This paper examines the feasibility of evaluating innovative models of working at the interface between primary care and secondary mental health services.

Methodological problems relevant to evaluation of innovative models of working at the interface are discussed.

Although there is some evidence that neurotic disorders can be more cost-effectively treated in primary care, many general practitioners (GPs), and possibly some patients, prefer referral to community mental health teams and community psychiatric nurses, which are provided by the secondary health care services. Since the latter are provided with the intention of improving serious mental illness their involvement in the care of neurotic illness can lead to tensions between GPs, local health authorities and service providers. There is little evidence to suggest that psychiatrists working in health centres using the ‘shifted out-patient’ model have eased this problem. By contrast the ‘consultation-liaison’ (C-L) model has a number of theoretical advantages; referrals to secondary care should be limited to those most in need of this level of expertise and GP management skills should improve, so leading to better quality of care for patients who are not referred.

Studies comparing the different models of service delivery are required to address the tensions that have arisen following changes in government policy. Further work is also needed to develop the necessary research tools.

This paper examines the social and psychological impact on victims of stalking.

A group of 100 victims of stalking completed a 50-item questionnaire on their experiences.

The majority of the victims were subjected to multiple forms of harassment including being followed, repeatedly approached and bombarded with letters and telephone calls for periods varying from a month to 20 years. Threats were received by 58 subjects, and 34 were physically or sexually assaulted. All but six victims made major changes in their social and work lives, with 53% changing or ceasing employment and 39% moving home. Increased levels of anxiety were reported by 83%, intrusive recollections and flashbacks by 55%, with nightmares, appetite disturbances and depressed mood also being commonly reported. Suicidal ruminations were acknowledged by 24% of victims. The criteria for a diagnosis of post-traumatic stress disorder were fulfilled in 37% of subjects, with a further 18% having the clinical features but not qualifying for a stressor involving threatened or actual physical harm.

The study indicates the extent of the social and psychological damage sustained by those subjected to persistent stalking, and underlines the inadequacy of the current legal and medical responses to the needs of these victims.

Amisulpride is a substituted benzamide with high selectivity for dopamine D2 and D3 receptors. The purpose of the study was to evaluate the effect of 100 mg amisulpride in patients with predominantly negative symptoms of schizophrenia.

This was a multi-centre, randomised, parallel-group, double-blind study. Patients received either amisulpride (100 mg/day) or placebo over a six-month treatment period.

A total of 141 patients were included, 69 received amisulpride, 72 placebo. Fifty-eight patients (41%) had received neuroleptic treatment prior to inclusion. The percentage of amisulpride patients completing the study (55%) was significantly higher than that with placebo (32%), and drop-out rates due to lack of efficacy were 27% with amisulpride and 47% with placebo. All efficacy assessments were statistically in favour of amisulpride compared with placebo. The overall incidence of extrapyramidal symptoms was comparable in both groups; only five patients started anti-Parkinsonian treatment during the study (one in the placebo and four in the amisulpride group).

Amisulpride is effective in the medium-term treatment schizophrenic patients with predominantly negative symptoms.

Approximately 5–10% of Caucasians (poor metabolisers) show impaired metabolism of at least 20 therapeutically important drugs, including a number of commonly used antipsychotic agents, because they lack the cytochrome p450 enzyme CYP2D6. The molecular basis of this defect is now well understood and simple genotyping tests using the polymerase chain reaction (PCR) have been developed.

To determine whether poor metabolisers are more susceptible to acute dystonic reactions and chronic movement disorders associated with the administration of antipsychotic drugs, we determined CYP2D6 genotypes in a group of 76 schizophrenics using previously described methods involving PCR and restriction fragment length polymorphism analysis.

There was no difference in genotype frequencies between the schizophrenics and a normal control population, suggesting that CYP2D6 genotype was not a factor in determining susceptibility to the disease. However, four of the five poor metabolisers compared with 44% of the remaining subjects were suffering from a movement disorder at the time of the study, although because of the small number of poor metabolisers in the group the difference was not statistically significant. Poor metabolisers were not more likely to suffer an acute dystonic reaction.

CYP2D6 genotype is not a determinant of susceptibility to acute dystonic reactions but may be a contributory factor in antipsychotic drug-induced movement disorders including tardive dyskinesia.

