We consider how far it is possible to predict a chronic course of a depressive disorder from psychosocial and clinical material available at the point of onset.

A population survey found 404 working-class mothers living in an inner-city area of London. The majority were interviewed three times over a 3-year period.

Chronicity (more than 12 months' duration) was strongly related to both childhood adversity (parental indifference, family violence or any sexual abuse) and current adult interpersonal difficulties. The lack of positive events during the course of the episode was also independently related to chronicity, but to a lesser degree. Clinical characteristics were relatively unimportant compared with psychosocial factors.

The childhood risk factors were particularly important (judged by a path analysis), and a challenge for future research will be to establish the intervening processes involved with this distal link.

We consider how well the psychosocial and clinical factors found to predict a chronic course for depressive episodes in the community, held for female psychiatric patients.

A consecutive series of depressed patients, aged 18 to 60, treated as in-patients, out-patients or day-patients at psychiatric departments of two London hospitals, were interviewed initially and at follow-up two years later.

Indices of childhood adversity and current interpersonal difficulties predicted episodes taking a chronic course (of more than 12 months' duration). Half of the episodes associated with one or the other factor were chronic, compared with 22% of those with neither. The patients were at higher risk than the community series (75% v. 34%) and this explains their much greater rate of chronicity. There was also some evidence that social support reduced risk. Clinical features and the presence of a personality disorder were unrelated to chronicity.

Similar psychosocial factors are important for predicting chronicity in both community and patient series.

Although a genetic component in schizophrenia is well established, it is likely that the contribution of genetic factors is not constant for all cases. Several recent studies have found that the relatives of female or early onset schizophrenic patients have an increased risk of schizophrenia, compared to relatives of male or late onset cases. These hypotheses are tested in the current study.

A family study design was employed; the probands were 195 patients with functional psychosis admitted to three south London hospitals, diagnosed using Research Diagnostic Criteria (RDC), and assessed using the Present State Examination (PSE). Information on their relatives was obtained by personal interview of the mother of the proband, and from medical records. Psychiatric diagnoses were made using Family History – Research Diagnostic Criteria (FH-RDC), blind to proband information.

There was a tendency for homotypia in the form of psychosis within families. The lifetime risk of schizophrenia in the first degree relatives of schizophrenic probands, and the risk of bipolar disorder in the first degree relatives of bipolar probands, were 5–10 times higher than reported population risks. Relatives of female and early onset (<22 years) schizophrenic probands had higher risk of schizophrenia than relatives of male and late onset schizophrenic probands. However, this effect was compensated in part by an excess of non-schizophrenic psychoses in the relatives of male probands.

These results suggest a high familial, possibly genetic, loading in female and early onset schizophrenia, but do not resolve the question of heterogeneity within schizophrenia.

Late paraphrenia is recognised as a heterogeneous disorder. This is reflected by the division of such patients into schizophrenia and delusional disorder in ICD-10. Earlier imaging studies have suggested that major structural abnormalities may be associated with the onset of psychosis in later life.

Fifty late paraphrenics and 35 age-matched healthy controls underwent structural magnetic resonance imaging of the whole brain in the coronal plane. Measurements were made of intracranial and brain volumes and the volumes of the intracerebral and extracerebral cerebrospinal fluid spaces.

No differences in intracranial, brain or extracerebral cerebrospinal fluid volumes between patients and controls were found. Late paraphrenic patients had greater lateral and third ventricle volumes than controls and the left lateral ventricle was larger than the right. When the patients were divided into appropriate ICD-10 diagnoses: paranoid schizophrenia (n = 31) and delusional disorder (n = 16), lateral ventricle volumes in the delusional disorder patients were much greater than those of the schizophrenics and almost twice those of controls.

Structural brain differences underly diagnostic heterogeneity within late paraphrenia. The brains of late onset schizophrenics are only subtly different from those of healthy elderly individuals.

Recent post-mortem and magnetic resonance imaging (MRI) studies strongly suggest a decrease in the volume of the hippocampus and other limbic temporal structures in schizophrenia. Therefore, we hypothesised that N-acetyl aspartate (NAA) which is found mainly in neurons and which can be measured by proton magnetic resonance spectroscopy (1H MRS) would be decreased in the limbic temporal region in schizophrenia.

Consenting subjects fulfilling DSM-III-R criteria for schizophrenia (n = 11) and matched healthy volunteers (n = 11) who were recruited in a tertiary university referral centre, participated in a 1H MRS brain study. Proton MRS spectra were obtained from a 12 cm3 voxel (2 × 2 × 3 cm) in the right and left hippocampus/amygdala region. A researcher blind to the source of the spectra, measured the NAA intensity in all subjects, which were then statistically compared across the two groups.

