Emotional disorder associated with physical illness falls into two main groups: ‘psychological reaction to physical illness’ and ‘somatic presentation of psychological disorder’. Psychological treatments are becoming more widespread in the general hospital setting, but there are few systematic evaluations.

A manual and computer (MEDLINE) literature search was performed. Studies which provided insight into clinical practice were selected for discussion, and randomised controlled trials of at least 6 weeks duration and inclusion of 30 or more subjects were selected for review.

Fourteen empirical studies were found: six involving patients with chronic organic disorder and eight involving patients with somatisation.

There is little empirical evidence that psychotherapeutic interventions are of benefit when applied indiscriminately to patients with organic disease. Further work is required to delineate subgroups of patients who may be responsive. There is mounting evidence that psychotherapy is beneficial in patients with somatisation disorders. Patients with very chronic symptoms may require intensive treatment approaches.

So far no comprehensive systematic review has been published about epidemiologic studies on suicides among medical practitioners. The aim here is to describe the variation of published estimates of relative risk of doctors to die from suicide.

A systematic review of published original articles on population-based studies, registered mainly in MEDLINE and fulfilling specific methodological requirements. Incidence rates and standardised mortality ratios were calculated for male and female doctors in relation to the reference groups.

The estimated relative risk varied from 1.1 to 3.4 in male doctors, and from 2.5 to 5.7 in female doctors, respectively as compared with the general population, and from 1.5 to 3.8 in males and from 3.7 to 4.5 in females, respectively, as compared with other professionals. The crude suicide mortality rate was about the same in male and female doctors.

In all studies the suicide rates among doctors were higher than those in the general population and among other academic occupational groups.

The natural course of cognitive performance, electrophysiological alterations and brain atrophy in ageing and Alzheimer's disease (AD) has been investigated in numerous studies, but only few attempts have been made to examine the relationship between clinical, electroencephalographic (EEG) and morphological changes with quantitative methods prospectively over longer periods of time.

Fifty-five patients with clinically diagnosed AD and 66 healthy elderly controls were examined biannually using a cognitive test (CAMCOG), EEG band power and volumetric estimates of brain atrophy.

On average cognitive performance deteriorated by 28 points on the CAMCOG in the AD group, the alpha/theta ratio decreased by 0.2, and the proportion of intracranial cerebrospinal fluid volume increased by 3.5% during a 2-year period. Similar changes were observed after a second 2-year interval. A multiple regression model demonstrated a significant influence of age on cognition and atrophy and a significant influence of the estimated duration of symptoms on cognition, alpha/theta ratio and brain atrophy at the initial examination. Cognitive performance at the first examination exerted significant effects on the performance and also on brain atrophy at re-examination after 2 or 4 years, whereas the EEG and neuroimaging findings at the previous examination were exclusively related to the corresponding findings at the follow-up examinations. In the control group no significant cognitive, EEG and morphological changes were observed after 2 and 4 years.

After 2 consecutive follow-up periods, we were able to verify significant deteriorations of cognition accompanied by neurophysiological and neuroradiological changes in AD, but not in normal ageing. In clinically diagnosed AD, cognitive performance at the follow-up examination could not be predicted by the previous alpha/theta ratio or by the previous degree of global brain atrophy, whereas the cognitive test score determined not only performance, but also structural findings at follow-up. Performance on cognitive tests appears to be a more sensitive indicator of the degenerative process than EEG band-power and morphological changes in manifest AD. Neuroimaging, neurophysiology and genetic risk markers may be more important for the early differential diagnosis than for the prediction of the course of illness.

Little data are available about the course or incidence of depression in dementia sufferers.

Monthly follow-up data over one year is reported regarding depression in a cohort of 124 dementia sufferers. Dementia was diagnosed according to DSM–III–R criteria. Depression was assessed with the Cornell Depression Scale and diagnosed according to RDC criteria. Cognitive functioning was assessed with the CAMCOG.

Eighty-nine of the 124 patients completed the follow-up. The annual incidence rates of RDC major depression and RDC minor depression were 10.6% and 29.8%, respectively. Twenty per cent of patients with depression experienced these symptoms for six months or longer. Patients with vascular dementia were significantly more likely to experience three or more months of depression than patients with other dementias. RDC minor depression was highly persistent among 23.8% of sufferers.

Depression is persistent in patients with vascular dementia. Some patients with minor depression have a dysthymia-like disorder.

Despite the problems involved in treating depression and concomitant medical disease, there are virtually no longitudinal studies on drug utilisation among depressed patients.

