Distressing mental imagery is hard to study experimentally in obsessive–compulsive disorder (OCD).

To develop a way to assess mental imagery in OCD during functional magnetic resonance imaging (fMRI).

A small randomised study, controlled for type and order of mental imagery and for treatment condition (exposure therapy guided by a computer or by a therapist, or relaxation guided by audio-tape). Before and after treatment, during fMRI scanning, patients imagined previously-rehearsed scenarios that evoked an urge to ritualise or non-OCD anxiety or a neutral state, and rated their discomfort during imagery.

The method evoked greater discomfort during OCD imagery and anxiety (non-OCD) imagery than during neutral imagery. Discomfort was reduced by cancelling imagery. Discomfort during OCD imagery (but not during anxiety non-OCD imagery) fell after exposure therapy but not after relaxation.

Results showed differences between OCD and non-OCD images and their change after successful treatment, and confirmed clinical suggestions that cancelling images reduced OCD discomfort. The method's success paves the way for further studies of mental imagery in OCD: for instance, during fMRI.

The concept of fixed, unshakeable (delusional) beliefs within the context of obsessive–compulsive disorder (OCD) is one that has received varying amounts of attention in the literature, and has not yet received universal acknowledgement. There are good grounds for including these cases within the diagnostic concepts of OCD, with significant implications for clinical management.

To present cases with unusual OCD, in order to re-evaluate the issue of delusions and OCD.

The cases of five subjects with delusions in the course of obsessive–compulsive disorder are presented to illustrate ‘delusional’ OCD. The management and outcome of these cases are discussed.

Fixity and bizarreness of beliefs in OCD occur on a continuum from ‘none’ to ‘delusional intensity’ and may fluctuate within subjects.

The idea that these cases may represent a form of OCD has implications for management, as, if this is correct, they should be able to respond to appropriate behavioural and/or pharmacological strategies used in OCD.

Depression may be associated with cognitive decline in elderly people with impaired cognition.

To investigate whether depressed elderly people with normal cognition are at increased risk of cognitive decline and Alzheimer's disease.

Two independent samples of older people with normal cognition were selected from the community-based Amsterdam Study of the Elderly (AMSTEL) and the Longitudinal Aging Study Amsterdam (LASA). In AMSTEL, depression was assessed by means of the Geriatric Mental State Schedule. Clinical diagnoses of incident Alzheimer's disease were made using a two-step procedure. In LASA, depression was assessed with the Center for Epidemiologic Studies Depression Scale. Cognitive decline was defined as a drop of ⩾ 3 on the Mini-Mental State Examination at follow-up.

Both in the AMSTEL and the LASA sample, depression was associated with an increased risk of Alzheimer's disease and cognitive decline, respectively, but only in subjects with higher levels of education.

In a subgroup of more highly educated elderly people, depression may be an early manifestation of Alzheimer's disease before cognitive symptoms become apparent.

If the established winter excess in births of people who subsequently develop schizophrenia is an effect of ‘seasonality’, this would be testable by examining the pattern of births in an equatorial region with no formal seasons.

To investigate whether there is any variation in month of birth among patients from equatorial Singapore with a diagnosis of schizophrenia.

All 9655 patients discharged from Singapore's national psychiatric hospital with a diagnosis of schizophrenia were included (year of birth range 1930–1984). We analysed aggregated data, as well as the data of subsamples grouped according to birth-year periods, in order to examine secular trends. One patient subsample (those born 1960–84) allowed exact matching againstthe general population data set and close testing of any seasonal influence.

Monthly variation in births was evident for both patients and controls; the patterns were very similar, apart from the patient sample showing a trough in March–April.

In an equatorial region, where ‘seasons’ are absent, no seasonal excess in births of those later developing schizophrenia was evident.

The acute and transient psychotic disorders (ATPD) in ICD–10 advanced the nosology of remitting psychoses with acute onset. But the proposed criteria for ATPD – especially in regard to duration – are tentative and need to be validated.

