The last 20 years have seen a rapidly growing interest in disorder of brain function in psychiatric illness but this is only the latest phase in a steady development of ideas over the last three centuries. Throughout this time, biological and psychological formulations of psychiatric disorder have co-existed and, at different periods, one or other has been the focus of attention. Thomas Willis, who coined the word ‘neurology’ 300 years ago, felt that psychiatric disorder represented brain disorder, but it was only during the nineteenth century, as understanding of brain function made its first real progress, that this opinion became more explicit and accepted. By the second half of the century, it was axiomatic that psychiatric disorder was synonymous with brain disorder (Griesinger, 1845; Maudsley, 1873; Ferrier, 1878); all that was lacking was the actual neurophysiological basis of mental disorder.

Since the pioneering study of psychiatric morbidity in primary care by Shepherd et al in 1966, it has become increasingly apparent that a substantial proportion (between 20% and 25%) of patients consulting their GP are suffering from some form of psychiatric disturbance (Goldberg & Blackwell, 1970; Hoeper et al, 1979). The composition of this psychiatric morbidity has been shown to be almost wholly affective in nature and largely mild in degree. In their important review Jenkins & Shepherd (1983) recently summarised the now extensive findings relating to overall minor psychiatric morbidity in primary care. However, recent collaborative studies between psychiatrists and GPs have identified that within this dilute pool of minor disorders, lurks a significant but poorly served population of patients suffering from depressive disorders which are by no means minor in degree. A number of crucial issues regarding this depression in primary care emerge which the present paper aims to review. In particular, how common is it, and how severe? How does it present and what, if any, are its special characteristics? What is the precise relationship between depressive symptoms and depressive illness presenting to the GP and what is the relationship between physical illness and depression? And finally, what is the course and outcome of depression in this setting and what are the indications for and effect of treatment?

This paper reviews the literature on the effect of severe mental illness on other members of the patient's family. The burdens of caring for a patient at home are considerable. They often affect the caring relative's social and leisure activities, and financial problems arise frequently. Relatives have difficulties in understanding and coming to terms with illness-related behaviour. ‘Negative’ symptoms are often a particular problem. Despite their burden, relatives do not complain much, although they receive little support, advice or information from the professionals engaged in treating the patient; much is now known about the difficulties relatives face, but we still need to know how they can best be helped. Failure to do this will have bad effects on both relatives and patients.

Although the clinical presentation and course of schizophrenia is highly variable, it is unclear whether this reflects heterogeneity at an aetiological level. The genetic evidence is reviewed concerning ‘traditional’ clinical subtypes as well as more novel categories derived from multivariate statistical methods and Crow's type I-type II classification. Recent data based on a twin series and reanalysis of older published family material suggest that attempts to divide up schizophrenia have resulted in splits between two or more categories of disorder which occupy different positions on the same continuum of liability. Thus, apparent heterogeneity is more likely to be due to quantitative difference in familial-genetic loading rather than qualitative differences. Similarly, the hypothesis that schizophrenia can be broadly divided into two groups, one genetic and the other non-genetic has little to support it. It seems improbable that any further useful and genetically relevant subdivision of schizophrenia can be effected on purely clinical grounds. Further progress awaits developments in the discovery of endophenotypes and the application of molecular genetic marker strategies.

In general, results of epidemiological studies on schizophrenia performed during the last century have the remarkable feature that no significant differences in expectancies and incidences have been found, neither between different populations nor over time. Recently, however, some studies have tended to show a noteworthy decrease in the incidence, as measured by statistics of first admissions. Possible sources of error are discussed, partly on the basis of recent Danish investigations. Although it is uncertain whether a true change in the incidence of schizophrenia has occurred, one feature is becoming evident: under modern treatment and care of-schizophrenics the natural history of the disease is becoming increasingly different between the two sexes. This fact, in combination with one of the hardest facts in schizophrenia research, namely the higher age of onset in females, may be useful starting points for hypotheses on aetiology, or at least necessary components of such hypotheses.

