Several case reports in the literature suggest that selective serotonin reuptake inhibitors can produce extrapyramidal symptoms.

Computerised literature searches were used to identify reports on extrapyramidal symptoms and serotonin reuptake inhibitors. Subsequently, manual searches were made for articles in which there was any indication of the mechanisms responsible for these extrapyramidal symptoms.

Only a few reports could be identified in which serotonin reuptake inhibitors were implicated in extrapyramidal symptoms in some patients.

Evidence is discussed from preclinical and clinical studies suggesting the interaction between serotoninergic and dopaminergic neurotransmitter system, as a possible mechanism for production of extrapyramidal symptoms.

There is pressure on acute admission services in inner-city areas. Two deprived London districts with markedly different acute bed ratios but similar sociodemographic backgrounds were compared to test the hypothesis that more facilities mean better service.

An instrument for auditing the use of short-stay hospital beds was constructed to collect information concerning admissions to, and short-stay patients in, the chosen districts during a three-month period.

There was a higher admission rate and substantially greater use of beds per unit population in south Southwark than in Hammersmith & Fulham. Much of the difference was attributable to a higher rate of admission of patients with affective disorders in south Southwark.

The results are not explained by variations in population need, longer in-patient stay, or poorer aftercare leading to early relapse. The question of whether there is over-provision of services compared with real need in south Southwark, or under-provision (particularly for people with affective disorders) in Hammersmith & Fulham, is considered but left open for discussion following a study of ethnic issues and the reasons for admission.

Twenty-six per cent of patients in two Inner London districts were admitted to acute wards under the provisions of the Mental Health Act. Compared with those not under compulsion, they were young, male, more likely to be of black Caribbean origin, and to have a diagnosis of schizophrenia of short duration. The hypothesis is tested that ethnicity determines rates of compulsory admission independently of the other factors.

Sampling and data collection methods were described in the first paper. Statistical analyses included a log-linear analysis of six key variables: compulsory admission, challenging behaviour, diagnosis, ethnicity, age, and sex.

There were no substantial differences between districts. Analysis provided two similar statistical models. In both, admission under the Act was strongly associated with challenging behaviour and diagnosis of schizophrenia. In the model of best fit there was no significant interaction term for ethnicity and compulsion. In the second model there was a weak association.

Ethnicity did not appear to be of outstanding importance in decisions to use the Mental Health Act. There was a strong link between ethnicity and diagnosis, independent of compulsion. Differences between the districts made no major contribution to the rates of compulsory admission.

In this series, rates of admission and daily bed use in south Southwark were 30% higher than in Hammersmith & Fulham, principally because of a higher rate of admission for affective disorders. Factors associated with compulsory admission did not differ between the districts. This final paper examines the severity of symptoms, the reasons given for admission and factors relevant to the judgement to admit, in order to test the hypothesis that more resources mean better service.

Sampling and data collection methods were described in the first paper.

In both districts, major reasons for admission were self-neglect and risk of self-harm, poor adaptive functioning, and poor acceptance of medication. In south Southwark, a group of patients had affective disorders and less severe symptoms but a stated risk of suicide. Rates for, and severity of, schizophrenia were similar in the two districts. Social and preventive reasons for admission were given more frequently in south Southwark, where patients had more often been in contact with services before admission. Staff there, but not in Hammersmith & Fulham, suggested that many could have benefited from alternative forms of residential care.

A ‘buffer’ of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.

This study was undertaken to fill gaps in our knowledge of the rate of mood disorder in teenage girls in transition from school to further education, employment or unemployment.

Girls aged 15–20 years (n = 529) whose names were drawn from general practitioner age/sex registers were interviewed at home and completed the Great Ormond Street Mood Questionnaire. Their mothers completed the 28-item General Health Questionnaire (GHQ). Social background variables were obtained.

Of the girls, 20.8% scored over the cut-off point previously established to indicate risk of psychiatric disorder. Scoring over the cut-off point was not associated with age or parental social class. It was associated with parental separation/divorce (P < 0.004), with maternal self-report on the GHQ (P < 0.001), and with parental unemployment (P < 0.04). Lowest self-report scores were obtained by girls who had left school and were in employment (P < 0.01).

About one in five of girls aged 15–20 are at risk of affective disorder. Self-reported mood disturbance is associated with a wide range of social and familial background variables, but not with age or parental socioeconomic status.

This study investigated the prevalence and background variables associated with anxiety and depressive disorders occurring in a community population of older teenage girls.