To evaluate: (a) the duration of remitting psychoses with acute onset; (b) the applicability of the ATPD criteria for these cases; and (c) differences in duration and ATPD diagnoses across sociocultural settings.

Data from the World Health Organization Determinants of Outcome study were used.

The 98 cases of remitting psychoses with acute onset had a modal duration of 2–4 months, with 43% falling in this range. Mainly because of this, few met the ATPD criteria. Duration and diagnostic findings were similar across settings.

ATPD criteria need refinement, especially in regard to duration. Further studies aimed at early detection and assessment of onset and duration of these disorders are needed.

Many people with substance use disorders are vulnerable to other psychiatric disorders and present to addiction treatment services with comorbid psychiatric symptoms.

To describe the prevalence of recent psychiatric treatment and current psychiatric symptoms and explore links between substance misuse, personal/social functioning and symptom severity.

Subjects were 1075 adults recruited to the National Treatment Outcome Research Study (NTORS), of whom 90% were opiate-dependent. Psychiatric symptoms at intake were recorded using sub-scales from the Brief Symptom Inventory.

Recent psychiatric treatment was reported by one in five subjects. Psychiatric symptom levels were high and females had elevated scores on all scales. Symptoms were elevated among opiate users who were also frequent users of benzodiazepines, alcohol and, in particular, stimulants. Gender, physical health, drug dependence and personal relationship problems were more powerful predictors of psychiatric symptoms than substance use.

Addictions service providers should be vigilant to psychiatric problems among their clients at intake to treatment. Psychiatric symptoms are more closely linked to polydrug use than to opiate use in this population.

Amino acid mixtures that lower brain availability of the serotonin (5-HT) precursor tryptophan produce acute depressive relapse in women with a history of major depression. Dieting also lowers brain tryptophan availability, but its effects on brain 5-HT function in recovered depressed women have not been studied.

To test the hypothesis that women with a history of major depression would show impaired regulation of brain 5-HT function during a period of dieting-induced tryptophan depletion.

Women with and without a history of major depression were placed on a daily 1000 kcal (approximately 4200 kJ) diet for three weeks. Before the diet and in the final week we measured fasting plasma tryptophan levels and the prolactin response to an intravenous tryptophan challenge.

Dieting lowered plasma tryptophan levels equivalently in women with and without a history of depression. In women without a history of depression, dieting also increased the prolactin response to tryptophan. This increase did not occur in women with a history of depression.

Women with a history of depression showed impaired regulation of brain 5-HT function in response to dieting.

People with learning disabilities and mental health problems have complex needs. Care should be provided according to need.

To develop a standardised needs-assessment instrument for adults with learning disabilities and mental health problems.

The Camberwell Assessment of Need for Adults with Developmental and Intellectual Disabilities (CANDID) was developed by modifying the Camberwell Assessment of Need (CAN). Concurrent validity was tested using the Global Assessment of Functioning (GAF) and the Disability Assessment Schedule (DAS). Test–retest and interrater reliability were investigated using 40 adults with learning disabilities and mental health problems.

CANDID scores were significantly correlated with both DAS (P<0.05) and GAF scores (P<0.01). Correlation coefficients for interrater reliability were 0.93 (user), 0.90 (carer), and 0.97 (staff ratings); for test–retest reliability they were 0.71, 0.69 and 0.86 respectively. Mean interview duration was less than 30 minutes.

The CANDID is a brief, valid and reliable needs assessment instrument for adults with learning disabilities and mental health problems.

Over 390 000 people in the UK are disfigured. Facial disfigurement distresses sufferers markedly but has been studied little.

To compare fearful avoidance of people with a facial disfigurement with that of a group of patients with phobia.

Comparison of Fear Questionnaire agoraphobia, social phobia and anxiety depression sub-scale scores of 112 facially disfigured people (who scored high on Fear Questionnaire problem severity in three survey studies) with those of 66 out-patients with agoraphobia and 68 out-patients with social phobia.

