The results from a prospective follow-up study of a group of schizophrenic patients suggest that a significant proportion (41 per cent) are likely to relapse during a two-year period despite the prescription of long-acting injectable neuroleptic drugs. Some will relapse because of a failure of the regime, but others (32–37 per cent) because the pharmacological protection of these drugs would appear to be less effective in certain patients. Even with the major advantages of the long-acting injectable neuroleptics over oral medication, the schizophrenic patient population remains a group with a high incidence of psychiatric and social morbidity which continues to require the full resources of both the hospital and community services.

Psychiatry has long identified schizophrenia as its defining disorder, its heartland as it has been called. In the past 20 years, this has had a number of negative consequences for psychiatry as a medical specialty, which result from the uncertainty of diagnosis and an increasing emphasis on demedicalising services in an attempt to provide social care outside hospital. These changes have probably increased the stigma attached to psychiatric practice and threaten to deskill doctors. They have also meant that services for other disorders do not meet the needs of patients. To continue to allow schizophrenia to be the paradigm condition is against the interests of psychiatrists and their patients.

A longitudinal investigation of psychiatric epidemiology in a general population (the Stirling County study) has indicated that the incidence of depression and anxiety disorders is low relative to prevalence, because these disorders have long durations. In an average year approximately nine adults among 1000 experience a first-ever episode of one of these disorders. Incident cases over the course of a 16-year follow-up were more likely to have had premonitory symptoms than to have been asymptomatic at the beginning of the study. Among the relatively small number of people who exhibited the clearest prodromal manifestations, incidence was 20 per 1000 annually. It might be possible to intervene before such disorders become fully formed and persistent if the precursors are given attention.

Behaviour therapy is defined as the application of the principles of modern learning theory to the treatment of neurotic disorders (Eysenck, 1960a, 1963). It defines neurotic “symptoms” as unadaptive conditioned autonomic responses, or the skeletal and muscular activities instrumental in moderating these conditioned autonomic responses. Treatment consists essentially in the extinction of autonomic, skeletal and muscular responses of this type. This extinction may be produced in a great variety of ways, but experience has shown that the most useful and important is probably the method of counterconditioning or “reciprocal inhibition” (Wolpe, 1958). This method takes two forms, according to the nature of the symptom. (1) When the symptom is of a dysthymic character (anxieties, phobias, depression, obsessive-compulsive reactions, etc.) it is assumed that the disorder consists of conditioned sympathetic reactions, and the treatment consists of reconditioning the stimulus (or stimuli) to produce parasympathetic reactions which, being antagonistic to the sympathetic ones, will weaken and finally extinguish them. These disorders we will here call “disorders of the first kind”. (2) When the symptom is of a socially disapproved type in which the conditioned stimulus evokes parasympathetic responses (alcoholism, fetishism, homosexuality), or where there is an entire absence of an appropriate conditioned response (enuresis, psychopathic behaviour), treatment (aversion therapy) consists of the pairing of the stimulus in question with strong aversive stimuli producing sympathetic reactions. These disorders we will call “disorders of the second kind”. (In putting the distinction between these two types of treatment in this very abbreviated form, we have used the terms “sympathetic” and “parasympathetic” in a rather inexact shorthand notation to refer to hedonically positive and negative experiences respectively; the reader familiar with the complexities of autonomic reactions will no doubt be able to translate these blanket statements into more precise language appropriate to each individual case. We have retained this use of the terms here because it aids in the general description given, and indicates the physiological basis assumed to exist for the hedonic reactions.)

The coroner's records of no accidental deaths resulting from poisoning, drowning and falling were examined for evidence of mental illness. Sixty per cent were classified as mentally ill before they died, depression, drug dependence and alcoholism accounting for over three-quarters of the diagnoses. Deaths given accident verdicts should be included in the study of the mortality of the mentally ill.

A group of 33 schizophrenic patients were typed for HLA-SD antigens and their qualitative clinical responses to chlorpromazine therapy determined. A highly significant positive correlation was found between response to chlorpromazine and HLA-A1 positive, while HLA-A2 positive subjects showed a significant negative correlation to chlorpromazine treatment.

In a second group of 17 patients the clinical responses to chlorpromazine were evaluated quantitatively, by WPRS, in HLA-A1 positive and HLA-A1 negative patients. There were no pre-treatment differences in the scores. After treatment the scores of positive patients were significantly lower, indicating that they responded to a greater degree.

Since the frequency of HLA-A1 in hebephrenic patients is higher than that in other schizophrenics this may explain our earlier finding that hebephrenics, as a group, respond better to chlorpromazine than do other schizophrenics.

Ever since Kraepelin introduced his schizophrenic-manic-depressive dichotomy in 1896, this classification of the functional psychoses has enjoyed virtually unanimous acceptance. However, the frequency with which the differentiation of schizophrenia from manic-depressive psychosis seems to present problems in clinical practice inclines one to question whether Kraepelin's classification was entirely adequate. The object of this paper will be to try and highlight some of the reasons for the existing confusion and tentatively to suggest possible means of clarifying the situation.

The question of whether a functional variant in the promoter of the serotonin transporter gene (5-HTTLPR) influences response to adversity and/or antidepressants has generated great interest and controversy. A review of the literature suggests that the issue is complicated by differences in methodology and sample ethnicity. When these confounders are accounted for, there probably is a real, if small, effect of 5-HTTLPR on response to both serotonin reuptake inhibitors and environmental adversity.

