The current economic recession in Europe and North America has led to a renewal of interest in the possible consequences of mass unemployment for the nation's health. This annotation assesses the relationship between unemployment and one indicator of morbidity: parasuicide (non-fatal deliberate self-harm). A previously published review of the literature is supplemented by more recent research, particularly from Edinburgh and Oxford.

Definite conclusions about the origin of schizophrenia concerning hereditary as well as psychosocial factors can be obtained when different forms of schizophrenia are investigated separately.

Deinstitutionalisation is a two-part process: the first involves discharging patients from hospital to the community, which has been done in many countries. The second part—the provision of adequate resources for good community care—has still to materialise almost everywhere. In New South Wales, the inpatient mental hospital population dropped by two-thirds in 20 years, yet the total number of hospital staff increased considerably during this time; on the other hand, in the community, where most of the patients are, there are relatively few staff. This has important consequences: it means that for many patients, their episode of illness has to progress unchecked until it is of sufficient severity for them to be admitted to hospital. When that happens, there will then be enough staff to give them good quality care, so that their symptoms can subside, but afterwards there will again be hardly anyone available to help maintain them and to prevent relapse.

Cross-cultural studies on immigrants from Pakistan and the New Commonwealth are reviewed, with emphasis on epidemiology and differences in clinical presentation. Their referral to the psychiatric service is also examined and deficiencies are noted. Awareness of transcultural issues among health professionals need to be increased in order to achieve diagnosis and improvements in health care.

The reduction of mental hospital populations in Britain and the United States has generated a considerable amount of literature on policy, but detailed studies of the effects on patients and the conditions under which they live after discharge are rare. In the United States, a National Institute of Mental Health review of the literature commented that “the question of what actually happens to patients who leave mental hospitals and re-enter the community is largely unanswered” (Bachrach, 1976).

Adolf Meyer was famous when 1 first met him in 1933. I was at that time a psychiatric resident at Bellevue Hospital, and Meyer was Psychiatrist-in Chief at Johns Hopkins Hospital. He had been asked by the sponsors of a fellowship I was given to act as guide and supervisor, and had agreed. I met and corresponded with him throughout the tenure of that fellowship, to 1940, spending a year in his department in Baltimore in 1938–1939, and saw him irregularly thereafter.

Belief in witchcraft, which serves a variety of social functions and personal defences, is bound to emerge in psychotherapy with individuals from a culture that holds such beliefs; endeavouring to understand it can open up new therapeutic possibilities. The nature of witchcraft, the profiles with which it intrudes into therapy, and the socio-psychological functions it fulfills are considered. Referring such patients to witchdoctors is morally unjustifiable, but the witch-doctor's folk-image provides a floating transference, around which the therapeutic relationship can be built. In dealing with witchcraft-ideation, understanding is based as much on cultural as on personal empathy, and to enhance its relevance, therapy may appropriate some of the functional dynamics of the witchcraft system into its own therapeutic manoeuvres.

From protozoa to mammals, organisms have been selectively bred for genetic differences in defensive behaviour which are accompanied by differences in brain and other biological functions. Studies of twins indicate some genetic control of normal human fear from infancy onwards, of anxiety as a symptom and as a syndrome, and of phobic and obsessive- compulsive phenomena. Anxiety disorders are more common among the relatives of affected probands than of controls, especially among female and first-degree relatives; alcoholism and secondary depression may also be over-represented. Familial influences have been found for panic disorder, agoraphobia, and obsessive-compulsive problems. Panic disorder in depressed probands increases the risk to their relatives of phobia as well as of panic disorder, major depression, and alcoholism. The strongest family history of all anxiety disorders is seen in blood-injury phobia; even though it can be successfully treated by exposure, its roots may lie in a genetically determined specific autonomic susceptibility. Some genetic effects can be modified by environmental means.

Updated guidelines are presented for the safe and effective use of lithium; covering indications, treatment management, duration of prophylactic treatment, side-effects and their prevention, overdosage, interactions, and contraindications. Alternatives to lithium and patient-doctor co-operation are discussed.

The nature of the relationship between anxiety and depression has been much debated. The research in the past 15 years is reviewed in the context of three conceptual models: (a) anxiety and depression differ quantitatively; (b) anxiety and depression differ qualitatively; and (c) combined anxiety and depression syndromes (anxious depressions) differ both quantitatively and qualitatively from either pure anxiety or pure depression. The major areas of research—phenomenological, treatment, course and outcome—are considered and findings in support of each position reviewed.

The dexamethasone suppression test was administered to 12 mentally handicapped depressed patients. One of the four patients with major depressive disorder, but none of those with other diagnoses, failed to suppress Cortisol production. The International Classification of Diseases and the Newcastle Diagnostic Index were found to be unreliable for use with severely mentally handicapped patients. Modifications are proposed which would allow the Research Diagnostic Criteria and Hamilton Rating Scale for Depression to be applied to patients with any degree of mental handicap.

Subcortical dementia refers to a clinical syndrome characterised by slowing of cognition, memory disturbances, difficulty with complex intellectual tasks such as strategy generation and problem solving, visuospatial abnormalities, and disturbances of mood and affect. The syndrome was first described by Kinnier Wilson, but further progress in development of the concept has occurred only within the past ten years. Subcortical dementia occurs in degenerative extrapyramidal disorders and has also been identified in inflammatory, infectious, and vascular conditions. Histologic, metabolic, and neurochemical investigations implicate dysfunction primarily of subcortical neurotransmitter systems and subcortical structures or subcortical-frontal connections in the genesis of the syndrome. Subcortical dementia contrasts neuropsychologically and anatomically with disorders such as dementia of the Alzheimer type that affect primarily the cerebral cortex. The clinical characteristics of subcortical dementia reflect the interruption of fundamental functions (motivation, mood, timing, arousal) mediated by phylogenetically and ontogenetically early maturing structures.