Girls aged 15–20 years (n = 529) whose names were drawn from general practitioner age/sex registers completed self-report Great Ormond Street Mood Questionnaires. From this sample, 143 girls (69 with high self-report scores and 74 controls) were intensively interviewed. Information was obtained on confiding/supportive relationships, family arguments and rows, quality of marital relationship, and degree of parental control. Psychiatric state was assessed by use of the Clinical Interview Schedule to provide a Total Weighted Score. A modified form of the Bedford Life Events and Difficulties Schedule was applied.

The estimated one-year prevalence rate for psychiatric disorder was 18.9%, and 16.9% for depression and anxiety disorders. Using a logit analysis, it was shown that maternal distress (P < 0.02) and the quality of the mother's marriage (P < 0.02) were independently associated with the presence of depression and anxiety disorders.

About 17% of girls in a community sample living at home showed a depression or anxiety disorder. Even in late adolescence, the presence of a mood disorder is closely linked to the quality of family relationships within the home.

An investigation to determine which prognostic variables are associated with behavioural treatment failure in obsessive-compulsive disorder (OCD). Empirically established prognostic variables measured at the start of treatment may lead to adjusted treatment programmes for these patients.

Forty patients, diagnosed with OCD, received a standardised treatment consisting of 18 sessions in vivo exposure and response prevention. Compulsive behaviour (MOCI) and obsessive fear (ADS) were the outcome measures. Prognostic variables included were initial severity of OC complaints, initial level of depression, problem duration, patients' motivation for treatment, quality of the therapeutic relationship, and marital dissatisfaction.

Greater initial severity of complaints (P < 0.01), and depression (P = O.03) predicted poorer outcome for compulsive behaviour. Greater initial severity of complaints (P < 0.01), and the conjoint variables higher level of depression, longer problem duration, poorer motivation for treatment, and dissatisfaction with the therapeutic relationship predicted poorer outcome for obsessive fear (P < 0.01).

The complaint-related variables of initial severity, initial depression, and problem duration, and the non-specific treatment variables of patients' motivation and quality of the therapeutic relationship, affect behavioural treatment outcome in OCD.

The relationship between antipsychotic drug treatment and sudden unexplained death remains unclear. The estimation of post-mortem blood drug concentrations should be helpful.

Eight medico-legal cases were reviewed with respect to behaviour of patient, type and dosage of drug treatment, mode of death, post-mortem findings and drug concentrations.

The problems of evaluating such drug levels are discussed. Five of the eight patients had probably toxic concentrations of antipsychotic and/or antidepressants, which caused death, usually involving cardiac arrhythmias.

In cases of sudden unexpected death, a sample of blood from a peripheral vein should be obtained immediately death is pronounced or the body discovered, and sent for analysis. To minimise such fatalities, the patient should be monitored carefully, with ECG if feasible, and electrolyte balance checked. The drug regimen used should be kept simple and large doses of antipsychotics and/or antidepressants avoided wherever possible.

Most studies of chronic benzodiazepine users consider selected populations which may be unrepresentative. This study was undertaken to examine possible differences between groups.

Subjects chosen were benzodiazepine users in general practice, a hospital clinic, and attending TRANX trials. Descriptive data were collected on characteristics and outcome.

RANX trial patients had the best outcome (P = 0.027). Hospital cases used high doses of anxiolytic benzodiazepines; concomitant mental disorder, including schizophrenia, was common. General practice cases were older and mainly used hypnotics (P < 0.05).

Because groups of benzodiazepine users are different, there cannot be one single management approach. Cases require individual medical assessment.

One of the most important outcomes following an episode of non-fatal deliberate self-poisoning is its repetition.

In a prospective follow-up study the subjects were 992 people responsible for 1096 consecutive episodes of deliberate self-poisoning recorded at a teaching hospital accident and emergency department. Risk factors examined were socio–demographic variables, psychiatric and self-harm history, aspects of the self-poisoning episode, and appearance and behaviour at accident and emergency; the frequency of each was compared between those patients who repeated within one year (n= 116) and those who did not (n = 876).

Those who repeated were more likely to have ingested more than one drug, to report a previous episode of self-poisoning, to be aged 25–54, and to have experienced previous psychiatric care or psychiatric admission. They were less likely to be in paid employment, or to have expressed a threat to another person or written a note. The best predictor – previous psychiatric contact – only had a positive predictive value of 21 % (95% confidence interval 16–25%).

Risk factors for repetition of self-poisoning should be kept up-to-date despite modest predictive power. More attention might be paid to clinical rather than socio–demographic aspects of self-harm.

A multi-dimensional approach was used to examine coping in chronic pain. The following hypotheses were tested: (a) patients who cope maladaptively also cope generally in a similar way; (b) patients' maladaptive coping is associated with childhood adversity.

