The starting-point for a physiological understanding of the above-mentioned diseases consisted in some new laboratory facts obtained in the course of the study of conditioned reflexes in dogs.

Seventy-nine patients with a diagnosis of hysteria were compared, on a number of variables, with a control group of neurological patients without psychiatric morbidity, and with psychiatric patients free from somatic complaints. Demographic information was obtained, and rating scales for the assessment of personality and mood, were administered, as well as Pilowsky's Illness Behaviour Questionnaire. The data confirm the high incidence of affective disturbance in particular, depression and anxiety in patients with hysteria. There was no link between hysteria and early hospitalisation, although associations were found with sexual disturbances, a past history of vague or undiagnosed illness, affective inhibition, and denial. Relationships between personality and illness behaviour reveal links between personality dimensions and the reporting of illness.

Patients who discontinued lithium after a mean of 29 ± 21 months prophylaxis were compared with a similar group who were not taking the drug; all had only been in hospital once, and satisfied DSM-III criteria for mania. During the first three months following withdrawal of lithium, significantly more patients relapsed than in the control group; after this period, the rate was identical. These findings suggest that lithium withdrawal exists as a clinical phenomenon and that a period of lithium treatment does not improve the long-term prognosis, once the drug has been stopped.

Frequencies of abuse and dependence assessed continuously within a drug surveillance system were analysed as a contribution to risk-benefit evaluations of benzodiazepines (BZDs). In 4.7% of 15 296 patients admitted to psychiatric hospitals between 1980 and 1985, BZDs had been involved in some kind of abuse or dependence. Primary BZD dependence, defined as physical dependence on BZDs in patients who had not been dependent before, was observed in about 1% of admitted patients. Linking these data with psychiatric diagnoses revealed a high risk of primary BZD dependence for inpatients (11.8%) with anxiety neurosis (ICD-9, 300.0), and a lower risk for neurotic (300.4) and for endogenous depressives (296.1) (risk 3.7% and 2.7% respectively). Older age was also related to primary BZD dependence. For depressive inpatients, the risk was twice as high in females as in males. Anecdotal observations advocate more systematic investigation of the emotional effects of long-term therapy with BZDs.

Cognitive-behavioural therapy (CBT) is of proven benefit for treatment of depression and has, over the past 5 years, been increasingly advocated as a treatment modality for schizophrenia. There has been considerable enthusiasm for the use of CBT in schizophrenia from psychiatrists, psychologists, psychiatric nurses and users alike. However, this enthusiasm may have precluded dispassionate evaluation of the effectiveness of this treatment. Even though an intervention is popular and is thought to be generally a ‘good thing’, we should not then take short-cuts through the evidence. In an era of limited resources every hour spent with a patient or training staff in a new technique must be justified. Is CBT really a worthwhile and effective treatment for patients with psychosis? This issue is debated by Dr Douglas Turkington, Senior Lecturer in Psychiatry in Newcastle upon Tyne and author of one of the leading texts on CBT for schizophrenia, and Dr Peter McKenna, consultant psychiatrist with the Cambridge Psychiatric Rehabilitation Service.

The results of a comparative trial of desensitization and psychotherapy for phobias have been reported (Gelder, Marks and Wolff, 1967). Desensitization was found to have a rapid and rather specific effect on phobic symptoms, which was followed by improvement in social adjustment. During group and individual psychotherapy, phobias and other symptoms changed more slowly and social adjustment often improved without any corresponding improvement in phobias. At the end of the investigation the phobias of 14 of the original 26 psychotherapy patients had shown no worthwhile improvement. Six months later, another follow-up showed that 5 had improved further, leaving 9 still unimproved. It was decided to try the effects of desensitization with these patients, particularly in view of a finding by Lazarus (1961) that desensitization helped patients who had not responded to a very brief form of group psychotherapy. As Lazarus worked with volunteer subjects rather than psychiatric patients, and as his “group therapy” averaged only eight weeks, his finding required confirmation before it could be applied to psychiatric patients.

Mental well-being is being used as an outcome measure in mental health services. The recent Chief Medical Officer's (CMO's) report raised questions about mental well-being in people with mental illness, including how to measure it. We discuss whether mental well-being has prognostic significance or other utility in this context.