Facially disfigured people and patients with social phobia had similar Fear Questionnaire scores. In contrast, facially disfigured people scored lower on the agoraphobia sub-score but higher on the social phobia sub-score than did patients with agoraphobia.

Facially disfigured people with psychological difficulties resembled people with social phobia on Fear Questionnaire social phobia, agoraphobia and anxiety/depression sub-scores but were less agoraphobic and more socially phobic than were people with agoraphobia. Facially disfigured people thus appeared to be socially phobic and to deserve the cognitive – behavioural therapy that is effective for such phobias.

Targeting resources on cost-effective care strategies is important for the global mental health burden.

To demonstrate cost–outcome methods in the evaluation of mental health care programmes in low-income countries.

Four rural populations were screened for psychiatric morbidity. Individuals with a diagnosed common mental disorder were invited to seek treatment, and assessed prospectively on symptoms, disability, quality of life and resource use.

Between 12% and 39% of the four screened populations had a diagnosable common mental disorder. In three of the four localities there were improvements over time in symptoms, disability and quality of life, while total economic costs were reduced.

Economic analysis of mental health care in low-income countries is feasible and practicable. Our assessment of the cost-effectiveness of integrating mental health into primary care was confounded by the naturalistic study design and the low proportion of subjects using government primary health care services.

Uncertainties remain about the role of serotonin in the aetiology and treatment of panic disorder.

To investigate the effect of reducing brain serotonin function on anxiety at rest, and following 5% CO2 provocation in normal controls and patients with panic disorder.

Twenty drug-free patients with DSM–III–R panic disorder and 19 controls received a tryptophan-free amino acid drink on one occasion and a control drink on the other in a double-blind, balanced protocol. 5% CO2 was given as a panic challenge after 270 minutes.

Plasma tryptophan fell by more than 80% both patients and controls after the tryptophan-free drink. Tryptophan depletion did not alter resting anxiety. In patients alone, tryptophan depletion caused a greater anxiogenic response and an increased rate of panic attacks (9 v. 2, P<0.05) after 5% CO2 challenge. No normal volunteers panicked.

Serotonin may directly modulate panic anxiety in patients with panic disorder. This may underlie the efficacy of serotonergic antidepressants in treating panic disorder.

Lipid peroxidation may be increased in schizophrenia, due to the illness, lifestyle or medication.

To determine plasma lipid peroxide levels and serum vitamin E and A levels in first-episode never-treated people with schizophrenia and in controls.

Thirty in-patients with a first episode of schizophrenia or schizophreniform psychosis were recruited, as were controls matched for gender, age, smoking and dietary status. Blood samples were taken, smoking status was recorded and body mass index measured.

There were no significant differences between patients and controls in plasma lipid peroxide levels. Seventy-three per cent of the patients smoked. Patients who smoked had a higher mean lipid peroxide level than non-smokers. Seventy-seven per cent of patients and 70% of controls had a ratio of vitamin Eto cholesterol of less than 5. Body mass index was lower in patients than in controls.

As a result of the high prevalence of smoking this group shows increased lipid peroxidation. Low serum ratios of vitamin Eto cholesterol in both patients and controls suggest an unsatisfactory diet.

The Mental Health Act 1983 (MHA) is due to be revised by Parliament in the near future.

To explore changes in the use of the Act since its introduction.

The Department of Health and the Home Office routinely collect data on the numbers of patients admitted to psychiatric hospitals under the MHA. We present absolute figures, by year, for the total numbers admitted under each section of the Act. We used the total psychiatric hospital admissions and total prison populations as denominator data.