Use of prescription drugs among all first-time users of antidepressants in a defined population five years before and six years after the index (first) treatment was compared to a referent group without antidepressant treatment. The generalised estimating equations (GEE) method was used for analysis.

The antidepressant-treated group used considerably more non-psychotropic drugs during the whole study period than the referent group. They also used more psychotropic drugs, a use which increased in connection with the initiation of antidepressant treatment and stayed high for a further five years.

The high use of prescription drugs indicated widespread somatic and psychiatric health problems during the whole study period. Antidepressant-treated patients are at risk for drug interactions and adverse effects, and would benefit from a closer collaboration between psychiatry and medicine.

It is widely believed that people in remote areas of the world suffer less emotional distress and fewer psychiatric disorders. Previous studies offer contradictory evidence.

First stage screening of two mountain villages in Chitral used the Bradford Somatic Inventory (BSI). Psychiatric interviews were conducted with stratified samples using the ICD–10 Diagnostic Criteria for Research.

The BSI was an effective screening test, with sensitivity of 80% and specificity of 77%. At a conservative estimate, 46% of women and 15% of men suffered from anxiety and depressive disorders. Literate subjects had lower levels of emotional distress than the illiterate. Higher socio-economic status was associated with less emotional distress. Members of joint and nuclear families were similar.

The study offers no support for the belief that people who live in Chitral lead stress-free lives or have low rates of psychiatric morbidity. Women may suffer more anxiety and depressive disorders than in Western societies.

The diagnostic category of generalised anxiety disorder (GAD) was originally intended to describe residual anxiety states. Over the years clinical criteria have been refined in an attempt to describe a unique diagnostic entity. Given these changes, little is known about the clinical course of this newly defined disorder. This study investigates the longitudinal course, including remission and relapse rates, for patients with DSM–III–R defined GAD.

Analysis of the 164 patients with GAD participating in the Harvard Anxiety Research Program. Patients were assessed with a structured clinical interview at intake and re-examined at six month intervals for two years and then annually for one to two years. Psychiatric Status Ratings were assigned at each interview point. Kaplan–Meier curves were constructed to assess likelihood of remission.

Comorbidity was high, with panic disorder and social phobia as the most frequently found comorbid disorders. The likelihood of remission was 0.15 after one year and 0.25 after two years. The probability of becoming asymptomatic from all psychiatric symptoms was only 0.08.

This prospective study confirms the chronicity associated with GAD and extends this finding to define the one and two year remission rates for the disorder. Likelihood of remission for GAD and any other comorbid condition after one year was half the annual remission rate for GAD alone.

Rapid-cycling bipolar disorder is defined as four or more affective episodes yearly. The conventionally recognised limit in episode duration is usually considered 24 hours (i.e. a cycle duration of 48 hours). We report a small series of intensively observed bipolar patients who showed much faster patterns of mood oscillation.

Detailed, systematic, longitudinal assessment of five bipolar patients during extended in-patient psychiatric evaluation were conducted, including retrospective life charting and prospective evaluation of daily mood by self and blinded observer ratings, and motor activity recording.

Our data demonstrate a spectrum of cycling frequencies in rapid-cyclers, including distinct, clinically robust mood shifts that occur at frequencies faster than once per 24 hours. Affective oscillations spanned a range of cycling frequencies from four episodes per year (rapid cycling) to those occurring within the course of weeks to several days (ultra-rapid cycling), to distinct, abrupt mood shifts of less than 24 hours' duration (ultra-ultra rapid or ultradian cycling). The time of onset and duration of these ultradian affective fluctuations are highly variable and they are observed in bipolar patients without evidence of personality disorder.

The potential clinical and theoretical implications of these first systematic observations of ultra-rapid and ultradian cycling in the context of the evolution of otherwise classical bipolar affective illness are discussed.

This study employed an alternative method for assessing serotonergic function to further evaluate our finding that cerebrospinal fluid (CSF) 5-hydroxyindole acetic acid (5-HIAA) in depressed suicide attempters with a lifetime history of higher lethality suicide attempts is significantly lower compared to depressed patients who have a history of low lethality suicide attempts.

We used dl-fenfluramine (60 mg) as a neuroendocrine probe to examine the serotonin system in 41 in-patients with a DSM–III–R major depressive episode, divided into two groups on the basis of a lifetime history of high or low lethality suicide attempts. Fenfluramine challenge test outcome was defined as the maximum prolactin response in the five hours following fenfluramine.

Patients with a history of a higher lethality suicide attempt had a significantly lower prolactin response to fenfluramine, even when controlling for cortisol, age, sex, weight, comorbid cluster B personality disorder, pharmacokinetic and menstrual cycle effects.

