Age of onset was examined for 139 members of 30 families affected by early-onset AD. Most (77%) of the variance of age of onset derived from differences between rather than within families. The constancy of age of onset within families was also observed in an analysis restricted to families derived from a population-based epidemiological study with complete ascertainment of early-onset AD. Furthermore, we observed clustering of age of onset within those families that support linkage to the predisposing locus on chromosome 21. Our data are compatible with the view that allelic heterogeneity at the AD locus may account for the similarity in age of onset within families. This finding may be of value for scientific studies of AD as well as for genetic counselling.

The major psychoses remain an enigma. Affective and schizophrenic psychoses are apparently present (probably at about the same lifetime prevalence of approximately 2%) in all human societies. Yet their aetiology is obscure. While a genetic contribution is acknowledged by most authorities, few accept that genes are a sufficient explanation of causation because: onset is in adult life; psychosis – particularly schizophrenia – is associated with a substantial fertility disadvantage; and most cases lack a family history of illness. But genetic determination has to be considered because onset is determined by chronological age rather than environmental insult (Crow & Done, 1986), adoption away from a family with schizophrenia does not reduce risk of illness, and no plausible environmental precipitant of psychosis has been identified. The fact that psychosis occurs across widely differing climatic, industrial, and social environments without obvious variations in incidence suggests that the disease is relatively independent of the external milieu. The suggestion that birth injury is relevant has been tested in a prospective study (the National Child Development Study) and found wanting (Done et al, 1991).

A review of the literature shows that there are strong associations of treated prevalence rates of psychiatric disorder with social class, sex, marital status, ethnic group and living alone; and moderate associations with living in inner-city areas and a high degree of residential mobility. The Jarman-8 index of social deprivation correlates with psychiatric admission rates for patients aged less than 65 years (R2–0.38). Individual census variables can themselves account for up to 0.71 of the variance in the admission rates, while combined in a stepwise multiple regression the census variables will account for over 0.95 of this variation. Multiple regression models using individual census variables and derived indices should be applied next on a wider geographical basis, and to narrower age, sex and diagnosis-specific psychiatric morbidity rates.

An alternative to the conventional separation of extrapyramidal and catatonic symptoms exists in the ‘conflict of paradigms' hypothesis, which proposes that there is a relative rather than absolute distinction between the two. The hypothesis predicts that a clinical association should exist between extrapyramidal and catatonic symptoms in schizophrenia. After rating 75 schizophrenic patients, a highly significant correlation between scores on the two classes of disorder was indeed found. This was composed of separate correlations between tardive dyskinesia and ‘positive’ catatonic phenomena, and Parkinsonism and ‘negative’ catatonic phenomena. The associations were not easily attributable to confounding factors and they were supported by factor analysis.

The effectiveness of day care versus out-patient care in the treatment of persistent severe anxiety and depression was compared in a controlled clinical trial. Of 96 consecutively referred patients meeting the entry criteria, 92 were followed up for six months. Patients were randomised to day care or out-patient care, and assessed at entry and at six months using the Standardised Psychiatric Interview and in terms of their time structuring and socialisation. Marked improvement in all three measures was seen for most of the day patients, but for few of the out-patients: this difference was highly significant for each measure. Day patients also rated themselves as coping more effectively and as more satisfied with their treatment. These differences could not be explained by differences in use of medication. Day treatment should remain an option for patients with persistent anxiety and depression resistant to outpatient treatment.

Pre-morbid schizoid and schizotypal traits and social adjustment were assessed blind to diagnosis by interviewing the mothers of 73 consecutively admitted patients with DSM–III schizophrenia or affective psychosis. Analysis of factors associated with pre-morbid deficits showed a highly significant interaction of diagnosis with sex, such that schizophrenic men showed much greater pre-morbid impairment than either schizophrenic women or men with affective disorder. Poor pre-morbid adjustment predicted an early age at first admission. The results can be explained by a neurodevelopmental disorder in some schizophrenic males.