Among the many clinical skills that psychiatrists must acquire, the ability to assess the risk of patients killing themselves is probably the most important and demanding. It is often a crucial factor when making clinical decisions, such as in the choice of treatments, when deciding whether admission to a psychiatric hospital is necessary and when implementing the Mental Health Act. This review first explores the problems in assessing suicide risk. Subsequently, the risks of suicide for patients with major psychiatric disorders and for particular clinical populations, including hospitalised patients and suicide attempters, are examined together with the findings from research investigations which can assist psychiatrists when making decisions about the risk of suicide.

There is growing conviction that childhood autism is a biologically based disorder. The evidence that has accrued in a variety of areas pertaining to biological abnormality in autism suggests that, with the possible exception of genetic factors, very few data are available that illuminate the autistic disorder specifically. Neurological models which might be useful in guiding further research are discussed and reasons for the slow progress in this important aspect of the study of autism are identified.

Because of its rarity, the neuroleptic malignant syndrome has been studied in a survey of the world literature. Similar conditions which occurred before the advent of neuroleptics have also been included, as they may indicate that the drugs are not totally to blame. It is also apparent that with modern treatments, the condition is not usually lethal. The implications of this for theories of dopaminergic disturbances underlying the mental illnesses involved are considered. An overall picture of the syndrome, its treatment and outcome, is presented from over 200 published references. The spread of recognition of the condition throughout the world and especially across linguistic barriers has been followed.

This paper describes the clinical features of selected examples of organic and psychogenic amnesia, and it discusses the nature of the dysfunction that these amnesias entail. The anterograde component of organic amnesia involves a severe impairment in acquiring (or learning) new information, rather than accelerated forgetting, and this may reflect an underlying limbic or neurochemical dysfunction. Retrograde amnesia has a basis which is (at least partially) independent of anterograde amnesia - in some patients, it appears to involve a failure to reconstruct past experience from contextual cues, and this may reflect a superimposed frontal dysfunction. Two types of confabulation are discussed, one of which (‘provoked’) is a normal response to poor memory, and the other ('spontaneous’) appears to reflect incoherent, context-free retrieval, associated with more severe frontal pathology. It is argued that many cases of psychogenic amnesia may resemble organic amnesia, in that they result from an impaired acquisition of information at the time of initial input, perhaps thereby predisposing the subject to subsequent retrieval difficulties.

Event-related potentials during a two-tone discrimination task were recorded in 24 schizophrenic patients, 16 depressed patients and 59 control subjects. Recordings were made when patients were medication-free. Fourteen schizophrenic and 13 depressed patients were retested at 1 and 4 weeks after the start of treatment, and 13 schizophrenic patients were also tested between 6 and 24 months after the initial recordings. In the schizophrenic group, the P3 latency was significantly prolonged compared with that in the control and the depressed groups, and remained unchanged both after 4 weeks treatment with therapeutic doses of neuroleptic drugs and at long-term follow-up. In the depressed group, the P3 latency did not differ from that of controls. P3 amplitude by contrast was reduced in both the acutely depressed and schizophrenic groups and following treatment became normal in the depressed group but remained reduced in the schizophrenic group. It is suggested that a prolonged P3 latency and reduced P3 amplitude indicate an impairment of auditory information processing in some patients with schizophrenia which is independent of the presence of acute psychotic symptoms and is not influenced by neuroleptic medication.

Interviews were conducted with the co-resident supporters of 79 elderly subjects. Forty of these elderly subjects had been diagnosed as being demented (20 mildly, 12 moderately and eight severely) following psychiatric assessment. The supporters were screened for psychological well-being with the 60-item General Health Questionnaire (GHQ) and the Relatives' Stress Scale (RSS). Supporters of demented relatives showed significantly raised levels of stress on the RSS, but no increase in psychiatric morbidity on the GHQ, when compared with the supporters of non-demented relatives. The implications of these findings are discussed.