For many years we and other colleagues in the Department of Psychiatry at Washington University School of Medicine in St Louis, Missouri have been concerned with the need to develop widely accepted, valid diagnostic criteria for psychiatric disorders. The aim has been to identify patient groups as homogeneous as possible. Diagnostic criteria, such as those used in this study, were therefore developed with the goal of maximising specificity (i.e. reducing false positives) while keeping sensitivity as high as possible (i.e. keeping false negatives low).

A new interview schedule for the diagnosis and measurement of dementia in the elderly is described. The schedule named the Cambridge Mental Disorders of the Elderly Examination (CAMDEX), consists of three main sections: (1) A structured clinical Interview with the patient to obtain systematic information about the present state, past history and family history; (2) a range of objective cognitive tests which constitute a minineuropsychological battery; (3) a structured Interview with a relative or other Informant to obtain Independent Information about the respondent's present state, past history and family history. The CAMDEX Is acceptable to patients, has a high inter-rater reliability and the cognitive section has been shown to have high sensitivity and specificity.

To examine how the measure of expressed emotion relates to family life, 30 relatives of schizophrenic patients were assessed for EE and then observed in ten-minute discussions with the patients. It was found that high-EE relatives express more negative emotional statements than low-EE relatives when face-to-face with the patient; they also talk more rapidly, and this speech rate is correlated with the patient speech rate. Whereas low-EE relatives expressed few criticisms or intrusive statements, high-EE over-involved relatives were more intrusive, and high-EE critical relatives were more critical as well as more intrusive in direct interaction. These findings emphasise the importance of understanding divergent EE sub-styles and the complementary behaviour of patients. The findings of an earlier Los Angeles study were replicated.

Three observations challenge Kraepelin's binary view of the functional psychoses: a bimodal distribution of the clinical features of manic-depressive illness and schizophrenia has not been demonstrated; affective illness appears to predispose to schizophrenia in later generations; and “schizoaffective’ illnesses cannot be separated in family studies from either of the prototypical psychoses. The alternative concept is that psychosis is a continuum extending from unipolar, through bipolar affective illness and schizoaffective psychosis, to typical schizophrenia, with increasing degrees of defect. According to this concept the genes predisposing to psychosis have a degree of stability that ensures that the form of the psychosis tends to remain the same within families, but there is also the possibility of change, implying that the genetic mechanisms themselves are variable. It is proposed that quantal changes in the “virogene’ are due to replications within the genome (e.g. the generation of tandem repeats of the element or a component of it); that such replications occur at a critical stage (e.g. gametogenesis, fertilisation, very early embryogenesis) in the course of reproduction; and that the “season of birth effect’ reflects the operation of the mechanism responsible for these replications.

Data were collected, using interviews with parents and teachers and rating scales, concerning the behaviour of two groups of mentally retarded children: 193 children with Down's Syndrome (DS) and 154 children with a similar degree of handicap were identified in the same schools. The proportions of children who had high scores on the Rutter or an additional behaviour check list, were similar in the two groups. Deviant behaviour was markedly more common in both sets of retarded children than in their siblings next in age; 31% of the children with DS and 29% of controls were judged to be well adjusted, while 38% of the DS children and 49% of the controls had significant behaviour disorder. Conduct disorders were most common in the children with DS. ‘Psychosis' was the most common diagnostic label in the control group, but was also found in the children with DS.

Beyond assuring biological survival, every society must have structures that nurture the young, prepare them for social roles and responsibilities, and that successfully integrate them with a reasonable level of motivation into ongoing patterns of activity. Societies must also have institutions that reinforce a sense of personal commitment to everyday affairs: the lack of a stake in social processes contributes to personal demoralisation and deviant behaviour. Deviance may also occur because of biological vulnerability or handicap, because socialisation fails, because demands exceed capacities, or as a result of sub-group identification being in conflict with dominant values. Psychiatric disorders are a sub-set of deviant behaviour.

Reasons are given why the hospital diagnosis of schizophrenia may be accurate enough for the proper study of certain aspects of its epidemiology. Studies in the seasonality of admissions and of births in schizophrenic patients have produced consistent results in different countries and at different times. The results are summarized, and causal hypotheses based on them are discussed. The idea that schizophrenia is a relatively recent disease is compatible with these hypotheses.

A case is presented for regarding the Attachment Dynamic as a theoretical model for hypotheses on the aetiology and management of neuroses and personality disorders. It is proposed that man has a number of natural propensities, including: (1) attaining “companionable interactions' with peers, in which competence is affirmed, self-esteem enhanced, and a state of well-being (”assuagement’) is promoted. (2) when hindered in the pursuit of interests and companionable interaction, an urge to seek support through proximity to, and often “supportive interaction’ with support-givers. (3) severe psychological distress (”disassuagement’) when support-givers cannot be induced to act effectively, with a propensity to devise defensive strategies, supplemented by psychological defence mechanisms; when maladaptive, these strategies are the source of neurotic symptoms and antisocial traits. Through these propensities, movement between companionable interaction and effective support sustains the urge to develop skills and explore interests creatively. However, this movement is hindered by the experience of repeated disassuagement and the need to maintain maladaptive defensive strategies.