Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.

We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966–1993) with the search terms mental disorders', ‘brain injury’, ‘eating disorders’, ‘epilepsy’, ‘suicide attempt’, ‘psychosurgery’, with ‘mortality’ and ‘follow-up studies’, and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.

Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.

If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

Data on the two-year pattern of course of illness have been collected in the WHO study of the Determinants of Outcomes of Severe Mental Disorder (DOSMD). These data are reanalysed using recursive partitioning, a method not yet applied to psychiatric data to test the hypothesis that subjects from participating centres in developing countries had better outcomes than those in developed countries.

Subjects were those from the DOSMD study for whom two-year follow-up data were available (n = 1056). The classification and regression trees recursive partitioning technique was used to examine the predictor variables associated with the outcome variable two year pattern of course.

Pattern of course was best predicted by centre, but two developed centres (Prague and Nottingham) grouped with the developing country centres excluding Cali, having better outcomes than in the remaining developed country centres and Cali. Type of onset (insidious v. non-insidious) was the next strongest predictor, but its effect differed across these two centre groupings. Effects for some groups were modified by other predictor variables, including age, child and/or adolescent problems, and gender.

The predominant predictor effects on two-year pattern of course continued to be centre and type of onset, but complex interactions between these variables and other predictor variables are seen in specific centre groupings not strictly defined by ‘developing’ and ‘developed’.

The finding of an earlier age at onset of schizophrenia in males compared with females, replicated across a number of studies, appears to be so robust as to support hypotheses about gender differences in the aetiology of the disorder. However, the possibility that this observed gender effect might reflect other confounding variables has not been adequately explored.

We analysed data on 778 men and 653 women, in three developing countries and in seven developed countries, who had been assessed in the WHO 10-country study of schizophrenia. We applied a generalised linear modelling strategy to estimate the unconfounded contributions of gender, family history, premorbid personality and marital status to age at onset.

The model that explained the highest percentage of the total variance indicated strong main effects (P < 0.001) for marital status and premorbid personality, a weak effect for family history, and an attenuated effect for gender. Two independent verification procedures suggested an independent onset-delaying effect for marital status (married), more marked in males.

The gender difference in the age at onset of schizophrenia is not a robust biological characteristic of the disorder. Failure to control for marital status and premorbid personality in male/ female comparisons of age at onset may explain a large part of the differences reported previously.

Familial liability in the functional psychoses had traditionally been examined by comparing mutually exclusive diagnostic categories. This study examines overlapping psychopathological dimensions in relation to familial morbid risk of psychosis.

We tested for associations between seven factor-analysis derived psychopathological dimensions and familial morbid risk of psychosis, in a sample of 150 patients with recent-onset functional psychosis and 548 of their first-degree relatives.

A syndrome characterised by affective blunting and insidious and early onset of illness, non-specifically predicted psychosis in the first-degree relatives, whereas a manic syndrome specifically predicted affective psychosis in the relatives. No other main effects were observed, but there were interactions with proband diagnosis: a syndrome characterised by bizarre behaviour, inappropriate affect, catatonia and poor rapport predicted psychosis in relatives of schizophrenic probands, and a syndrome of depressive: symptoms predicted psychosis in relatives of schizoaffective probands. Positive symptoms were not associated with illness in the relatives.

Genetic effects in the functional psychoses may comprise non-specific components that canalise a general, early-onset, affective blunting phenotype and several other, more specific, influences on phenotypic variation.

Although modern psychiatric services seek alternatives to hospitalisation wherever appropriate, the national trend toward higher bed occupancies on acute psychiatric wards has refocused attention on community-based alternatives and methods of assessing reed for acute care.

We surveyed key decision makers in a community-oriented district service with a low acute psychiatric bed to population ratio, in order to examine alternatives to hospitalisation in a cohort of consecutive admissions over a six-month period.

Alternatives to acute ward hospitalisation were identified for 29% of admissions, and for 42% of those with an admission duration of more than 60 days. Residential options were chosen more often than intensive community support. Simulated bed day savings were considerable.

In a community-oriented service, key decision-makers could identify further alternatives to acute ward hospitalisation, although relatively few non-residential, community support options were chosen. Although this methodology has limitations, data based upon keyworker judgements probably have greater local ‘ownership’, and the option appraisal process itself may challenge stereotyped patterns of resource use.

Mental health legislation allows for treatment needs to override civil liberty. Mental health review tribunals act as a counterbalance. This study examines the long-term outcome of patients reviewed by a tribunal, and in particular whether the tribunal, in its concern for civil liberty, might be discharging patients prematurely.

All non-offender patients from a defined catchment area reviewed by the tribunal between the inception of the 1983 Mental Health Act and 31 December 1991 were followed-up until 31 May 1993.

Those discharged by the tribunal did not differ significantly from those refused discharge in subsequent survival period in the community, in readmission rate or in final outcome.

Within the limitations of a non-experimental study, the main hypothesis was not supported. An intensive study of family and personal life in the three months after discharge would cast useful additional light on the soundness of tribunal decisions.

A recent simulation concluded that the serotonin-specific reuptake inhibitor (SSRI) paroxetine was more cost-effective than the tricyclic antidepressant (TCA) imipramine, despite substantially higher medication acquisition costs.

We replicated the previous model and revised key assumptions which drove the results. The revised model was subjected to sensitivity analysis.

