It has been argued that many patients in special hospital beds do not need to be there. In the 1990s there were initiatives to discharge women and people with learning difficulties.

To test for trends in special hospital discharges and to examine annual resident cohorts.

This study was from case registers and hospital records. The main measures were numbers and annual rates for referrals and beds offered; the Mental Health Act 1983 (MHA) classification of mental disorder; adjusted population rates by region; admission episodes; legal category of detention; admission source and type of offence.

The median annual number of residents was 1859 (range 1697–1910), with an 8% fall for the period. This particularly affected people in mental impairment categories. Numbers were sustained in the male mental illness groups. Discharges, mainly to other institutions, increased. There was no overall change over the 10 years in length of stay for treatment, but successive admission cohorts from 1986 did show some reduction, even with solely remand order cases excluded.

Service planners need a longitudinal perspective on service use. Trends over 10 years to both fewer admissions and more discharges have reduced the special hospital population, but despite new treatments for schizophrenia, men under mental illness classification, as well as transfer from other secure settings, have gone against this trend.

Alzheimer's disease manifests considerable heterogeneity, the cause of which is unknown.

To determine the familial (genotypic) influence on phenomenology (phenotype) in Alzheimer's disease.

Affected sibling pairs with Alzheimer's disease were assessed for a range of cognitive and non-cognitive symptoms. Resemblance for phenotypic characteristics was estimated using intraclass correlations for continuous traits and by pairwise concordance for dichotomous traits. The relationship between age of onset and APOE genotype was examined using linear regression analysis.

Significant familial effects on age of onset (intraclass correlation 0.41) and mood state (intraclass correlation 0.26), and a relatively high pairwise concordance for agitation (excess concordance 0.1) were found. The APOE locus was found to account for 4% of the variance in age of onset.

Substantial familial influence on age of onset, depression and agitation suggests that genotype does influence phenotype in Alzheimer's disease. Establishing the molecular basis for this phenotypic variation may prove relevant to other neuropsychiatric disorders.

Depression is the most common mental disorder in the community-dwelling elderly.

To determine the three-year prognosis of depression in a cohort of 127 community-dwelling elderly subjects and identify factors relevant to outcome.

The subjects, diagnosed depressed at year 0 using the GMS–AGECAT package, were followed up three years later. A number of factors were investigated for an association with recovery from, or persistence of, depression.

At follow-up, 30.2% of the depressed subjects had died, 34.9% had persistent or relapsed case-level depression, 24.5% had other case- or subcase-level mental illness and 10.4% had recovered completely. Physical ill-health, bereavement and positive family history of depression were associated with poor outcome, whereas treatment with antidepressant medication significantly improved prognosis.

Late-life depression in community-dwelling subjects is a chronic condition. However, the positive response to antidepressant medication suggests that it should be vigorously treated.

PET studies of verbal fluency in schizophrenia report a failure of ‘deactivation’ of left superior temporal gyrus (STG) in the presence of activation of left dorsolateral prefrontal cortex (DLPFC), which deficit has been attributed to underlying ‘functional disconnectivity’.

To test whether these findings provide trait-markers for schizophrenia.

We used H215O PET to examine verbal fluency in 10 obligate carriers of the predisposition to schizophrenia, 10 stable patients and 10 normal controls.

We found no evidence of a failure of left STG deactivation in carriers or patients. Instead, patients failed to deactivate the precuneus relative to other groups. We found no differences in functional connectivity between left DLPFC and left STG but patients exhibited significant disconnectivity between left DLPFC and anterior cingulate cortex.

Failure of left STG ‘deactivation’ and left fronto-temporal disconnectivity are not consistent findings in schizophrenia; neither are they trait-markers for genetic risk. Prefrontal functional disconnectivity here may characterise the schizophrenic phenotype.

Several reports postulate that manic depression and schizophrenia share environmental risk factors. Although obstetric adversity has been suggested as a risk factor for schizophrenia, few studies have examined its relationship to bipolar affective disorder.

To assess the rate of obstetric complications incurred by patients with mania compared with controls.

From the Dublin Psychiatric Case Register we identified individuals with a discharge diagnosis of mania and traced their birth records. Each case was matched with a control of the same gender, born in the same hospital, in the same year, matched for maternal age, parity and social class. Two obstetric complication scales were used to make blind evaluations of labour and delivery data.

Patients with mania did not experience a greater frequency or severity of labour and delivery complications than their matched controls. Rates of obstetric adversity were unrelated to the presence or absence of family history of psychiatric disorder. Obstetric adversity was unrelated to the age at first diagnosis.

These findings suggest that obstetric adversity is not a risk factor for later mania.

Patients with chronic fatigue syndrome (CFS) and depressive illness share many, but not all, features.

To test the hypothesis that patients with CFS have abnormal cerebral perfusion, that differs from that in patients with depressive illness.

We recruited 30 patients with CFS who were not depressed, 12 depressed patients and 15 healthy volunteers. Regional cerebral perfusion at rest was assessed using region of interest (ROI) and voxel-based statistical parametric mapping (SPM) techniques.

