There is considerable inconsistency in the results of studies of the psychological and sexual sequelae of the menopause and their treatment.

A search of the literature on Medline was made of studies of psychological symptoms in women who were either naturally or surgically menopausal or who were receiving hormone replacement therapy for menopausal symptoms.

There is evidence of a small increase in psychological morbidity (not usually amounting to psychiatric disorder) preceding the natural menopause and following the surgical menopause. Psychosocial as well as hormonal factors are relevant. While the response of psychosocial symptoms to hormone replacement therapy with oestrogens is variable and most marked in the surgical menopause, in some studies the effect is little greater than that for placebo. Where sexual symptoms are present, there is more consistent evidence that hormone replacement therapy is effective.

In the light of the available evidence, the current use of hormone replacement therapy to treat psychological symptoms detected at the time of (but not necessarily therefore due to) the natural menopause must be questioned. It does appear that oestrogen therapy ameliorates psychological symptoms after surgical menopause.

Gender may have a significant impact on the prevalence, age at onset, symptoms, course and outcome of schizophrenia, as well as on the pattern of psychopathology in relatives.

We examined these questions in the Roscommon Family Study, in which the probands were epidemiologically sampled from a case registry and followed up an average of 15 years after onset. Face-to-face interviews were conducted with 86% of traceable living relatives.

The treated lifetime prevalence of DSM–III–R schizophrenia was 0.54 ± 0.06% in men and 0.28 ± 0.04% in women. No significant differences were seen in the age at onset, symptoms, course or outcome of schizophrenia. The risks for schizophrenia, schizophrenia spectrum disorders, affective illness and alcoholism were similar in relatives of male and female schizophrenic probands.

Gender has little impact on the presentation and course of schizophrenia in the west of Ireland. The familial liability to schizophrenia did not differ in affected men and women. No evidence was found that schizophrenia in women, compared to men, is, from a symptomatic or familial perspective, more closely related to affective illness. The substantial gender difference in the prevalence rate of schizophrenia in Ireland cannot be explained by women having a greater resistance to the familial predisposition to illness.

Afro-Caribbean immigrants are reported to have a high rate of schizophrenia compared with other population groups.

In a prospective first contact study of schizophrenia in Jamaica in 1992, 335 patients were examined using the Present State Examination.

285 patients were evaluated as having a PSE ‘restrictive’ S + diagnosis of schizophrenia, and 32 as having a ‘broad’ S?, P, or O diagnosis of schizophrenia. With a population of 2.46 million, this represents a first-contact incidence rate for ‘restrictive’ schizophrenia of 1.16 per 10 000 population, and an age-corrected (15–54) incidence rate of 2.09 per 10 000.

Incidence rates for schizophrenia in Jamaica are lower than those reported in Afro-Caribbean immigrants in the UK and Holland, and within the reported range for other population groups worldwide.

Neurological soft signs (NSS) such as a disturbed finger-to-thumb opposition are frequently found in schizophrenia. To identify the underlying cerebral changes we investigated sensorimotor cortex and supplementary motor area (SMA) activation during finger-to-thumb opposition using functional magnetic resonance imaging (fMRI).

Ten DSM–III–R schizophrenics and seven healthy controls were included. All subjects were right-handed. fMRI was carried out in a resting condition followed by an activation state (finger-to-thumb opposition) and the activities in the sensorimotor cortices and SMA recorded.

All subjects showed a significant activation of the SMA and both ipsilateral and contralateral sensorimotor cortices. In the controls, ipsilateral finger-to-thumb opposition was associated with a greater left than right hemispheric sensorimotor cortex coactivation. When compared with the healthy controls, the schizophrenic patients showed a decreased activation of both sensorimotor cortices and SMA, as well as a reversed lateralisation effect.

Sensorimotor cortex and SMA dysfunction are associated with motor disturbances in schizophrenia.

Patients with schizophrenia differ from controls in several measures of brain structure and function, but it is uncertain how these relate to clinical features of the illness. We dichotomised patient groups by treatment response to test the hypothesis that treatment-resistant patients exhibit more marked biological abnormalities than treatment-responsive parients.

Twenty treatment-responsive and 20 treatment-resistant patients with schizophrenia, matched for sex, age, and illness duration, were compared by magnetic resonance imaging, single photon emission tomography, and detailed neuropsychological assessment.

Brain-imaging variables were not statistically related to treatment response, although poorly responsive patients had lower volumes of most brain structures. Several highly significant differences emerged between patient groups on neuropsychological testing. Episodic memory functioning distinguished patient groups even after we controlled for global cognitive impairment.