Most scenarios in the revised model showed that the TCA is equally or more cost-effective than the SSRI. Model revision producing these results were changes in assumptions about switched treatment success rates, treatment length and initial treatment success. The revised model appears sensitive to drug acquisition and delivery costs and costs of treatment failure.

Based on the model, a policy of using TCAs as first-choice antidepressant treatment, with SSRIs reserved for those patients not doing well initially, appears more cost-effective than the reverse sequence. Given limitations in current knowledge about key parameters to include in a simulation model, large prospective random-assignment cost-effectiveness studies are needed.

Exemplified by a randomised trial on antimanic treatment, this paper addresses the question of whether selection of patients for drug trials may limit the applicability of study results from the randomised patients to a wider population.

During two-year period, all consecutively admitted patients from a defined catchment area were screened for inclusion criteria concerning age, diagnosis and severity of illness. The subsequently excluded subgroups of patients were compared with the randomised patients by multivariate data analysis.

One hundred and sixty-four patients met the inclusion criteria. However, after exclusion for various reasons, only 27 (17%) patients remained for randomisation. The randomised patients and the excluded patients differed substantially.

The generalisability of trial results is limited. Reports of randomised drug trials should carefully describe the screening procedure for inclusion and, when possible, present relevant comparisons-between the randomised patients and the various subgroups of excluded patients.

The purpose of this study was to examine the effect of treatment on the long-term course of geriatric depression.

Eighty-four elderly patients who had responded to treatment of the index episode of major depression were maintained on full-dose antidepressant medication and followed on a monthly basis for two years. Relapse and recurrence were treated in a systematic manner.

The cumulative probability of surviving for two years without relapse or recurrence was 74%. Of the 14 patients who suffered recurrence following recovery from the index episode, all responded to a change of treatment, and 71% remained well for the remainder of the study. The risk of recurrence was significantly increased by a delayed response to treatment of the index episode.

Continuation and maintenance treatment with full-dose antidepressant medication, frequent follow-up, and vigorous treatment of relapses and recurrences, were associated with a good outcome in this group of elderly patients.

The management of disturbed behaviour in facilities for those with learning disabilities involves a spectrum of approaches including the prescription of emergency medication, restraint and seclusion. The use of these techniques has recently come under close scrutiny.

All incidents requiring emergency medication or seclusion that occurred in a large hospital for those with learning disabilities were studied over a six-months period. The precipitating factors, course and outcome of those who had received emergency medication or seclusion were then examined.

In all, 286 incidents involving 72 individuals occurred during the study period. The episodes requiring seclusion comprised 19% of all incidents. Two-thirds of the patients involved were male but six female patients accounted for 36% of all incidents. During the second part of the study, when the staff knew that the treatments used were being monitored, there was a significant reduction in use of restraint and emergency drugs given intramuscularly. Patients receiving seclusion were judged to have a better outcome one hour after the onset of the incident compared with those who received medication.

Despite concerns about the use of seclusion, the results of this survey suggest that procedures that remove the patient from the environment contributing to the disturbance may have certain advantages in this population.

A few recent linkage studies have shown a possible locus for bipolar disorder on chromosome 18. Cytogenetic studies may assist in the further localisation of susceptibility loci on this chromosome.

A search was made for abnormalities of chromosome 18 in two separate large cytogenetic databases. In Denmark detection of mental illness in subjects with chromosome abnormalities was done by cross-linking the two separate register of psychiatric and chromosome disorders. In Scotland the Cytogenetic Registry of the MRC Human Genetics Unit undertakes long-term clinical follow-up of all cases with chromosome abnormalities.

Cross-linking the two Danish register's revealed a family with the rare karyotype abnormality inv(18) (p11.3;q21.1) with one inversion carrier who also suffered from bipolar disorder. In this family there were two other cases of bipolar disorder, but the karyotype of these cases could not be established. One family in Scotland showed a case of schizophrenia in a carrier of inv(18) with the same breakpoints as the Danish family.

We suggest further studies of the 18p11.3 and 18q21.1 regions in order to identify genes involved in bipolar affective disorder and schizophrenia.

This study investigates patterns of qat use among 207 Somalis living in London.

Subjects were recruited using privileged access interviewing. Somalian interviewers were recruited who shared the same culture as the subjects. Data were collected by means of a structured interview.

One hundred and sixty-two subjects (78%) had used qat. The majority (76%) used more qat than in Somalia. Some users reported moderate dependence; a minority reported severe problems. Adverse psychological effects included sleep problems, anxiety and depression. Medical problems associated with qat use were rare.

Qat users who continue to use this drug when it is transplanted from a traditional context may experience difficulties. Qat use can also be seen as playing a positive role in supporting the cultural identity of the Somalian community. Severe problems were rarely reported. Qat consumption should be considered when addressing health-related topics with patients from those communities in which qat use is common.

ECT is rarely used as a prophylactic treatment. A 74-year-old woman with unstable bipolar affective disorder receiving maintenance ECT presented a unique opportunity to measure the cognitive effects of continuing ECT.

A single case report with serial psychometric testing during over 400 ECT treatments as a single maintenance treatment.

Serial testing did not demonstrate progressive cognitive deterioration, but consistent cognitive deficits typical of acute treatment were evident. The degree of cognitive difficulty may be related to the frequency of treatment.

Maintenance ECT can be an effective prophylactic treatment for selected patients. Cognitive effects would appear to be no greater than with acute treatment and seem to be non-progressive.