This study describes an inquiry concerning patients (65 in all) who were referred to the Socio-Professional Rehabilitation Department (CHS Le Vinatier, Bron) over 14 months. The aim was to study the influence of occupational therapy on the clinical evolution of psychotic patients, and more specifically on their quality of life. Two evaluations using questionnaires filled out both by the patients and the medical staff were performed. One evaluation was carried out at admission, and the second 3 months later. The studied variables were the patients' symptoms, quality of life and ability to perform a task. Validation studies showed the answers to questionnaires to be reliable indicators. It was found that this group of psychotic patients was anxious rather than depressed, and fairly autonomous; their dissatisfaction mainly concerned material conditions. The initial factors most related to quality of life after 3 months of treatment were mainly connected with their ability to perform a task, and to a lesser extent with the initial gravity of symptoms.

The concept of a 5-HT related, anxiety and/or aggression-driven, stressor-precipitated depression is formulated and discussed. It comprises the following elements. The 5-HT ergic disturbances found in some depressed individuals - and of them particularly lowered CSF 5-HIAA - are linked to the anxiety- and the aggression-components of the depressive sydrome. In this type of depression - called 5-HT related depression - dysregulation of anxiety and/or aggression are primordial and mood lowering is a derivative phenomenon. In other words this is a group of anxiety/aggression-driven depressions. The 5-HT ergic impairment in certain types of depression is a trait-phenomenon, ie, persists during remission. This disturbance makes the individual susceptable for perturbation of anxiety- and aggression-regulation. Anxiety and (overt or suppressed) anger, are core constituents of the stress-syndrome. Thus, the 5-HT ergic disturbance will induce a heightened sensitivity for stressful events, ie, the latter will induce more readily than normal, stress phenomena , among which anxiety and anger. The latter psychological features induce lowering of mood and thus “drive” the patient into a fullblown depression. Furthermore it is predicted that anxiolytics and serenics (ie, anti-aggressive drugs) that act via normalisation of 5-HT ergic circuits, will exert a antidepressant effect in 5-HT related depression, in addition to their therapeutic actions in anxiety disorders and states of increased aggressiveness, respectively. The exact nature of the 5-HT ergic impairment in 5-HT related depression has yet to be elucidated.

European psychiatrists and psychiatric service planners are confronting new ethical dilemmas as a direct or indirect result of European integration. These dilemmas present themselves at a variety of levels, ranging from the individual doctor-patient relationship to national and international legislations. We review some of the areas in which ethical questions may arise as a result of increasing European unity. Some of the issues may seem minor but are likely to have some impact on any psychiatrist exposed to transcultural practice in the European Union. Other examples have been selected not because they are common but because of their massive ethical ramifications. Attempts, by psychiatrists, to address these issues pro-actively are few and far apart.

In the context of the discovery of the cerebral ligand for the cannabis receptor, and the elucidation of its genetic sequence, we discuss the psychomimetic properties of Cannabis sativa, and explore the relationship between cannabis intoxication and mood. We suggest that renewed study of acute cannabis encephalopathy would be rewarding not only in deepening our understanding of consciousness in healthy adults, but also in helping us to understand the perceptual world of the child, the elderly, and some of our patients.

The development of pharmacological agents in treating alcoholism represents one of many different ways to suppress alcohol intake. Regarding the hypothetical involvement of different neurochemical systems in “alcohol craving”, specific substances have been examined in animals models (especially rats) and increasingly in man. Promising results in reducing “alcohol craving” were described in the use of different kinds of chemical substances. “Craving” therefore can hardly be explained on the basis of a deficit in only one neurochemical (neurotransmitter) system. This conclusion is supported by the data. The efficiacy of many anti-craving substances described in smaller studies must first be confirmed in clinical studies on a wider scale.

This paper reviews and presents data of practical impact for those administering electroconvulsive therapy (ECT). In the first section, physical and physiological aspects of the stimulus as well as methods of stimulation are discussed. The second section deals with indications for ECT, efficacy and treatment modalities such as seizure duration, treatment frequency and total number of ECT applications. The last section is devoted to side effects, risks, comedication and comorbidity.