On SPM analysis there was increased perfusion in the right thalamus, pallidum and putamen in patients with CFS and in those with depressive illness. CFS patients also had increased perfusion in the left thalamus. Depressed patients differed from those with CFS in having relatively less perfusion of the left prefrontal cortex. The results were similar on ROI analysis.

Abnormal cerebral perfusion patterns in CFS subjects who are not depressed are similar but not identical to those in patients with depressive illness. Thalamic overactivity may be a correlate of increased attention to activity in CFS and depression; reduced prefrontal perfusion in depression may be associated with the greater neuropsychological deficits in that disorder.

Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health.

To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders.

Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained.

Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended.

Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.

Psychiatric hospital inpatients are known to be at high risk of suicide, yet there is little reliable knowledge of risk factors or their predictive power.

To identify risk factors for suicide in psychiatric hospital in-patients and to evaluate their predictive power in detecting people at risk of suicide.

Using a case–control design, 112 people who committed suicide while in-patients in psychiatric hospitals were compared with 112 randomly selected controls. Univariate analysis and multivariate analyses were used to estimate odds ratios and adjusted likelihood ratios.

The rate of suicide in psychiatric in-patients was 13.7 (95% CI 11.7–16.1) per 10 000 admissions. There were five predictive factors with likelihood ratios >2, following adjustment: planned suicide attempt, 4.1; actual suicide attempt, 4.9; recent bereavement, 4.0; presence of delusions, 2.3; chronic mental illness, 2.2; and family history of suicide, 4.6. On this basis, only two of the patients who committed suicide had a predicted risk of suicide above 5%.

Although several factors were identified that were strongly associated with suicide, their clinical utility is limited by low sensitivity and specificity, combined with the rarity of suicide, even in this high-risk group.

The emergence of new skills in the setting of dementia suggests that loss of function in one brain area can release new functions elsewhere.

To characterise 12 patients with frontotemporal dementia (FTD) who acquired, or sustained, new musical or visual abilities despite progression of their dementia.

Twelve patients with FTD who acquired or maintained musical or artistic ability were compared with 46 patients with FTD in whom new or sustained ability was absent.

The group with musical or visual ability performed better on visual, but worse on verbal tasks than did the other patients with FTD. Nine had asymmetrical left anterior dysfunction. Nine showed the temporal lobe variant of FTD.

Loss of function in the left anterior temporal lobe may lead to facilitation of artistic or musical skills. Patients with the left-sided temporal lobe variant of FTD offer an unexpected window into the neurological mediation of visual and musical talents.

The majority of patients with Alzheimer's disease live outside institutions and there is considerable serious psychological morbidity among their carers.

To evaluate whether family intervention reduces the subjective burden of care in carers of patients with Alzheimer's disease and produces clinical benefits in the patients.

A prospective single-blind randomised controlled trial with three-month follow-up in which the experimental group received family intervention and was compared with two control groups.

There were significant reductions in distress and depression in the intervention group compared with control groups at post-treatment and follow-up. There were significant reductions in behavioural disturbance at post-treatment and an increase in activities at three months in patients in the intervention group. Based on an improvement on the General Health Questionnaire resulting in a carer converting from a case to a non-case, the number to treat was three immediately post-treatment and two at follow-up.

Family intervention can have significant benefits in carers of patients with Alzheimer's disease and has a positive impact on patient behaviour.

Self-efficacy, a characteristic that is protective against depressive symptoms, may be undermined by stressful life events.

To estimate the effects of stressful life events on self-efficacy, and to examine self-efficacy as a mediator of the effect of stressful life events on symptoms of depression.

Using a sample of 2858 respondents from the longitudinal Americans' Changing Lives study, path analyses were used to evaluate interrelationships between self-efficacy, life events and symptoms of depression controlling for a variety of potentially confounding variables. Separate models were estimated for those with and without prior depression.

For those with prior depression, dependent life events had a significant, negative impact on self-efficacy. For those without prior depression, life events had no effect on self-efficacy.

For those with prior depression, self-efficacy mediates approximately 40% of the effect of dependent stressful life events on symptoms of depression.

It has been suggested that adults with medically unexplained physical symptoms experienced greater ill-health then others (either in themselves or their families) during childhood.

To test these hypotheses.

We used data from the Medical Research Council (MRC) National Survey of Health and Development, a population-based cohort study established in 1946 (n=5362). Subjects were followed from birth in 1946 until 1989 (age 43 years). As outcome, we used operationally defined medically unexplained hospital admissions at age 15–43 years. Exposure variables included childhood illness, and illness in parents during the childhood of the subjects.

The risk set (n=4603) comprised individuals still in the Survey at age 15. Ninety-five unexplained hospital admissions were identified. Subjects whose mothers reported below-average health in the father were at increased risk of subsequent unexplained admissions. Below average reported health in the mother was not associated with this increased risk. Defined physical diseases in childhood were not associated, but persistent abdominal pain at age 7–15 years was.

Unexplained hospital admissions are associated with certain childhood experiences of illness, but defined physical illness in childhood is not a risk factor.

Methods of suicide and suicide rates in England and Wales have fluctuated considerably since the 1960s.

To review the changes that have occurred in suicide rates in England and Wales between 1960 and 1997.