The data provide further support for the hypothesis that serotonin dysfunction is associated with more lethal suicide attempts, and suggests that higher lethality suicide attempters or failed suicides resemble completed suicides both behaviourally and biochemically.

The suicide rate in young men, but not young women, is rising. One possible route to suicide prevention is through general practice but recent evidence suggests that young suicides are not likely to attend GP surgeries prior to death.

We carried out a retrospective examination of general practice contacts by a 2-year sample of suicides under 35 years of age in the 12 health districts of Greater Manchester. In the 61 young suicides who were known to attend a GP in the three months before death, we recorded (a) the number of consultations each week in the three months before suicide; (b) sex differences in rates of and reasons for consultation; (c) frequency of recorded risk assessment at the last GP visit before suicide.

The number of GP visits increased significantly before death. A monthly increase was more evident in males, but the increase in the week before death was more marked in females. There was no sex difference in the rate of GP visits before suicide; both sexes were most likely to attend for psychological reasons. Significant suicide risk had been noted at none of the final GP visits.

There remains a potential role for GPs in preventing suicides by young people of both sexes. The recent increase in suicide by young males does not appear to be related to a lower rate of GP attendance before death. Future training of GPs in this area should focus on risk assessment.

Linguistic analysis is of great potential benefit to psychiatry as a research and assessment tool, but the skill and time it demands means that it has not been widely used. This paper describes a much simplified form of syntactic analysis.

A detailed protocol for the Brief Syntactic Analysis (BSA) was written, based on earlier work by Morice and Ingram. Three psychiatrists were trained in its use, and inter-rater reliability established through independent ratings of 12 transcripts taken from a mixed group of psychiatric patients and a group of non-psychiatric controls. Concurrent reliability of the BSA against the Morice and Ingram analysis was established by comparing measures from the two methods on 16 transcripts of mixed patients.

There were high levels of agreement between the three psychiatrists and between the BSA and the Morice and Ingram analysis, although one-way ANOVA indicated that for some variables there were small but statistically significant absolute differences between the two. The reasons for this were discussed. A principal components analysis confirmed the presence of three factors corresponding closely to the three families of linguistic variables.

The results indicate that psychiatrists can be trained to use a syntactic analysis with high levels of agreement. The BSA, which takes much less time to complete, produces measures that are comparable with the original analysis from which it was derived.

Several studies have revealed linguistic differences between diagnostic groups. This study investigates the extent to which these differences are accounted for by factors such as chronicity, or disturbances in cognition associated with acute psychosis.

Transcripts of interviews with patients suffering from RDC schizophrenia (n=38), mania (n=11) and controls (n=16) were examined using the Brief Syntactic Analysis (BSA). Patients were within two years of first onset of psychotic symptoms, and received tests of working memory and attention.

The speech of patients with schizophrenia was syntactically less complex than that of controls. Patients with schizophrenia and mania made more errors than controls. These differences were, to some extent, related to group differences in social class, working memory and attention, although significant group differences in language persisted after the effects of covariates were removed.

The study confirms the existence of differences in the speech of psychiatric patients. Low complexity appears to be a particular feature of speech in schizophrenia, even in the earliest stages of the condition. The importance of this finding is discussed in relation to two recent theories of schizophrenia: Crow's evolutionary model, and Friths neuro-psychological model.

This is the first attempt to study the prevalence and clinical characteristics of somatisation (ST) in a representative primary care sample in Spain.

The sample consisted of 1559 consecutive patients attending eight randomly selected health centres in Zaragoza, Spain, examined by two-phase screening. First phase (lay interviewers): Spanish versions of GHQ–28, CAGE questionnaire, substance abuse, Mini-Mental State Examination. Second phase (research clinicians and psychiatrists): Standardised Polyvalent Psychiatric Interview, which permits the reliable coding of Bridges & Goldberg's ST criteria.

The prevalence of somatisers was 9.4% (34.5% of the cases) and most patients (68.7%) were diagnosed in the depression or anxiety DSM–IV categories. The severity was moderate in 40.1 % and 66.6% were chronic (six or more months). No significant demographic differences were found with non-cases. Backache was the most frequent somatic presentation (71.4%).

ST in primary care is a much broader phenomenon than categories such as somatoform disorders reflect. It may be less influenced by sociodemographic factors, but more chronic than previously reported.

This study is the first attempt to document the differences between somatisers (STs) and psychologisers (PGs) in Spanish primary care patients.

A sample of 1559 consecutive patients attending eight randomly selected health centres in Zaragoza, were examined in a two-phase screening using Spanish versions of GHQ–28, CAGE questionnaire, substance abuse, MMSE and SPPI. STs and PGs were diagnosed according to operationalised Bridges & Goldbergs criteria.