It is widely believed by psychiatrists that patients who require behavioural psychotherapy need to be referred for such treatment to a specialist in the subject. Two assumptions underlie this idea. One is that behavioural treatment requires a detailed knowledge of learning theory which is possessed by few psychiatrists. The other assumption is that behavioural methods are too time-consuming for a busy psychiatrist in a routine outpatient or primary care clinic.

Over 70 prevalence studies of schizophrenia published since 1948 are reviewed. Despite problems of method, the studies suggest that there may be significant differences in prevalence among different populations and that prevalence may change over time. Further research is needed on how much differences in diagnosis or the course of schizophrenia contribute to the variable prevalence rates. The paper suggests the following as areas for additional enquiry: a possible north-south gradient, special populations (e.g. American Hutterites, northern Swedes, western Irish, castes in India) and ongoing case registers in areas of suspected high and low prevalence.

A new brief questionnaire, the Bulimic Investigatory Test, Edinburgh (BITE), for the detection and description of binge-eating is described. Data from two separate populations demonstrate satisfactory reliability and validity. The scale has measures of both symptoms and severity. All items in the DSM-III definition of bulimia and Russell's definition of bulimia nervosa are covered but the questionnaire is more than just an operationalised checklist of these diagnostic criteria.

In a general practice population, 274 elderly married couples completed the Mental Status Questionnaire (MSQ), the 60-item General Health Questionnaire (GHQ) and the Leeds General Scales for the Self-assessment of Depression and Anxiety. The only relationship detected between cognitive impairment on the MSQ and psychiatric morbidity in the partner was a fairly weak negative correlation between the wives' MSQ and the Leeds Depression score of their husbands. These findings differ from those of previous studies, which have found high rates of psychiatric morbidity in the relatives of demented patients, and the possible reasons for these differences are discussed. Most importantly, other studies have involved the relatives of patients referred to psychiatric services, and these families may be quite different from those in which the demented relative is not referred to a psychiatrist.

Patients with chronic schizophrenia were examined by nuclear magnetic resonance imaging of the brain. Subgroups of the syndrome with high positive or high negative symptom scores and ventricular dilatation were compared with each other and with normal controls in respect of regional spin lattice relaxation time (T1) changes. Significant differences were not observed between the schizophrenic subgroups and controls but there were significant differences between the subgroups themselves. The presence of tardive dyskinesia was associated with increased T1 of the basal ganglia. The significance of these results is discussed in relation to findings using other techniques.

In a prospective study, 100 cancer patients and their relatives were separately interviewed using a structured interview to examine whether the diagnosis of cancer should be communicated to patients and relatives; the reasons for doing so or not, the emotional reactions of patients and families; any change in the attitude of relatives; behaviour of patients and patient's expectation, on diagnosis, of the course of their illness. The majority of patients, who knew their diagnosis (71 %), wanted to be told the truth. The majority of relatives wanted to know the truth themselves (81 %) without the patients being told (77%). Patients did show immediate emotional reactions like anxiety and dejection, however they appeared to accept the diagnosis. Findings suggest that in an Indian setting the attitude of family members is more positive. The role played by sociocultural factors in the acceptance of the truth is discussed.

The characteristics of West Indian patients admitted to a Birmingham hospital following deliberate self-poisoning were compared with those of White self-poisoners. West Indian patients were more likely to be young, female and single. They were less likely to have previously self-poisoned, have received previous psychiatric treatment, or be suffering from a personality disorder or alcoholism, but were more often followed-up by a social worker. Rates of self-poisoning for those aged under 25 were similar but for those aged over 25 were lower for West Indians than Whites.

The case histories of five men who met DSM-lll criteria for bulimia and details of their physical characteristics are given. Various eating disorder questionnaires were administered and the results indicated that most of these instruments would not have identified the men as suffering from an eating disorder. The necessity of caution in asserting the prevalence of bulimia using these measures is emphasised.