The hormonal effects of apomorphine, a direct-acting dopamine receptor agonist, in schizophrenic patients are of interest in view of the therapeutic efficacy of dopamine receptor antagonists. In this study, apomorphine (0.75 mg s.c.) and placebo were administered to unmedicated acute and chronic schizophrenics and controls. Apomorphine-induced prolactin suppression did not discriminate between the groups. However, an inverse relationship between basal prolactin levels and the severity of positive symptoms was detected in the patients with acute schizophrenia, consistent with a role for dopamine in the genesis of these symptoms. Growth hormone increments after apomorphine administration were blunted in the chronic schizophrenic patients, particularly those with ‘negative’ symptoms. It is argued that this blunting is not due to previous neuroleptic therapy and may represent evidence of structural change in the hypothalamus in this group of patients.

Ninety-four Canadian-born psychiatric patients who committed suicide were compared with 23 foreign-born patients committing suicide in Canada. East Europeans were over-represented, and significant differences were found in the age distribution, stress, level of education, social isolation, and methods of suicide. Most foreign-born patients had come to Canada for family or economic reasons but were unemployed, with poor social integration. Employment, homing, education, social integration and a support network seem to be important in preventing these deaths. Cultural evaluation of the patient and early intervention is recommended.

Single photon emission computerised tomography (SPECT) was used to measure regional brain uptake of technetium-99m hexamethyl-propyleneamine oxine (Tc99m-HMPAO) in elderly patients with Alzheimer's disease (AD), multi-infarct dementia (MID) and normals (n = 20 in each group). Different patterns of uptake were found between groups when cortical uptake was normalised to cerebellar uptake. Reductions occurred in all regions in AD, being most marked in temporal and posterior parietal areas. Significant correlations were found in AD between memory impairment and decreased temporal uptake bilaterally, and between duration of illness and reduced uptake in most brain regions. MID patients showed higher uptake in the anterior parietal region than did the other groups. A variable comparing anterior to posterior uptake significantly discriminated the two patient groups.

Previously, the addition of lithium to haloperidol has been reported to be of modest benefit to schizoaffective patients. To test this treatment on a different sample, 36 mainly schizophrenic patients were subdivided on the basis of the median of their initial depression score on the BPRS into depressive and non-depressive schizophrenic subjects. Each group randomly received haloperidol plus placebo or haloperidol plus lithium for 8 weeks. The schizophrenic patients who were on the depressive side of the median BPRS depression score were found to be the most resistant to neuroleptic treatment alone, and benefited from the addition of lithium.

The chemical structure of a neuroleptic does not reliably predict the exact profile of its therapeutic action. We considered the question whether the biochemical action of a neuroleptic, and specifically the ratio between DA-receptor block and NA-receptor block, might have a higher predictive value in this respect. In this context we carried out a double-blind study of the therapeutic value of clozapine and perphenazine in acute psychoses of varying symptomatology and aetiology. There are strong indications that clozapine has only a slight inhibitory effect on transmission in central DA-ergic neurons, but markedly inhibits transmission in central NA-ergic neurons, and that the reverse applies to perphenazine. In view of these data we expected perphenazine to be a stronger antipsychotic and a weaker sedative than clozapine, and vice versa. The plausibility of this hypothesis was demonstrated. Partly also on the basis of earlier research, we concluded that the biochemical action of a neuroleptic is a more faithful predictor of its therapeutic action profile than the chemical structure.

Mild learning disability is associated with an increased risk of affective disorder. This study examines the extent to which adult socio-economic disadvantage and ill health contribute to this risk. Samples were drawn from the 1958 National Child Development Study. Relative to a comparison group, mild learning disability at age 11 was associated with elevated rates of depressive symptoms throughout adult life, and carried a six-fold risk of chronic depressed mood. The group difference in depressed mood at age 43 years was in large part mediated by variations in adult socio-economic disadvantage and ill health.

All referrals to medical officers in Brixton Prison over a five-month period in 1989 were examined. This paper reports the progress through this remand prison of those men who were considered to be suffering from a major psychiatric disorder. Many men had been charged with relatively minor offences. The net effect of medical intervention was to delay release from custody. Because of the administrative delays inherent in the system of medical referral and hospital admission under section 37 of the Mental Health Act 1983, it was those prisoners who were most ill who tended to remain in prison for the longest periods. Judged in terms of its efficiency to ensure speedy treatment for mentally ill remanded offenders, the present system is regarded as cumbersome and extremely inefficient. It is suggested that greater use should be made of section 48 of the 1983 Act to divert mentally ill, remanded offenders from prison.