Cerebral structure and blood flow have a limited effect on treatment response in schizophrenia, but long-term episodic memory impairment is associated with, and may predict, poor prognosis.

There has been evidence that psychopathology in schizophrenia consists of three separable syndromes: reality distortion, disorganisation, and psychomotor poverty. The objective of this study was to explore the relationship between planning and execution of movement and each of the syndromes in schizophrenia.

Twenty-one right handed DSM–III–R schizophrenic patients performed a total of 80 trials of a motor movement task, varying distance of movement × size of the target × hand. Times taken to plan the movement (RT) and to carry it out (MT) were examined for their relationship with contemporaneous as well as lifetime profiles of the three syndromes in schizophrenia.

Significant correlations are reported between RT and current as well as lifetime measures of disorganisation syndrome. Somewhat weaker correlations are reported between RT and psychomotor poverty, but only for the right-handed tasks. Partial correlations suggest that the influence of neuroleptic medication explains all but one of the correlations between psychomotor poverty and RT, but does not account for the relationship between disorganisation and RT. No other relationship emerged between any of the movement and symptom measures.

These findings indicate that dysfunction in movement planning is related primarily to concurrent disorganisation, as well as to the prominence of disorganisation over the patient's history.

We examined whether acute transient psychoses can be distinguished from schizophrenia and the affective disorders.

We studied 46 cases of nonaffective acute psychosis in the Chandigarh Acute Psychosis Study. With respect to separation from schizophrenia, we examined the distribution of duration of the episode. With respect to separation from affective disorders, we assessed the frequency of affective symptoms.

Duration was bimodal, suggesting the presence of two distinct conditions of short and long duration. Affective symptoms were minimal, suggesting that these were not atypical affective syndromes.

Acute transient psychoses conform neither with schizophrenia of brief duration nor with atypical affective psychosis, and thus require separate classification as proposed in the ICD–10.

Psychiatric case registers (PCRs) are particularly useful for studying patterns of care over time. Methods of ‘survival analysis’ have rarely been used for assessing such data.

A longitudinal study was conducted over 10 years (1 January 1982 to 31 December 1991) on 1423 first-ever psychiatric patients, using the PCR of South Verona, Italy. The product-limit method, the log-rank test, the Cox regression model and the Poisson regression analysis were used to analyse episodes of care and relapses.

The duration of the episodes of care increased consistently from the first to the fifth episode. The probability of opening a new episode of care after the first one increased consistently from the second to the sixth episode. The only variable significantly associated with the length of the first episode of care was diagnosis (highest probability of having longer episodes for schizophrenic patients), while the length of the breaks following the first episode of care was associated with diagnosis, sex and occupational status (highest probability of opening a second episode of care for schizophrenic subjects and those with alcohol and personality disorders, for males, and for unemployed patients). The probability of opening a new episode of care decreased with time since last contact and increased with number of previous contacts.

The community psychiatric service in South Verona is fulfilling its original aim, that is, to give priority to the continuity of care for patients with chronic and severe mental illnesses. Survival analyses proved to be useful methods for assessing episodes of care.

Our aim was to describe the medium-term course (2–3 years) in a series of victims who had experienced severe trauma.

We selected a consecutive series of 31 trauma victims and applied a structured clinical schedule (CAPS-2) to their psychiatric evaluations prepared for the court on two separate occasions approximately one year apart.

Post-traumatic stress disorder and depression were the commonest diagnoses, occurring in 39% and 16% of the victims respectively when they were first assessed. Most had improved between the assessments and this was especially the case for the re-experiencing of the trauma and over-arousal, but less so for avoidance; 20% of subjects showed no improvement, often being handicapped by secondary psychiatric illness.

Traumatised victims generally showed recovery in the 2–3 years after the trauma, but this was slow and was not universal.

In March 1987, the P&O car ferry Herald of Free Enterprise capsized killing 193 passengers. Seventy-five survivors and relatives were referred by their solicitors to the authors for assessment of psychological injury.

Information was gathered retrospectively and systematically from clinical notes and legal reports.

The commonest symptoms suffered were sleep disturbance, loss of concentration and increased anger. The commonest diagnoses were post-traumatic stress disorder, other anxiety states and depression. Depressive symptoms were commoner in those who had been bereaved, anxiety symptoms were commoner in those who had not. Reluctance to discuss symptoms and to attend a psychiatric clinic was a common feature.

As expected, bereavement led to grief and depressive symptoms, whilst passengers who were not bereaved were more likely to suffer anxiety symptoms. Contrary to expectations, the degree of immersion during the accident did not influence the type or degree of symptoms. Those with worse symptoms were more likely to attend the clinic. Women showed more affective symptoms and men more substance abuse.