Formal admissions rose from 16 044 in 1984 to 26 308 in 1996, a 63% increase. Admissions under the MHA have increased as a proportion of all admissions. The increase is mainly accounted for by changes in the use of Part II of the Act, in particular sections 2 and 3. The use of forensic sections (Part III) has also increased, with a marked increase of sections 47 and 48. Use of Part X of the Act (sections 135 and 136) declined in the late 1980s but rose again in the 1990s.

Formal admissions are more common than they were in 1984, despite there being fewer psychiatric beds. This is probably due to changes in the provision of psychiatric services, and changing societal pressures on psychiatrists away from libertarianism and towards coercion.

The high mortality from suicide in patients admitted to hospital with an affective disorder is well documented, although specific causes of mortality and changes in mortality are less well studied.

To describe the pattern of mortality in patients with affective disorder and to study changes in suicide riskduring the study period.

All patients (n=54 103) admitted for the first time to a psychiatric hospital in Denmarkduring the period 1973–1993 because of affective disorder were included in this study. The mortality rate was compared with that of the general population.

Mortality from natural and unnatural causes was elevated in all subgroups of affective disorder. The risk of suicide among patients ill for one year or less after first admission increased during the period 1973–1993.

More attention should be paid to the risk of suicide and to physical illness in patients with affective disorders.

Psychological debriefing is widely used for trauma victims but there is uncertainty about its efficacy. We have previously reported a randomised controlled trial which concluded that at 4 months it was ineffective.

To evaluate the 3-year outcome in a randomised controlled trial of debriefing for consecutive subjects admitted to hospital following a road traffic accident.

Patients were assessed in hospital by the Impact of Event Scale (IES), Brief Symptom Inventory (BSI) and questionnaire and re-assessed at 3 months and 3 years. The intervention was psychological debriefing as recommended and described in the literature.

The intervention group had a significantly worse outcome at 3 years in terms of general psychiatric symptoms (BSI), travel anxiety when being a passenger, pain, physical problems, overall level of functioning, and financial problems. Patients who initially had high intrusion and avoidance symptoms (IES) remained symptomatic if they had received the intervention, but recovered if they did not receive the intervention.

Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims.

Some women dread and avoid childbirth despite desperately wanting a baby. This is called tokophobia.

To classify tokophobia for the first time in the medical literature.

Twenty-six women noted to have an unreasoning dread of childbirth were interviewed by the same psychiatrist, who was not the treating doctor. A qualitative analysis of these psychiatric interviews was performed.

Phobic avoidance of pregnancy may date from adolescence (primary tokophobia), be secondary to atraumatic delivery (secondary tokophobia) or be a symptom of prenatal depression (tokophobia as a symptom of depression). Pregnant women with tokophobia who were refused their choice of delivery method suffered higher rates of psychological morbidity than those who achieved their desired delivery method.

Tokophobia is a specific and harrowing condition that needs acknowledging. Close liaison between the obstetrician and the psychiatrist in order to assess the balance between surgical and psychiatric morbidity is imperative with tokophobia.

Rapid eye movement (REM) sleep behaviour disorder is a relatively new diagnostic category. It has never before been associated with a treatable depressive condition.

To repot on a 74-year-old man with a history of depression and REM sleep behaviour disorder, associated with mild cognitive impairment.

Assessment using brain CT, MRI, PET, electroencephalography, neuropsychological testing and nocturnal polysomnography.

Depression was treated with sertraline. Sleep laboratory studies supported a diagnosis of REM sleep behaviour disorder, which was treated with clonazepam. Sleep apnoea, revealed later, was treated with nasal continuous positive airways pressure. Brain MRI showed mild atrophy, but neuropsychological testing indicated no progressive cognitive deterioration.

This case draws attention to REM sleep behaviour disorder and its potential interaction with depression and cognitive impairment, producing symptoms which can be mistaken for early dementia. The diagnosis of REM sleep behaviour disorder is easily missed, and it requires careful history-taking and sleep investigation in all suspected sufferers. Associated neurological, sleep and psychiatric conditions (including depression and cognitive impairment) may confound the diagnosis.