“Except as occasional consultants, the less men doctors have to do with female lunatics the better”. (Lowe, 1883)

“As long as women are over-represented among mental patients and family caretakers and under-represented among psychiatrists, administrators and politicians, their lives will continue to be unhappily affected by decisions in which they take no part”. (Showalter, 1987)

Variation in their year and month of birth was studied in the 13 661 schizophrenics born between 1914 and 1960 known to the Scottish Psychiatric Case Register. Year-to-year fluctuations in the number of schizophrenics per 10 000 live births were outside chance limits. So were month-to-month fluctuations between January 1932 and December 1960, and this was largely due to fluctuations in the numbers of schizophrenics born in February, March, April and May. Time-lagged correlations with mean monthly temperatures suggest that in these same four months the incidence of schizophrenia is influenced by temperature six months previously – the lower the temperature in the autumn the higher the incidence of schizophrenic births the following spring. If these findings can be confirmed in other data sets, they would suggest that some influence which varies consistently with season and temperature is contributing to the aetiology of schizophrenia and may exert its effects as early as the third or fourth month of foetal development.

Depression in treated samples shows an approximately 2:1 female predominance. The sex ratio is not due simply to more help-seeking behaviour in women, for it applies equally in studies of community prevalence. Differential acknowledgement and direction of distress may be a partial explanation, supported by male predominance of alcoholism and completed suicide, and by a possible recent increase in depression in young men. Biological mechanisms acting through hormonal effects on the brain are plausible, but hard to test. Epidemiological studies indicate that much of the excess occurs in married women aged 25–45 years with children. This strongly suggests social causation and highlights the vulnerable situation of young mothers. The full explanations for the sex difference are not yet clear, but are likely to combine factors related to expression of distress, biology and social situation.

Although it is well recognised that schizophrenic patients are more often born in winter, the significance of this finding remains obscure. Data relating to season of birth and family history were analysed for 561 patients with an ICD–9 diagnosis of schizophrenia. Patients with no family history of any psychiatric disorder group were significantly more likely to be born in winter than patients with a first-degree relative affected by schizophrenia. In comparison with normal population controls, only those without a family history exhibited a significant excess of winter births, suggesting an environmental factor of greater aetiological significance in these patients.

The variety and complexity of schizophrenic movement disorders renders them difficult to assess. In particular, the complex disorders of motility that appear to reflect disturbance of the will demand an evaluation of the purpose of the movement. The difficulties of assessment are compounded by the fact that the antipsychotic drugs used to treat the illness can produce motor disorders that resemble the disorders intrinsic to the illness. In advancing his ‘conflict of paradigms' hypothesis, Rogers (1985) implied that emphasis on the distinction between intrinsic and drug-induced movement disorders might be misplaced because of overlap not only in the observable characteristics of these disorders, but also in the underlying neuropathology.

Genes are now accepted as being important in the aetiology of schizophrenia (Gottesman & Shields, 1982; McGuffin et al, 1987), and over the past decade the emphasis in genetic research has shifted away from genetic epidemiology to searching the chromosomal DNA for the genes themselves. Despite this increasing technical sophistication, the application of linkage analysis to families multiply affected by schizophrenia has been accompanied by the familiar controversy over the exact borders of the adult clinical phenotype (Sherrington et al, 1988; St Clair et al, 1989). Indeed, the preoccupation of researchers with the vagaries of the clinical definition has resulted in repeated attempts to use genetic studies to determine the relative validity of different operational definitions of schizophrenia (McGuffin et al, 1984; Farmer et al, 1987). To us, such studies beg the question of how precisely genes are involved in the aetiology of schizophrenia; after all, genes code for proteins, not for auditory hallucinations in the third person.

In a replication of an earlier published study, case notes of 75 elderly in-patients with bipolar affective disorder were examined. Few of the patients had experienced a manic episode before the age of 40. Mean age of onset of affective disorder was 46 years, and first manic episode at 60 years. Cerebral insults before the first manic attacks were recorded in a substantial number of cases, and a family history of mental illness was less common among this group. Bipolar affective disorder is relatively common as a reason for admission of elderly patients.