The aim of this study was to examine the relationships between side effects occurring in the first two months of treatment with a contraceptive pill and questionnaire-assessed neuroticism. Because the side effects of contraceptive pills are now widely known, doctors' and patients' expectations could be a significant influence in reporting side effects. In order to control for these non-pharmacological variables we therefore designed a double blind trial of a contraceptive and an inert pill involving an intensive study of a small group of patients. It was assumed that neurotic patients were more likely to report side effects, but that if the degree of neuroticism could be controlled, any significant differences in reports of side effects would be due to the active substance.

Lithium is an established treatment for affective disorders with good evidence of antisuicidal properties. Alzheimer's disease rates are relatively reduced in patients with bipolar disorder on lithium and a recent trial of lithium in amnestic minimal cognitive impairment is indicative of potential benefits. This should stimulate further, larger-scale studies.

Although a polydiagnostic approach to the definition of psychotic disorder provides many advantages to the researcher, there are also disadvantages. A comparison between several different sets of operational criteria using the opcrit computer program on a consecutive series of 397 psychotic subjects is described. The results show that although current diagnostic procedures are generally reliable, such approaches can still only supplement skilled clinical judgement, and there remain many pitfalls for the unwary.

In the search for environmental causes of mental disorder, the epidemiologist looks for an association between the disorder and some environmental factor. The significance of such an association can only be determined by a comparison of the patient population with a control population. Ideally, die control population will be the general population from which the patients have been drawn, but because this often presents great technical difficulties an alternative is to compare one diagnostic group with another. Sound conclusions cannot, however, be drawn from such a comparison unless it is known how far the diagnostic groups differ for factors which influence, or are thought likely to influence, the association being studied. Such factors, of which age- and sex-distribution are the most obvious, will often include social and cultural status. Cultural status—at least in so far as this may be equated with religion and country of birth—can be allowed for by confining the comparison to patients of a particular religion and place of birth. As regards social status, it is the patient's background rather than his present condition which seems important; for on the one hand present social status will be varyingly influenced by the type and severity of disorder, and on the other hand a person's general social behaviour and attitude (in as far, at least, as these are associated with the sort of social factors which psychiatrists have commonly studied) are more likely to stem from the type of upbringing he had than from his recent experiences.

The possible psychiatric diagnostic utility of certain quantitative EEG measures was evaluated by further analysis of previously reported data from 242 unmedicated patients and 94 non-patients. Time series of amplitude, frequency and wave symmetry measures for 12-lead EEGs (eyes closed and open) were factor analyzed across leads. Factor scores meeting specified criteria in multivariate analyses were entered into discriminant analyses comparing pairs of the following groups: non-patients, neurotics, personality disorders, overt schizophrenics, latent schizophrenics, major depressives and manics. The following discriminations were obtained with at least 50 per cent sensitivity, and diagnostic confidence rates from 69 to 92 per cent: (a) non-psychotic patients (neuroses, personality disorders) from overt schizophrenics, latent schizophrenics or manics; (b) major depressives from latent schizophrenics or manics; (c) non-patients from schizophrenics (overt and latent), depressives or manics. Most discriminations were replicable in split-half analyses. Possible utility of EEG measures in differential diagnosis is supported.

Are viruses the cause of mental illness, or does stress or mental disorder produce impaired immunity, with increased susceptibility to infection? These two separate but not unrelated questions have been debated periodically and there has been much renewed interest recently, with increased sophistication in immunology and widespread topical concern about immunodeficiency. The neuropsychiatry of the acquired immunodeficiency syndrome (AIDS) (Snider et al, 1983; Carne & Adler, 1986; Wortis, 1986; Burton, 1987; Fenton, 1987) and the validity of a ‘post-viral fatigue syndrome’ as a clinical entity (Behan, 1983; Southern & Oldstone, 1986; Dawson, 1987; David et al, 1988) are not discussed here, but have been dealt with in the editorials and reviews cited.

Tourette syndrome is a disorder of chronic multiple motor and vocal tics with an age of onset between 2 and 15 years. Clicks, grunts, barks, coughs and yelps are common vocal manifestations, while coprolalia eventually occurs in 60 per cent of cases (Shapiro et al, 1978). Nine years or more (Bruun and Shapiro, 1972) may pass between the onset of the disorder and its diagnosis. Although mental and mood changes are not an intrinsic part of the syndrome, suicide may occur secondary to the profound social disruption produced by the disorder.

Are research interview techniques adequate in assessing signs and symptoms? This question is investigated by obtaining two sets of interview schedule ratings on 49 patients, one by a research psychiatrist applying the interview and one by the patient's psychiatrist using all available information. The latter was considered a clinical standard with which a cross-sectional research interview could be contrasted.

These two data sets were subjected to several types of analysis commonly undertaken with research interview ratings. Results indicated that the research interview adequately represents symptom data, but is seriously lacking in the assessment of observed behaviour. The effect of this difference depends on the goals of the study and the nature of the data analysis. If overall group findings are desired, or if analysis relies primarily on symptom data, results with a research interview may be similar to results based on a far more extensive evaluation. On the other hand, if conclusions are to be drawn on individual patients, or if data analysis relies heavily on observed behaviour, then data derived from research interviews are questionable.