ST was found to be three times more prevalent than PG, but the ratio ST: PG was highest (10.5) in the DSM–IV category dysthymia. Generalised anxiety disorder was the most frequent diagnosis in STs and major depressive episode the most frequent in PGs. No significant differences between the two groups have been found in demographic characteristics. Total GHQ scores were significantly higher in PGs, but global SPPI scores were not. Most psychopathological scores were higher in PGs, but both somatic symptoms and suspiciousness were higher in STs. The psychopathological findings are consistent with hypotheses related to blame avoidance and defensiveness in STs.

ST is three times more prevalent than PG, but the ratio ST: PG depends heavily on diagnostic categories. While most psychopathological scores are higher in PGs, both patient groups are similarly disturbed. Previously assumed socio-demographic differences between STs and PGs have not been found in this study.

There is a need for a valid self-rating questionnaire to screen for psychiatric morbidity in patients with chronic fatigue syndrome (CFS). This study had the aim of assessing the utility and validity of two commonly used measures.

Scores obtained on the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) were compared with various diagnostic and severity ratings obtained via a validating clinical interview, the Schedules for the Clinical Assessment of Neuropsychiatry (SCAN) in 95 consecutively referred subjects at a medical out-patient clinic who fulfilled standard criteria for CFS, and 48 healthy controls. Outcome measures were validating coefficients and receiver operating characteristics (ROC) for different thresholds and scoring on GHQ and BDI and index of definition (ID) as measured by SCAN; and Pearson and point by serial correlation coefficients for different diagnostic groups derived via SCAN and defined according to ICD–10 and DSM–III–R.

GHQ and BDI perform poorly as screeners of psychiatric morbidity in CFS subjects when compared with various SCAN derived ratings although results for controls are comparable with other studies.

Neither the GHQ nor BDI alone can be recommended as screeners for psychiatric morbidity in CFS subjects.

First rank symptoms are central to the diagnosis of schizophrenia, but their complexity makes it difficult to validly detect them in people with learning disability. This report investigates ability of PAS–ADD to detect schizophrenia, validated against expert clinical opinion.

The sample consisted of 98 patients with learning disability, and a key informant for each sample member. Clinical opinions of the referring psychiatrists were sought using a symptom checklist. Reportage of remission, and the number of core schizophrenia symptoms identified, were used to estimate level of symptom activity at time of interview.

The proportion of schizophrenia cases detected by PAS–ADD increases with the number of active core symptoms identified by the referrer. Where two or more core symptoms were indicated, PAS–ADD detected 71 % cases. The most frequently fulfilled criterion was third-person auditory hallucinations. Six schizophrenia diagnoses disagreed with the clinician, four of which were referred as being hypomania. Overall symptom frequency detected by PAS–ADD was positively correlated with IQ.

Results suggest there may be scope for modifying the ICD–10 diagnostic algorithm for use with learning disability, particularly in relation to the delusions and negative symptoms criteria.

We investigated the hypothesis that prenatal exposure to the 1957 A2 influenza increases the risk of schizophrenia in adulthood.

We traced a cohort of individuals known to have been exposed to the 1957 influenza epidemic during gestation and an unexposed cohort matched for period of gestation and hospital of birth. Follow-up information on psychiatric illness in subjects was sought from two sources: maternal interview and psychiatric hospital admission data.

Follow-up information was obtained on 54% of the sample: 238 subjects from the influenza-exposed group and 287 subjects from the unexposed group. There was no increased risk of schizophrenia among the exposed cohort compared to the unexposed cohort (relative risk 1.1; 95% CI 0.41–2.95), although there was an increase in depressive illness (relative risk 1.59; 95% CI 1.15–2.19).

The association between prenatal influenza and an increased risk of schizophrenia in adulthood has thus far been found only in population-based data and is not supported by the present observational study which has information about exposure and outcome in individuals.

Previous research has indicated that deluded patients may experience difficulties when testing hypotheses. In this study, hypothesis-testing strategies were assessed in patients with persecutory delusions, depressed patients and normal controls.

Subjects were presented problem items describing typical everyday situations with either positive or negative outcomes and were required to choose strategies to prove that one of three variables was responsible for the outcomes.

Consistent with previous research into sensible reasoning, subjects chose to manipulate the variable hypothesised to be responsible for the outcome (disconfirmation strategy) more when the outcome was negative than when it was positive, and chose to manipulate the remaining variables (confirmation strategy) more when the outcome was positive. No group differences were observed.

No evidence was found of abnormal hypothesis-testing strategies in deluded patients.