NAA intensities were significantly reduced in the right hippocampus/amygdala region of schizophrenic patients (P = 0.038). The difference of the left side did not reach significance at the 95% confidence level.

The findings of decreased NAA in this study suggest that there may be a decrement in neuronal number or tissue volume of the right hippocampal/amygdala region in schizophrenia. Biochemical alterations in the metabolism of NAA in schizophrenia may be an alternative explanation. The findings are consistent with other types of post-mortem and in vivo evidence for hypoplasia of the limbic temporal structures in schizophrenia, postulated to be of neurodevelopmental pathogenesis.

Many studies of community care show little overall improvement in patient functioning. This study investigated whether cognitive impairment mediates the effect of the increased opportunities offered by the community.

Behaviour, symptoms, sociodemographic variables and information processing of a random sample of chronic psychiatric patients were examined. Six years later, social and behavioural outcomes were measured.

The overall change in the group was negligible. Individual variation can be accounted for by two factors: time since transfer to the community, and initial information processing problems. Patients transferred for at least three years showed significant improvements. Schizophrenic patients without information processing problems improved, but those with deficits got worse.

The identification of mediating factors should allow better rehabilitation plans, and alleviate the toxic effects that transfer has on some patients' functioning.

This exploratory study compares the prevalence of personality disorders and traits in people over and under 55 years of age. The comorbidity between personality and other psychiatric disorders is also examined.

Psychiatrists examined 810 subjects in a two-stage community survey. The semi-structured Standardized Psychiatric Examination was used to diagnose all DSM-III personality disorders and other psychiatric disorders.

The older subjects were significantly less likely than the younger subjects to have any personality disorder (6.6% v. 10.5%; relative odds = 0.42, 95% confidence interval = 0.25–0.70, P<0.001). Antisocial and histrionic personality disorders were much less prevalent in the older than younger subjects (P < 0.05). The older subjects also had significantly fewer maladaptive personality traits (x2 = 88.9, d.f. = 3, P < 0.001). The patterns of comorbidity between personality disorders and other psychiatric disorders were different in the two age groups.

It is important to evaluate personality in patients of all ages. While some older patients no longer meet criteria for personality disorder, maladaptive traits may become evident during times of stress.

The study tested specific hypotheses that (a) there is an increased incidence of psychiatric disorders in asymptomatic heterozygotes for Huntington's disease (HD) compared with the normal homozygotes, and (b) there is an increased incidence of psychiatric disorders in the adult offspring of Huntington's disease patients compared with their partners.

A controlled study was made of 93 apparently healthy individuals (at 50% risk), who had given DNA samples for the predictive test, and 70 of their partners. Current and past psychopathology was assessed and compared with the DNA predictive test results based on linkage analyses. The results of psychiatric assessments of the two groups were compared.

DNA test results were available for 53 subjects (of 93). Five subjects at risk for HD were omitted from the study. The asymptomatic heterozygotes (n = 20) showed no significant increase in the incidence of any psychiatric episode, depression, schizophrenia or behavioural disorder when compared with the normal homozygotes (n = 33). The whole tested group showed a significantly greater number of psychiatric episodes than their partners (n = 43).

Asymptomatic HD gene carriers do not have a greater incidence of psychiatric disorders than the non-gene carriers born to a HD parent.

The induction agent propofol is known to reduce electroconvulsive therapy (ECT) seizure duration. It is assumed that outcome from depression is adversely affected by this agent. This study compares propofol and methohexitone as induction agents for ECT.

In a prospective, randomised, double-blind study 20 subjects with major depressive disorder (DSM-III-R criteria) received propofol or methohexitone anaesthesia. The Hamilton Depression Rating Scale and Beck Depression Inventory were used to assess depression before therapy, at every third treatment, and at the end of therapy. Seizure duration was measured using the cuff technique.

Mean seizure durations (P < 0.01) and mean total seizure duration (P < 0.01) were shorter in the propofol group. There was no difference in outcome.

Use of propofol may not adversely affect outcome from depression and it is not necessarily contraindicated as an induction agent for ECT. Our results should be interpreted cautiously, and larger studies are needed.

Following reports of recent increases in adult male suicides in England and Wales, suicide rates for children and adolescents are reviewed.

By using estimated mid-year populations for five-year age bands, the suicide rates for 10–14 year-olds and 15–19 year-olds are calculated between 1960–1990. The same method is used to obtain rates for ‘undetermined’ death and ‘accidental’ death by causes comparable to suicide.