Thirty-five people who had suffered a recent onset of symptoms of depression and/or anxiety were interviewed soon after being seen by a clinician, and again six months later. Symptom scores at the second interview were predicted by whether any plans subjects had formed by the first interview had gone wrong, by major non-health difficulties, and by internal, stable and global attributions made at the first interview about the event or difficulty that was most distressing before symptoms became severe.

Two classifications, DSM–III and catego4–derived ICD–8, included in the CIDI, are compared in 63 in-patients and out-patients with a broad range of psychiatric illness. Agreement for main diagnosis between these classifications was statistically significant for two time frames, the present state and lifetime. However, while diagnostic assignment by catego4 remained fairly constant between time frames, there was a marked shift in DSM–III-assigned diagnosis, with cases changing from anxiety state diagnosis (present state) to affective disorder (lifetime). Thirty-nine subjects were assigned a DSM–III diagnosis of affective disorder for lifetime illness compared with 21 assigned to this diagnostic group by catego4.

The reasons for women in Europe and North America being prescribed over twice as many psychotropic drugs as men are complex. Psychiatric disorders such as depression and anxiety appear to be more common in women than in men, and women more commonly complain of psychological symptoms. There may be a gender bias in medical diagnosis and choice of medication. Sociological factors may also be involved, including the likelihood that women have fewer outlets than men for symptom control by activities outside the home (e.g. the social use of alcohol). Women also have special problems including pregnancy, lactation, child rearing and pre-menstrual tension. Probably, much use of psychotropic-drug use for women (and men) is inappropriate and not closely related to the symptoms or conditions for which they are prescribed. Furthermore, the chronic use of some psychotropic drugs, especially benzodiazepines, may compound the problem by inducing dependence and withdrawal symptoms.

Family size, sex of siblings and birth order were examined in 225 bulimic patients of normal weight, all stemming from the same circumscribed catchment area. Although bulimia can occur in any size family, all-female sibships were significantly over-represented. In small families at least, the bulimic patient was highly likely to be the only or eldest daughter. In small sibships, a bulimic who was first-born was significantly more likely to have a younger sister; if second-born she was more likely to have an elder brother. Despite the very large sample size, no final conclusion can be made on birth order.

A battery of neuropsychological tests sensitive to frontal lobe impairment was administered to 43 chronic schizophrenic patients to delineate the abnormality of mental processing associated with the syndromes of psychomotor poverty and disorganisation, which had been identified in a previous study of the segregation of schizophrenic symptoms. Psychomotor poverty was found to be associated with slowness of mental activity, including slowness of generating words. The disorganisation syndrome was associated with impairment in tests in which the subject is required to inhibit an established but inappropriate response.

Among 16 chronic schizophrenic in-patients, all had at least one neurological soft sign (NSS), and 6 (40%) had definite neurodysfunction. NSS and TD scores were highly intercorrelated, and NSS were significantly correlated with neuroleptic drug exposure. NSS correlated positively with both positive and negative symptoms and cognitive impairment but not with cerebral ventricular size on CT. Patients with neurodysfunction had more positive and negative psychopathology, cognitive impairment and TD than those without. Cerebral ventricular sizes and family histories of schizophrenia were similar in both NSS groups. The presence of NSS may be a simple but important way of identifying a subgroup of schizophrenics with neurodevelopmental predisposing abnormalities, and vulnerability to TD.

Acutely ill patients presenting for admission in two district psychiatric services were randomly allocated to day-hospital or in-patient care. In both services a quarter of all admissions could not be allocated because they were too ill (half of these were compulsory admissions); these patients were predominantly manic and schizophrenic patients with pronounced psychotic symptoms and disturbed behaviour. In one service 80% (41/51) of patients randomly allocated to day-hospital treatment were successfully engaged in treatment compared with 54% (19/35) in the other service. This difference arose because only patients with mildly disturbed behaviour could be treated at the second day hospital. For patients who were successfully allocated, the outcome of treatment was similar in terms of psychiatric symptoms and social functioning. The results of a treatment trial for acutely ill patients in one district service cannot be generalised to other district services without due attention to the factors, such as staffing levels, which determine the degree of disturbed behaviour that can be tolerated in the day hospital.