Suicide rates, derived from total annual suicides and the estimated annual resident population, were obtained from the Office for National Statistics.

Suicide rates decreased in both genders between the early 1960s and the mid-1970s. The rate for males then increased between 1975 and 1990, while the rate for females continued to fall. Between 1990 and 1997, the rate decreased for males and females in all age groups, particularly for those using motor vehicle exhaust gas; the latter finding is associated with increasing use of catalytic converters.

Following the increase in suicide among males until 1990 there was a decrease for both genders between 1990 and 1997, consistent with the ‘Health of the Nation’ target.

Recent concern about drug use has focused attention on the illegal income generated by users.

To investigate factors associated with drugs expenditure and to estimate the cost of illegal acquisitions used to pay for drugs.

We collected self-report data from 954 current injectors, interviewed at multiple street, needle/syringe exchange and drug treatment sites throughout Glasgow.

Injectors' mean weekly drug spending was £324. The mean annual illegal drugs spend was estimated to be £11 000 per injector. We provide a central estimate – £194 million per annum – of the retail value of goods acquired illegally by injectors in Glasgow in order to pay for drugs. Higher drug spends were associated with having been imprisoned more often and with those reporting acquisitive crime, drug dealing and prostitution. Treatment with methadone, among individuals who injected in the previous two months, was associated with a 20% reduction in atypical spend on drugs.

Treatment effectiveness needs to be measured both in terms of health benefit and in terms of reduction in drugs expenditure and recidivism.

Of available self-rated social phobia scales, none assesses the spectrum of fear, avoidance, and physiological symptoms, all of which are clinically important. Because of this limitation, we developed the Social Phobia Inventory (SPIN).

To establish psychometric validation of the SPIN.

Subjects from three clinical trials and two control groups were given the 17-item, self-rated SPIN. Validity was assessed against several established measures of social anxiety, global assessments of severity and improvement, and scales assessing physical health and disability.

Good test – retest reliability, internal consistency, convergent and divergent validity were obtained. A SPIN score of 19 distinguished between social phobia subjects and controls. The SPIN was responsive to change in symptoms over time and reflected different responses to active drugs v. placebo. Factorial analysis identified five factors.

The SPIN demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.

The relationship between depression and low blood pressure is unclear.

To examine the temporal relation between low blood pressure and depression in a two-year follow-up.

The study group consisted of 1389 subjects aged 59–71 years; 1272 (92%) were examined after two years. Subjects completed the Center for Epidemiological Studies–Depression (CES–D) and the Spielberger inventory scales to assess depressive and anxiety symptoms respectively. Data were collected on socio-demographic characteristics, smoking and drinking habits, medical history, drug use and blood pressure measures.

Among 1112 subjects who were considered as non-depressed at baseline, logistic regression models showed that low diastolic blood pressure (DBP) and decrease of blood pressure were predictors of high depressive symptomatology at follow-up. Baseline high CES–D scores did not predict low blood pressure two years after.

In our study, low blood pressure was a risk factor for, but not a consequence of, high depressive symptomatology.

Older people in nursing and residential homes often have complex disabilities and behavioural disturbances. Recent publicity has highlighted the dangers of medication in this group, and controls over prescribing have been suggested.

To investigate the effect of a review of medication by a pharmacist.

An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.

The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).

This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality.

Quality of life (QOL) has gained importance as a global measure of social and clinical outcome in schizophrenia.

To identify the clinical correlates of QOL at the time of first presentation with schizophrenia.

Over two years, consecutive first-episode psychosis patients presenting to a catchment area psychiatric service underwent validated clinical assessments of premorbid adjustment, illness duration, symptoms and QOL.

At presentation, subjects already had a diminished QOL. Although independent of gender and age at onset of psychosis, QOL was influenced by premorbid adjustment, duration of untreated psychosis and symptoms.

Reducing the duration of untreated psychosis may have a beneficial effect on the subsequent QOL of patients presenting with schizophrenia. First-episode patients with a protracted duration of untreated psychosis or impaired premorbid adjustment may warrant specific treatment interventions to prevent the development of secondary handicaps.

Recent studies of the relationship between the apolipoprotein E (APOE) gene and Alzheimer's disease in adults with Down's syndrome have revealed inconsistent results.

To assess the role of the APOE gene in the manifestation of Alzheimer's disease in adults with Down's syndrome.

We studied the APOE genotypes of 24 adults with dementia and 33 non-demented adults with Down's syndrome over 35 years of age, and an additional group of 164 non-learning disabled adults. We also carried out a meta-analysis of all previously published studies of association between APOE and Down's syndrome, incorporating the current data.

We observed a non-significant excess of APOE ε4 and a reduction of ε2 in adults with dementia compared with non-demented adults with Down's syndrome in our sample. However, meta-analysis showed a significantly higher frequency of ε4 in adults with dementia compared with non-demented adults with Down's syndrome (odds ratio=2.02, 95% CI 1.33–3.07, P=0.001), but no significant reduction in the frequency of ε2.

The APOE ε4 allele acts as a risk factor for the age-specific manifestation of Alzheimer's disease in people with Down's syndrome.