The only group to show an increase in suicide rate since the 1970s has been males aged 15–19 years. This increase persists even when ‘undetermined’ and ‘accidental’ death rates for causes similar to suicide are examined. The increase is associated with an increase in hanging and self-poisoning with vehicle exhaust gas.

The increase in suicide rate in 15–19 year-old males may indicate increased psychosocial stress, particularly affecting this age/gender group.

The aim was to investigate the effect of tiapride (100 mg three times a day for at least one month) on outcome following detoxification.

The setting was a tertiary referral centre. The study design was randomised, double-blind, and placebo-controlled. One hundred routinely admitted alcohol-dependent patients were entered, and 54 completed the trial. Outcome was assessed by considering drinking status at three months and six months follow-up, and by comparing psychological status at intake and follow-up using the Crown-Crisp Experiential Index, the Litman Self-esteem scale and a Satisfaction with Life Situations scale. We also compared performance over the six months before admission with the three and six months of follow-up on measures of health, social and drinking variables.

Tiapride proved better (usually at statistically highly significant levels) than placebo at promoting: abstinence, self-esteem, and satisfaction with life situations; and at reducing: alcohol consumption, use of health service resources, and levels of neuroticism.

Tiapride merits serious consideration in the longer-term treatment of alcoholic patients.

An epidemiological survey was made of war trauma and its consequences in the general population.

One member aged over 15 years from each of 101 randomly selected families in a Primary Health Area in Sri Lanka were interviewed using the Stress Impact Questionnaire.

Nearly one-half had experienced between five and nine war stresses, and one-quarter experienced over 10 (mean 6.66). Only 6% had not experienced any. Sixty-four per cent had developed psychosocial sequelae, including somatisation (41 %), post-traumatic stress disorder (27%), anxiety disorder (26%), major depression (25%), hostility (19%), relationship problems (13%), alcohol and drug misuse (15%) and functional disability (18%).

The trauma experienced correlated strongly with psychosocial and somatic symptoms.

The proportion of children with psychiatric disorders treated in primary care is not known in most developing countries.

In a two-stage epidemiological study, 990 children aged between 7 and 14 years were screened with the parents' version of the Rutter scale. Of these, a stratified sample of 227 was interviewed jointly with their mothers, using the children's version of the Schedule for Affective Disorders and Schizophrenia (K-SADS).

We obtained a weighted prevalence of 19.6 ± 2.5% for the presence of one or more DSM-III-R disorders. Depressive disorders were present in 6.0%, anxiety-related disorders in 4.7%, and conduct disorders in 6.1%.

Psychiatric disorders in children are common in primary care. Doctors working at this level of care need the skills to detect and treat them.

The aims were to determine the prevalence of psychiatric morbidity among primary care attenders in a poor suburb of Santiago and to study the relationship with health service use.

A cross-sectional survey was made of 163 consecutive attenders to a primary care clinic.

Eleven per cent of the sample gave a psychological reason for consultation and the prevalence of psychiatric morbidity was 53%, defined using the revised Clinical Interview Schedule. Women and those of lower socio-economic status were at higher risk. Physicians recognised 14% of the psychiatric morbidity. Attenders with psychiatric morbidity consulted more frequently.

There is a need to improve the recognition and management of psychiatric morbidity in primary care in Chile and other less developed countries. This could lead to the more efficient use of scarce health care resources in primary care.

We investigated the prevalence of depression among 255 elderly general practice patients and the practitioners' performance in identifying depression.

Elderly patients attending 14 general practices entered a screening phase with GHQ-12 and MMSE. Those positive were then interviewed with GMS and HAS.

DSM-III-R major depression affected 22.4%, dysthymic disorder 6.3%, not otherwise specified (n.o.s.) depression 7.1 %. General practitioners performed fairly well: identification index 88.4%, accuracy 0.49, bias 1.85.

Depression was markedly high. A selective progression of depressed elderly from the community to general practitioners is implied.

The roofless have not been previously surveyed in detail looking specifically at their psychiatric status.

All roofless people in a discrete area were interviewed in their ‘skippers’ using a semi-structured interview. Other roofless people helped in case finding and diagnostic validity was confirmed using a computerised case register.

Sixty-five people were interviewed. High rates of substance abuse (n = 48, 75%), and very low rates of psychotic illness (n = 2, 3%) were found. High rates of serious physical morbidity, of imprisonment and of being the victim of a crime were found.

The roofless have multiple severe medical, social, and psychiatric problems. These all must be addressed when considering the provision of services.