Cross-sectional and retrospective data were collected from 68 consecutive patients (aged 18–70) at a pain clinic where their disease was non-systemic and the pain had lasted for at least three months. Sixty-one patients were interviewed using the Structured Clinical Interview for DSM–III–R, and the Measure of Parental Care in Childhood. All patients completed questionnaires on their pain and personality.

Two coping styles emerged from factor analysis. One was associated with chronicity, psychiatric morbidity, harm avoidance, immature defence style and reporting parental indifference.

Patients may be predisposed to cope maladaptively after the experience of parental indifference in early life. Such coping is likely to reflect more general patterns.

Autoscopy is defined here as a visual experience where the subject sees an image of him/herself in external space, viewed from within his/her own physical body. This paper reviews the literature both historically and conceptually, and includes a quantitative study of accumulated cases.

Cases published since 1935 and meeting the above definition for autoscopy (n = 53) were included, together with three personally-observed patients. A clinical protocol was completed for each case, including information about the autoscopic image. Cases were compared using non-parametric statistics on dichotomised variables.

There were 38 men and 18 women, with a mean age of 39.5 years (range 13–78). Of the subjects, 33 (59%) had a neurological illness, most frequently epilepsy (18 cases). Right and left sided lesions were equally represented. Psychiatric disorder was often present (33 cases, 59%), most commonly delirium, depression or psychosis. The features of the images seen were diverse, but speaking images were associated with younger age, male sex, psychotic illness, longer duration of image, and hypnagogic/hypnopompic experiences.

Autoscopy may arise from a convergence of several variables, including gender, personality factors, neurological and/or psychiatric disease, exhaustion and dissociation, whose interaction may override the normal inhibition of temporal lobe activity. A cognitive neuropsychological hypothesis is proposed, together with avenues for future research.

This study investigates whether anomalies in the sign language of prelingually deaf schizophrenics can be elicited and described systematically.

Thirty schizophrenic and seven manic adults were recruited on the basis of a British Sign Language (BSL) version of the Present State Examination. Thirty-seven controls were matched for sex, age and ethnicity. Each participant became deaf before the age of two, and uses BSL as the primary means of communication.

Analysis reveals: (a) anomalies which are similar to those occurring in the spoken language of hearing schizophrenics; and (b) another series which is closely related to the life experience of deaf subjects and to the visuo-spatial medium itself.

There is evidence that formal communication disorder does occur in sign language. This has implications for more efficient diagnosis and management of deaf persons presenting to psychiatric services, as well as for the mechanisms of schizophrenic symptomatology itself.

This is an exploratory study of readmission in mood disorder.

The study is naturalistic and employs survival analysis. We identified 821 individuals with ICD–9 diagnoses, drawn from the Tasmanian Mental Health Register.

No demographic variables influence the time to readmission. Two groups emerge: those with affective psychoses, and those with neurotic depression, brief depressive reaction and depressive disorders not elsewhere classified. The former group demonstrated shorter times to readmission than the latter. There was no support for a unipolar–bipolar distinction.

Affective psychoses have a less favourable outcome than expected. There was support for an endogenous-neurotic distinction.

The efficacy of depot antipsychotic drugs in the prophylaxis of bipolar affective disorder was investigated.

Life charts were constructed for 18 outpatients with bipolar disorder receiving prophylactic treatment with depot medication. The durations of affective episodes were compared during periods on or off medication.

The subjects suffered fewer relapses and spent significantly less time in hospital (P = 0.001) for treatment of manic, depressive and mixed affective illness during treatment with depot antipsychotics.

Depot antipsychotic medication may be a useful prophylactic treatment for certain patients with bipolar affective disorder.

British Journal of Psychiatry (1994), 165, 827–829

This study assessed the long-term effects of family intervention on schizophrenic relapse.

Forty schizophrenic patients who had participated in a family intervention trial and who had not experienced relapse at two years after discharge from the index admission were traced through case notes and hospital records. The percentage of patients experiencing a relapse was estimated for patients in the family intervention group, the high-EE control group, and the low-EE control group, at five years and eight years after discharge.

There were significantly fewer relapses in the family intervention group than in the high-EE control group at both five years and eight years. The number of relapses in the low-EE control group was lower than in the high-EE control group, but this just failed to reach significance.

The benefit of family intervention and the predictive power of EE are sustained over eight years. Expressed emotion (EE) has remained a remarkably robust predictor of relapse in schizophrenia. Kavanagh (1992) cited 20 out of 23 prospective studies that showed patients who returned to live with high-EE relatives had higher relapse rates over 9–12 months after discharge than did patients returning to live with low-EE relatives. Seventeen of these studies reported this difference to be significant.

British Journal of Psychiatry (1994), 165, 829–832