The dopamine D3 receptor gene (DRD3) is a meaningful candidate gene because it unifies the dopamine and the limbic hypotheses for schizophrenia. We tested for an allelic association between schizophrenia and the DRD3 Mscl alleles, hypothesising heterogeneity between childhood/early adolescence-onset schizophrenia (CO-SZ) and adult-onset schizophrenia (A-SZ).

The frequencies of the DRD3 alleles were compared between 70 DSM-III-R schizophrenics (35 CO-SZ and 35 A-SZ) and 79 controls.

Compared with the controls, the subsample of A-SZ, but not CO-SZ, showed an over-proportion (P = 0.025) of allele 1. The association was not found in the total sample, combining the two subsamples.

Consistently with former studies, our data suggest an aetiological heterogeneity between CO-SZ and A-SZ and a possible specificity of the excess of allele 1 to the familial form of schizophrenia and to schizophrenia with a better outcome.

The prevalence of schizophrenia is known to be greater in urban than in rural areas. Less studied are differences between the patients themselves and, more specifically, their use of psychiatric services.

The prevalence of schizophrenia was determined in rural Nithsdale in Scotland and urban Nunhead and Norwood in South London. Information about patients' psychiatric history, use of services during the study year and global assessment of functioning were obtained from case records and staff.

There were no significant differences in prevalence rates between Nithsdale patients, all White (2.78 per 1000 general population), Nunhead (3.46 per 1000) and Norwood (2.24 per 1000) Whites; rates were significantly higher among the non-Whites in Nunhead (7.36 per 1000) and Norwood (5.53 per 1000), who were mainly Black Caribbeans. Nithsdale patients were at a higher level of functioning and made substantially more use of psychiatric services. During the study year, 42% of Nithsdale patients used more than one of three principal community services, namely day, out-patient and community psychiatric nursing care.

The prevalence of schizophrenia is no different in rural Nithsdale and inner-city Nunhead and Norwood, when only White patients are considered. Nithsdale patients were at a higher level of functioning and made more use of available psychiatric services.

Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary.

As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs.

Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts.

The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.

Little is known about the long-term mortality and causes of death after first psychiatric admission.

A consecutive series of 87 patients admitted for the first time from a strictly defined catchment area to Saxondale Hospital, Nottinghamshire, who were discharged in 1974 and 1975, were traced in 1992 to either their general practitioner or death. The causes of their deaths were ascertained and the observed mortality was compared with expected mortality.

Twelve subjects had died. None had committed suicide, and there were no open verdicts or accidental deaths. Although the observed mortality was higher than expected, there was no significant excess.

There may be little scope for reducing suicide rates by targeting patients for careful follow-up after discharge from their first psychiatric admission. More research is required before large investments are made in potentially fruitless interventions to achieve the objectives of The Health of the Nation.

Case management has become the statutory basis of community care in the UK for people with long-term mental disorders, although a randomised controlled trial found no important improvements over standard care. Here we compare the costs and cost consequences of this intervention with standard care.

Resource-use data were collected over a six-month baseline period and for 14 months after randomisation on all patients in the trial.

At 14 months the ratio of control group to treatment group weekly costs was 1.09 (95% CI 0.86–1.38) for total costs; 1.12 (0.76–1.65) for state benefits, and 1.21 (0.61–2.42) for health care costs. Costs were thus lower in the treatment group, but these differences were not significant.

Retrospective power calculations indicated that the trial could have detected differences of 30% in total cost, but would have required 700 patients per arm to detect a 20% difference in health care costs. Hence this study, which had adequate power to detect clinically meaningful differences, was found to be far too small to detect large differences in costs. Funding agencies increasingly request that clinical trials include economic alongside clinical end-points: these findings may have important lessons for that policy.

Despite the growth in patient satisfaction studies, scant attention has been paid to the satisfaction of patients with a first episode of psychotic illness soon after presentation to services. We were particularly interested in any ethnic differences in satisfaction at this seminal stage in patient care.

Using multi-item questionnaire, face-to-face interviews were conducted with patients and relatives 12 months after first contact with psychiatric services. Relatives were also questioned on support and advice issues related to after-care.

