In spite of intensive research, no causal anatomical lesion has been found in schizophrenia. It may instead be caused by malfunctioning circuits in the corollary discharge, feed forward (CD–FF) systems of thought.

To integrate with the CD–FF hypothesis recent data showing that subcortical motor systems participate in thinking.

We review CD–FF concepts in relation to recent evidence that ‘motor’ brain structures participate in cognitive processing.

Malfunctioning of CD–FF systems that integrate thinking and consciousness could produce auditory hallucinations, delusions and disorganised thought.

We hypothesise that the pathophysiology of schizophrenia lies in integrative circuits of basal ganglia, thalamus and frontal cortex. Fruitful research directions would include elucidation of CD–FF circuits at even higher brain levels, the behaviour of these circuits during dreaming, and their responses to late maturational events including synaptic elimination.

In the treatment of panic disorder with agoraphobia, the efficacy of pharmacological, psychological and combined treatments has been established. Unanswered questions concern the relative efficacy of such treatments.

To demonstrate that moclobemide and cognitive–behavioural therapy (CBT) are effective singly and more effective in combination.

Fifty-five patients were randomly assigned to an eight-week treatment of: moclobemide plus CBT; moclobemide plus clinical management (‘psychological placebo’); placebo plus CBT; or placebo plus clinical management.

Comparisons between treatments revealed strong effects for CBT. Moclobemide with clinical management was not superior to placebo. The combination of moclobemide with CBT did not yield significantly better short-term results than CBT with placebo. The CBT results remained stable during a six-month follow-up, although a substantial proportion of patients treated with placebo plus CBT needed additional treatment.

CBT was highly effective in the treatment of panic disorder with agoraphobia and reduced agoraphobia to levels that were comparable to those of non-clinical controls.

Data concerning appropriate treatment in panic disorder following an initial response to acute therapy are limited.

To assess the safety and efficacy of continued fluoxetine treatment following successful acute therapy of panic disorder.

Patients who responded to acute fluoxetine treatment were randomised to 24 weeks of continued fluoxetine or placebo.

Fluoxetine responders randomised to continue on their acute-phase fluoxetine dose experienced statistically significant improvement in panic attack frequency and phobia rating scale score over 24 weeks of therapy, while those switched to placebo experienced statistically significant worsening in Hamilton Anxiety (HAM–A), Hamilton Depression (HAM–D) and SCL–90–R rating scores.

Fluoxetine was associated with improved clinical outcomes compared with placebo during continuation therapy.

Earlier work on the protective role of social support in onset and course of depressive disorder suggested that its provision might be relevant for outcome.

To evaluate volunteer befriending as an intervention among women with chronic depression in inner London.

A randomised controlled trial, with awaiting list control design, with outcome measured as Present State Examination (PSE)-based full or partial remission after one year.

A statistically significant effect upon remission was found for befriending. Other treatments monitored naturalistically did not relate to remission, nor did initial duration of chronic episode or comorbidity, but there was an association with initial PSE score. The findings are discussed in relation to standard drug-trial results and to another befriending intervention with the elderly.

The results are not unpromising. Additional trials with less restricted intake conditions, and in more naturalistic general practice settings, might confirm volunteer befriending as a useful adjunct to current treatments.

Volunteer befriending promoted remission of chronic depression when clinical and other treatment variables were controlled.

To examine the role of other psychosocial factors relevant for outcome.

Factors measured at baseline interview were examined in multivariate analyses along with psychosocial factors occurring during follow-up, such as ‘fresh-start’ experiences and new severe events and difficulties.

Fresh-start experiences and a standard attachment style were found to enhance chances of remission, with new severe stressors and markedly poor coping strategies liable to prevent it, with volunteer befriending continuing to play a role.

The positive result reported in the preceding paper is unlikely to be an artefact. However, fresh-start experiences, absence of new severe stressors and standard attachment style were more important predictors of remission. This knowledge might profitably be incorporated into the evaluation of existing treatments.

Little is known about men who commit sex offences in the context of psychosis.

To examine the relationship of illness and psychotic symptoms to sex offending in men with schizophrenia.

A search of Home Office records was completed for all 84 male restricted hospital order in-patients with schizophrenia, resident in any hospital in England and Wales during May 1997, with an index conviction for a contact sex offence against a woman.

At the time of their index offences 80 men were psychotic and half of them had delusions or hallucinations related to the offences. Specific delusional or hallucinatory drive was pertinent in only 18 men but the majority of men committed their first sex offence after onset of schizophrenia. Exclusive sex offending was uncommon.

When a man with schizophrenia commits a serious sex offence the illness is, more commonly than not, relevant to that offence even though a direct symptom relationship may be relatively unusual.

Serotonin (5-HT): dopamine imbalance may underlie neuroleptic-induced akathisia.

To evaluate the efficacy of the 5-HT2 antagonist, mianserin in neuroleptic-induced akathisia.

Thirty neuroleptic-treated patients with schizophrenia were randomly allocated in a double-blind design to receive either mianserin (15 mg/day) or placebo for five days. Patients were assessed at baseline and on Days 3 and 5 by the Barnes Akathisia Scale (BARS), as well as by other relevant clinical rating scales.

Compared with the placebo group, the mianserin-treated patients showed a significant reduction in all four BARS subscales by Day 5, with mean reductions in the BARS global score of 9.9% and 52.2%, respectively (P=0.006). Response to treatment (a reduction of at least two points on the BARS global subscale), was noted in six patients (40%) in the mianserin group and only one patient (9.1%) in the placebo group (P=0.04, log odds ratio 2.23).

Mianserin at a low dose may be a promising therapeutic option for patients with acute neuroleptic-induced akathisia.

