk factors for suicide among patients with schizophrenia, particularly factors relating to hospitalisation.

From the cohort of all 9156 patients, the 508 who had committed suicide were individually matched to 10 controls from the same cohort, and data were analysed using conditional logistic regression.

Suicide risk was particularly high during the first 5 days after discharge, and increased risk was also associated with multiple admissions during the previous year, previous suicide attempts, previous diagnosis of depression, male gender, and previous admissions to general hospitals for physical disorders. After adjusting for these factors, no effect was found for age. There was some evidence of an excess of suicides during temporary leave from the psychiatric department.

The findings suggest that preventive measures could be focused on the first period after discharge, when closer monitoring and better social support may be needed. This may also apply to patients on temporary leave during a period of admission.

Cognitive impairment, frequently found in patients with schizophrenia, may be associated with negative symptoms and dyskinesia. However, antipsychotic medication may be a confounding variable. These putative associations may be clarified by examining never-treated patients.

Never-treated elderly schizophrenic patients (n=19) living in south-east India were compared with treated patients (n=25) and normal subjects (n=55). Memory was assessed by the Wechsler Memory Scale, negative symptoms by the Positive and Negative Syndrome Scale, and dyskinesia by the Abnormal Involuntary Movements Scale.

Normal subjects had a higher mean memory quotient than patients. There were no significant differences between never-treated and treated patients. Negative symptoms were associated with a poorer memory in the never-treated group. There was no association between memory and dyskinesia.

There is an association in never-treated patients between a poorer memory and negative symptoms, but not between a poorer memory and dyskinesia.

An assessment of the monetary costs of treating a group of Nigerian out-patients with schizophrenia, in comparison with insulin-dependent diabetics, was made.

Fifty out-patients with schizophrenia (mean age 42.9) and 40 with diabetes (mean age 41.9), attending government hospitals in Lagos, were assessed at six-monthly intervals, for direct and indirect costs (US$=82 naira; minimum monthly wage=500 naira)

Twenty (40%) of those with schizophrenia and eight (20%) of the diabetics had no income at all. The mean total cost of schizophrenia in six months (2951.4 naira) or US$ 35.9) was significantly less than that of diabetes (11 791 naira or US$ 143). The cost of antipsychotic drugs accounts for 52.8% of the cost of schizophrenia; insulin injections accounted for 92.8% of the total cost of diabetes. Patients with schizophrenia and their relatives suffered significantly more loss of working days. Cost of illness was not significantly correlated with age and duration of illness.

Because of drastic currency devaluation, and lack of disability benefits and nursing homes, the findings contrast with Western reports where cost of drugs constitutes 2–5%, and indirect costs constitute over 50% of the total cost of schizophrenia.

The prevalence of mental disorders among the community-dwelling elderly in the catchment area of a psychiatry for the elderly service in Dublin was determined.

A sample of 1232 individuals aged 65 years and over, identified from general practitioner practice lists, was interviewed using the Geriatric Mental State–AGECAT package.

Depression and organic disorder occurred with prevalences of 10.3 and 4.1%, respectively. Depression diagnostic cases had comorbid anxiety at case level in 17.3% and at sub-case level in a further 59.9%. Organic diagnostic cases had comorbid depressive or anxiety symptoms, at case or sub-case level, in 32%

Depression is the most common mental disorder among the elderly in Dublin. The frequency of anxiety symptoms in the presentation of depression may be a factor in the under-diagnosis or misdiagnosis of depression in the community-dwelling elderly. Comorbid anxiety and depression in organic disorder may represent treatable symptoms.

Population studies indicate that subjective memory complaints by elderly people are correlated with cognitive performance. These complaints have some predictive power regarding the development of dementia. The present study attempted to replicate this finding, and investigated which variables determine subjective memory complaints.

Participants in the Amsterdam Study of the Elderly (n=2114; 65–84 years of age), who were not demented and had a normal MMSE score (> 23) at baseline, were re-examined after four years. Subjective complaints were measured using a previously developed scale. Dementia and depression were measured using the Geriatric Mental State Schedule (GMS). Premorbid intelligence was measured by the Dutch Adult Reading Test (DART)

Memory complaints at baseline contributed a small but significant amount of diagnostic information with respect to the prediction of future dementia. Depressive symptoms at baseline had no predictive value when these memory complaints were accounted for. Subjective memory complaints were associated with depression, baseline MMSE score, and premorbid intelligence.

Subjective memory complaints are not just secondary to depression, but in part reflect realistic self-observations of cognitive decline.

Patients with chronic fatigue syndrome (CFS) report neuropsychological symptoms as a characteristic feature. We sought to assess cognitive performance in patients with CFS, and compare cognitive performance and subjective workload experience of these patients with that of two disease comparison groups (non-melanchonic depression and acute infection) and healthy controls.

A computerised performance battery employed to assess cognitive functioning included tests of continuous attention, response speed, performance accuracy and memory. Severity of mood disturbance and subjective fatigue were assessed by questionnaire.

All patient groups demonstrated increased errors and slower reaction times, and gave higher workload ratings than healthy controls. Patients with CFS and non-melancholic depression had more severe deficits than patients with acute infection. All patient groups reported more severe mood disturbance and fatigue than healthy controls, but patients with CFS and those with acute infection reported less severe mood disturbance than patients with depression.

As all patients demonstrated similar deficits in attention and response speed, it is possible that common pathophysiological processes are involved. The differences in severity of mood disturbance, however, suggest that the pathophysiological processes in patients with CFS and acute infection are not simply secondary to depressed mood.

The complex nature of insomnia and its relationship with organic and mental disorders render diagnosis problematic for epidemiologists and physicians.

A representative UK sample (non-institutionalised, > 14 years old) was interviewed by telephone (n=4972; 79.6% participation rate) with the Sleep-EVAL system. Subjects fell into three groups according to presence of insomnia symptom (s) and/or sleep dissatisfaction.

Insomnia symptoms occurred in 36.2% of subjects. Most of these (75.9%), however, reported no sleep dissatisfaction. In comparison, those also with sleep dissatisfaction had higher prevalence of sleep and mental disorders and longer duration of insomnia symptoms, and were more likely to take sleep-promoting medication, dread bedtime, and complain of light sleep, poor night-time sleep and daytime sleepiness.

Insomnia sufferers differ as to whether they are satisfied or dissatisfied with sleep. Although insomnia symptoms are common in the general population, sleep disturbances among sleep-dissatisfied individuals are more severe. Sleep dissatisfaction seems a better indicator of sleep pathology than insomnia symptoms.

There has been no report of comorbid transsexualism and obsessive–compulsive disorder (OCD) or of their differential course over follow-up.

Such comorbidity and follow-up are documented in a case report.

A man who had been transsexual and homosexual since early adolescence developed severe OCD at age 40 as he became depressed when his mother, to whom he was very close, died. Two years later he was referred for his OCD. He refused treatment for his transsexualism. As his OCD and mood improved with self-exposure therapy, his transsexualism and homosexuality remitted also. Four years later depression and transsexualism recurred and remained to six-year follow-up despite full remission in OCD continuing throughout.

The sequence is like that in other cases in whom unusual sexual behaviour remitted for years after comorbid disorders improved with various treatments, or after circumstances changed.