Most patients and relatives were generally satisfied with the treatment, and with the ‘humane’ qualities of psychiatric staff, but were less satisfied with the ‘hotel’ aspects of hospital care. Patients, and particularly relatives, were most concerned about levels of information and advice received. Relatives were dissatisfied with after-care. There were no significant differences between Black and other patients, but some differences between their relatives. Patients born abroad were significantly more satisfied than those born in Britain, irrespective of ethnicity. Compulsory detention under the Mental Health Act was also significant in determining low satisfaction for patients and especially for their relatives.

For improved care in the community patients and their relatives need to be seen as partners in care rather than as passive recipients. The issue of information-giving by psychiatric services demands serious attention. Black patients and their relatives were not especially likely to be dissatisfied.

Previous research has generally found that variations in relatives' affective attitudes (expressed emotion; EE) towards a schizophrenic family member could not be accounted for by differences in the severity or form of the patient's symptomatology. These findings have been based on clinicians' ratings of psychopathology in patients.

To approach the question from a different perspective, videotaped interactions between a patient and family members, obtained four to five weeks after hospital discharge, were coded for subclinical signs of psychopathology expressed by the patient. The Behavioral Subclinical Rating Scale (BSRS) was developed to compare subclinical levels of non-verbal and paralinguistic symptoms expressed by patients from both high- and low-EE families.

Highly significant differences were found in the BSRS data. Patients from high-EE families showed more hostile and unusual behaviour with relatives than those from low-EE homes, who, in contrast, showed more anxious behaviour.

These data suggest that a complex transactional model is necessary to understand how family attitudes evolve during the course of a relatives' schizophrenic disorder.

The symptoms of dementia are the most obvious stressors to which caregivers are exposed and many studies have investigated the association of such symptoms with the adverse consequences of caring. The present paper represents the only dedicated review of this literature.

Manual and computer (MEDLINE) literature searches were performed.

Seventeen empirical studies were found.

Variability in conceptual and methodological approaches and inconsistencies in the reported findings have prevented firm conclusions from being drawn. However, the literature provided support for a relationship between non-cognitive features in dementia and psychological problems in caregivers, and suggested possible associations between cognitive deficits and some negative care-giver outcomes. New methodological and conceptual approaches are required if decisive evidence is to be forthcoming. This information is a prerequisite for investigations into the causal mechanisms that sustain these relationships, and for rationally designed interventions.

This study aimed to determine the prevalence of psychiatric disorder in young adults with homzygous sickle cell (SS) disease and in controls with normal haemoglobin, and to examine factors associated with psychiatric disorder.

The study design was cross-sectional. Subjects were aged 18–20 years: 63 with SS disease and 89 controls. The Psychiatric Assessment Schedule was used to determine psychiatric disorder at index of Definition level 5.

Psychiatric disorder was identified in 18 (29%) SS disease patients and in 22 (25%) controls. In SS patients, psychiatric disorder was not related to illness severity but was associated with leaving school early, difficulties in social adjustment, impaired cognitive function and having previous psychiatric difficulties. Male SS patients with psychiatric disorder all had low body mass index (BMI < 17.60). In controls, psychiatric disorder was associated with female gender, unemployment and difficulties in social adjustment.

The prevalence of psychiatric disorder was similar in patients and controls, although associated factors tended to be different. The association with low BMI in SS men merits further study.

The spontaneous diurnal variation of mood and other symptoms provides a substrate for the examination of the relationship between symptoms and regional brain activation in depression.

Twenty unipolar depressed patients with diurnal variation of mood were examined at 8 a.m. and 8 p.m. with neuropsychological measures, clinical ratings and single photon emission tomography (SPET). Brain perfusion maps were spatially transformed into standard stereotactic space and compared pixel-by-pixel. A parametric (correlational) analysis was used to examine the relationship between symptom severity and brain perfusion, both between and within subjects.

Global depression severity and an independent ‘vital’ depression factor were associated in subjects with increased perfusion in cingulate and other paralimbic areas. In addition there was a probable association between an increase in an anxious-depression factor and reduced frontal neocortical perfusion.

Depressive symptom changes are associated with metabolic changes in the cingulate gyrus and associated paralimbic structures.

The theory of cognitive analytic therapy is extended to offer an understanding of borderline personality disorder (BPD).

A structural model (the multiple self states model) and a classification of different levels of developmental damage are proposed.

The model offers an explanation of the phenomenology of BPD.

The multiple self states model provides insights that will be useful for clinicians involved in the psychotherapy and management of BPD patients.