Animal experimental studies suggest that the amino acid valine may decrease brain serotonin (5-HT) function by inhibiting the transport of the 5-HT precursor, L-tryptophan, across the blood barrier. The aim of the present study was to assess whether valine could decrease brain 5-HT function in healthy subjects and provoke symptomatic relapse in recently remitted depressed patients taking antidepressant drug treatment.

We studied the effect of valine (30 g) on the prolactin (PRL) response to the 5-HT releasing agent, d-fenfluramine, in healthy male subjects and on the mood of 12 remitted depressed patients taking either selective serotonin re-uptake inhibitors (n = 10) or lithium and amitriptyline (n = 2).

Valine significantly lowered the PRL response to d-fenfluramine in healthy subjects. In the remitted depressives, valine caused a mild but detectable lowering of mood on a number of measures but only one patient experienced a significant relapse in mood.

Valine administration may decrease brain 5-HT neurotransmission in humans. This effect could explain the mild increase in depressive symptoms in patients taking 5-HT-potentiating drugs.

We investigated whether reported psychiatric morbidity was increased after termination of pregnancy compared with other outcomes of an unplanned pregnancy.

This was a prospective cohort study of 13 261 women with an unplanned pregnancy. Psychiatric morbidity reported by GPs after the conclusion of the pregnancy was compared in four groups: women who had a termination of pregnancy (6410), women who did not request a termination (6151), women who were refused a termination (379), and women who changed their minds before the termination was performed (321).

Rates of total reported psychiatric disorder were no higher after termination of pregnancy than after childbirth. Women with a previous history of psychiatric illness were most at risk of disorder after the end of their pregnancy, whatever its outcome. Women without a previous history of psychosis had an apparently lower risk of psychosis after termination than postpartum (relative risk RR = 0.4, 95% confidence interval CI = 0.3–0.7), but rates of psychosis leading to hospital admission were similar. In women with no previous history of psychiatric illness, deliberate self-harm (DSH) was more common in those who had a termination (RR 1.7, 95%CI 1.1–2.6), or who were refused a termination (RR 2.9, 95%CI 1.3–6.3).

The findings on DSH are probably explicable by confounding variables, such as adverse social factors, associated both with the request for termination and with subsequent self-harm. No overall increase in reported psychiatric morbidity was found.

Functional brain imaging with technetium-99m d,l-hexamethyl propyleneamine oxime (HMPAO) Single Photon Emission Tomography (SPET) allows us to explore the cerebral pathophysiology of Gilles de la Tourette's Syndrome (GTS).

Fifty patients and 20 controls were examined. Patients were rated for tic severity and mood. Scans were analysed quantitatively using internal ratios to the occipital cortex.

Patients differed from controls on measures of relative blood flow to the left caudate, anterior cingulate cortex and the left dorsolateral prefrontal cortex. Severity of tics was related to hypoperfusion of the left caudate and cingulate and a left medial temporal region. Hypoperfusion in the left dorsolateral prefrontal region was related to mood.

The areas found to be hypoperfused in this study are consistent with known functions of fronto-striatal circuits. A wide range of perfusion patterns is seen, however, and no characteristic patterns for behavioural subgroups has been documented with this technique.

In developed countries, most dementia appears to be due to Alzheimer's disease and vascular dementia. We report rates for incidence of subtypes of dementia based on clinical diagnosis.

This study was a 2.4-year (s.d. 2.6 months) follow-up of a cohort aged 75 years and over, seen initially in a prevalence study of dementia. A screening interview in 1173 survivors was followed in a subsample of 461 respondents by a diagnostic interview 1.8 months after screening (s.d. 1.5 months). This comprised a standardised interview with respondent and informant, with venepuncture where possible. Clinical diagnoses of subtypes were made by specified criteria.

The incidence of Alzheimer's disease of mild and greater severity was 2.7/1000 person-years at risk (1.6–4.4); in men 1.5 (0.8–2.7) and in women 3.3 (1.8–5.9). The incidence of vascular dementia was 1.2/100 person-years at risk (0.7–1.9); in men 1.1 (0.4–2.8) and in women 1.2 (0.7–2.0). Alzheimer's disease, but not vascular dementia, showed a marked increase with age, particularly in women. Rates for minimal dementia of different subtypes showed similar age and sex effects, but were much higher for Alzheimer's disease than vascular dementia.

The striking rise in incidence rates of dementia in the very old appear to be due to Alzheimer's disease, while rates for vascular dementia remain relatively constant. These trends are particularly marked for minimal dementia, but emphasise the importance of Alzheimer's disease in the community as a cause of cognitive decline of all degrees.