It has long been known that most patients with bipolar disorder have a course marked by multiple recurrence of major depressive and manic episodes. More recently, many epidemiological studies have shown that at least 50% of unipolar depressive patients have one or more subsequent episodes of depression in their lifetimes. Likewise, relapse following successful short-term treatment of depression is so common that it is now recommended to prolong treatment in the form of maintenance pharmacotherapy. Interest in preventing the recurrence of depression has been stimulated by the results from long-term trials involving antidepressant drugs and lithium. However, these pharmacological studies suffer somewhat from methodological deficits, making difficult any clear and complete interpretation of their results. While some methodological recommendations have now been established to compensate for previous deficits (eg, definition of relapse and recurrence, duration of acute and maintenance treatments, statistical analysis of efficacy), unfortunately, many key points still remain to be resolved (eg, selection of patients, dosage in maintenance and prophylactic phases, maximum length of a course of treatment, etc).

Since the DSM-III, the category of dysthymia includes patients that were previously considered as neurotic, reactive, characterological, temperamental, minor or atypical depressives as opposed to a category of endogenous, autonomous, morbid, major or typical depressives. Despite certain confusion, the need for a nosological category is very important for patients suffering from years of depressive mood, with a significant impact on their life-styles and adaptation, as they can benefit enormously from modern antidepressant treatments. DSM-IV and ICD-10 describe dysthymia in a very similar way although there are significant differences. The differences are the consequence of the lack of sufficient scientific data in some points and the need to take a decision, but also to indicate areas for future research. Other differences are the consequence of major discrepancies in basic perspectives of the classifications (ie, the importance given to disablement for the diagnosis). The similarities between both classifications allow the use of either of them for most purposes. Research on the different classifications should help in better defining the concept of dysthymia and mood disorders in general (ie, the cut-off points between them) and of psychiatric nosology.

The pattern of family burden was compared in 32 relatives of schizophrenic patients and 32 relatives of people with mental retardation, using a standardised semistructured interview named “Accertamento della Disabilità e del Carico Familiare” (Assessment of Disability and Family Burden). There were few quantitative differences between the two samples of relatives, although relatives of schizophrenics presented a tendency for a higher degree of both objective and subjective burden in some areas. Problems frequently reported were the presence of emotional distress, poor social relationships and lack of holidays or free time activities. Relatives of schizophrenics specifically claimed the presence of financial difficulties, while those of people with mental retardation were concerned by problems with neighbours.

Rehabilitation aims at avoiding unfavourable consequences of a disorder and its care and at training and improving impaired and compensatory skills. The needs of the main diagnostic groups with resulting cognitive or social impairments, namely mental retardation, infantile autism, chronic depression, severe psychoneurosis, substance abuse, schizophrenia, and dementia in old age, have specific aspects. An increased need for rehabilitation was prompted by the worldwide movement of deinstitutionalisation, which hit above all the socially most vulnerable schizophrenics. The instruments and methods of rehabilitation for the socially disabled mentally ill go far beyond the sphere of psychiatry. Individualised rehabilitation must be in mutual interaction with the social and occupational environment. The socially disabled individual is, for example, dependent upon awareness and acceptance in the community, upon financial and social support or upon the availability of a job. In the case of persisting deficits, supportive measures at different levels are needed to compensate or to minimize severe consequences of impairments. Their approach is by the social environment with the objective to grant the optimum quality of life combined with a minimum loss of independence. The great variety of measures often required at the same time must be based on a network of services and their purposeful coordination. Psychiatric rehabilitation requires a functioning social system and, in times of scarce resources, political priorities.

This paper summarizes several issues related to the mental health aspects of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) and its use in the field of rehabilitation. Rehabilitation is characterized by multiple interventions, demanding extensive communication and coordination among different care providers. The ICIDH will be useful in the field of rehabilitation by providing a sound framework for consequences of diseases or disorders if clear descriptions and assessment guidelines of the categories are given. The development of dedicated assessment instruments linked to the ICIDH will be useful to many health workers to assess the needs of the patients, to evaluate services and to measure the outcomes of rehabilitation interventions, thus creating a common language for disablements.