Despite the lack of consistent empirical support, modern diagnostic criteria of schizophrenia give particular emphasis to Schneider's first-rank symptoms (FRSs).

To examine the diagnostic significance of FRSs for schizophrenia by trying to overcome the limitations of previous studies.

This study examined the diagnostic accuracy of FRSs for schizophrenia in 660 in-patients with the full spectrum of functional psychotic disorders. Schizophrenia was diagnosed according to three criteria: DSM–III–R broad, DSM–III–R narrow and Feighner, the latter being considered as the gold standard because it does not give particular emphasis to FRSs.

FRSs were highly prevalent in both schizophrenia and non-schizophrenic psychoses. The likelihood ratios (and 95% Cl) of one or more FRSs for Feighner, DSM–III–R narrow and DSM–III–R broad schizophrenia were 1.06 (0.94–1.20), 1.23 (1.09–1.39) and 1.73 (1.44–2.08), respectively. These data indicate that FRSs do not significantly increase the likelihood of having schizophrenia.

FRSs are not useful in differentiating schizophrenia from other psychotic disorders. Diagnostic systems for schizophrenia that are heavily based on these symptoms may arise from a tautological definition of the disorder.

Hospital-based studies suggest that depression in old age relates to organic brain changes.

To determine whether these findings are confirmed in a population-based sample.

A population sample of non-demented 85-year-olds (227 mentally healthy and 62 with DSM–III–R depression were given a neuropsychiatric examination and computerised tomographic scans of the brain, and followed for three years.

On the Mini-Mental State Examination, those with a low educational level with major depression performed worse than the mentally healthy; this distinction was not evident among those who had received higher education. Measures of brain atrophy were similar in depressed and mentally healthy individuals. The three-year incidence of dementia was increased in those with early-onset major depression.

Higher education may protect against cognitive symptoms in depressed individuals. The association between depression and cerebral atrophy in the elderly is not very strong. The higher incidence of dementia in those with early-onset major depression may be due to a longer lifetime duration of depression, emphasising the importance of detecting and treating depression in the community.

Resources to address the needs of parents of intellectually disabled children in developing countries are limited.

The efficacy of interactive group psychoeducation on measures of parental attitude towards intellectual disability was assessed in southern India.

Fifty-seven parents randomised to 10 weeks of experimental and control therapy were assessed using the Parental Attitude Scale towards the Management of Intellectual Disability. The pre- and post-intervention measurements were done by a single-blinded rater and compared.

The intervention group had a statistically significant increase in the outcome scores and clinical improvement in the total parental attitude score, orientation towards child-rearing, knowledge towards intellectual disability and attitude towards management of intellectual disability, but no change in attitude towards the intellectual disability subscale.

Interactive group psychoeducation is effective for changing the attitude of parents with intellectually disabled children, and is a viable option to be developed in situations where resources are limited.

Systematic clinical investigations of consecutive suicides have found psychiatric disorders in 90–95% of subjects (depressive disorder 30–87%).

To investigate use of psychotropics in men and women of different ages who commit suicide.

Results of toxicological screening in 5281 suicides in Sweden 1992–94 were studied.

Psychotropics were detected in 45.3% of the suicides. Antidepressants were detected in 12.4% of the men and 26.2% of the women (7.2% and 14.2%, respectively, of those under 30 years of age). Neuroleptics or antiepileptics (in the absence of antidepressants) were detected in 8.3%, and anxiolytics/hypnotics alone in 20.5% of the subjects. Overdose by an antidepressant was the probable cause of death in 2.1% of the men and 7.9% of the women.

The pattern of psychotropics detected in toxicology was incongruent with the pattern of diagnoses found in the clinical investigations of suicides mentioned above. Depression appears to be undertreated in individuals committing suicide, especially in men and in subjects under 30 years of age.

Regular assessment of mood is often important for treatment but traditional measures can be time-consuming. A quick ‘litmus test’ is needed.

To test the reliability and validity of a single-item scale for mood.

Mood was measured repeatedly in 812 patients (258 in-patients, 554 out-patients) being treated in an anxiety disorders unit. Patients had self- and clinician ratings of a single-item depression scale and also rated the 21-item Beck Depression Inventory (BDI–21). Their single-item scores were compared with BDI–21 scores and with outcome measures.

The single-item depression scores correlated 0.71 to 0.78 with the BDI–21 scores. Clinically useful cut-off points were identified. Depression scores at discharge, but not pre-treatment, correlated significantly with improvement in the main problem.

The quick single-item depression scale, whether rated by patient or by clinician, is a reasonable rough guide to mood in anxiety disorders and saves time for the patient and the clinician compared to longer measures.

The occurrence of a seizure during electroconvulsive therapy (ECT) should be confirmed. Most clinicians use motor seizure monitoring alone and recent guidelines have not considered electroencephalogram (EEG) monitoring mandatory.

To examine the potential pitfalls of motor seizure monitoring.

Consenting consecutive patients (n=232) were prospectively studied at the first ECT session using both motor and EEG seizure monitoring. It was ensured (by titration) that all the patients had an adequate EEG seizure. Adequate and prolonged seizures were defined according to the latest recommendations of the Royal College of Psychiatrists.

Motor seizure was inadequate in 15 (7%) of patients. EEG seizure was prolonged in 38 (16%) of patients. Fifteen patients (39%) did not have a prolonged motor seizure. Motor seizure correlated well (r=0.8, P < 0.001) with EEG seizure when the latter was adequate, but not when prolonged (r=0.12, P > 0.5).

Motor seizure monitoring without EEG is undependable. The study provides a rational basis for the Royal College of Psychiatrists' definition of prolonged EEG seizure.