The proposed distinction between familial and sporadic schizophrenia has proved a useful tool for research into the aetiology of the disorder although evidence for the proposed association between large cerebral ventricles and the sporadic form has been contradictory. We have reviewed the literature and found evidence that in the context of brain structure, the familial — sporadic distinction may apply to men but not women with schizophrenia. This may explain some of the observed sex differences in schizophrenia and some of the confusion in the literature. Based upon this review, we examined our own data on 138 schizophrenic subjects with no family history (sporadic) and 24 with such a history (familial). As predicted, cerebral ventricle size was largest in men with sporadic schizophrenia, there being no effect in women. We propose a meta-analysis of existing data in order to pursue this phenomenon further.

We assessed hemisphere function in right-handed male chronic schizophrenic patients using dichotic listening tests. We evaluated digit, tonic and transitional tests in patients with paranoid schizophrenia (n = 8), patients with disorganized schizophrenia (n = 8) and in control subjects (n = 8). The dichotic listening analysis discriminated between paranoid and disorganized schizophrenia. In disorganized schizophrenia, functional impairment of both hemispheres was demonstrated, while in paranoid schizophrenia dysfunction was more prominent in the right hemisphere. These results indicate the possible involvement of right hemisphere dysfunction in the pathophysiology of chronic paranoid schizophrenia, in contrast to dysfunction of both hemispheres in chronic disorganized schizophrenia.

The considerable debate about the justification of coercive measures in psychiatry includes medical, ethical, legal and political arguments, patients' subjective experience of involuntary injections or restraint is barely investigated. A semi-structured interview was used to evaluate retrospective attitudes in 40 (32 schizophrenic) patients, treated involuntarily with injection of neuroleptic drugs or restrained. Of these patients, 48% rated these measures as necessary or positive, 23% as negative, and 30% were indifferent. Only patients with good insight into their disease were able to accept the involuntary treatment retrospectively as positive. Reasons for treatment refusal were inadequacy of the measures (58%), negative previous experience with neuroleptic drugs (47%), eg, akathisia, and reservations against the medical system itself (28%). ‘Fear’ and ‘powerlessness’ were the predominant feelings which patients experienced when confronted with coercive measures. Restraint was more disliked than injections. The results support the notion that disease concept and the ability to acknowledge mental illness are major factors influencing a schizophrenic patient's decision to accept of refuse treatment.

The WHO Collaborative Study on Psychological Problems in General Health Care examined the frequency, form, course and outcome of psychological problems in general health care settings. A total of 25,916 general health care attenders at 15 sites in 14 countries were screened using the 12-item General Health Questionnaire (GHQ-12). Of those screened, 5,438 were assessed in detail using a Primary Health Care version of the Composite International Diagnostic Interview (CIDI-PHC) in conjunction with the Brief Disability Questionnaire, the Social Disability Schedules, a self rated overall health status form and the 28-item General Health Questionnaire. The analysis has shown that sleep problems were common at all sites with: 26.8% of all patients having some form of sleep problem and 15% of the patients examined had trouble falling or staying asleep. Of those with sleep problems, 51.5% had a well-defined International Classification of Diseases 10th Revision (ICD-10) mental disorder (such as depression, anxiety, somatoform disorders or alcohol problems) and 48.5% of those with sleep problems for at least two weeks or more did not fulfil the criteria for any well defined ICD-10 diagnosis. Persons with sleep problems reported a degree of disability in the performance of their daily activities and social roles even when they had no symptoms of psychological disorders. When such symptoms were present the disability was significantly increased.

A large body of literature has accumulated within the last decade concerning the fragile X syndrome, the most common cause of X-linked mental retardation. The first article of this review summarizes the peculiar genetic mechanisms and molecular biology properties (eg, unstable DNA triplet repeats), which have been characterized since the detection of the FMR-1 gene in 1991. However, the most important question concerning the function of the FMR-1 gene is still an unresolved issue and is in need of future research. The second article of this review addresses the clinical picture, neuropsychological functioning and psychopathological characteristics of pre- and full mutation carriers.

A review of epidemiological studies about incidence of dementia among the aged is presented. Empirical studies on incidence of dementia have shown considerably differing estimations. Nevertheless, in all studies, an age-related increase in incidence becomes clearly apparent. Epidemiological field-studies could not yield consistent findings concerning the association of incidence and gender. However, most studies found an increased incidence for men until the age of 70–80 years. In older age most studies reported the same incidence for men and women or found an increased incidence of dementia in women. The findings are reviewed and discussed in the context of methodological issues.