Reduced serotonergic (5-HT) function and elevated testosterone have been reported in aggressive populations.

To investigate relationships between impulsivity, aggression, 5-HT function and testosterone in male offenders with personality disorders.

Sixty male offenders with DSM–III–R personality disorders and 27 healthy staff controls were assessed using the Special Hospital Assessment of Personality and Socialisation (SHAPS), impulsivity and aggression ratings, d-fenfluramine challenge and plasma hormone concentrations.

The SHAPS non-psychopaths and those with schizoid personality disorders had enhanced 5-HT function (prolactin response to d-fenfluramine). Reduced 5-HT function was found in offenders with DSM–III–R borderline personality disorders and those with a history of repeated self-harm or alcohol misuse. The 5-HT function was inversely correlated more strongly with impulsivity than with aggression. Plasma testosterone correlated positively with aggressive acts. The SHAPS primary psychopaths had lower initial cortisol and higher testosterone concentrations than controls.

Future studies are needed to investigate regional brain 5-HT function.

Previous research associating hypotension with depression has produced inconsistent results. A possible reasons is that depressive symptom scales reflect both high negative affect and low positive affect.

To examine the association of hypotension with depressive symptoms, negative affect and positive affect.

Community survey of 340 elderly persons aged 77–99 years.

Diastolic hypotension had a weak association with depression, no association with negative affect and a strong inverse association with positive affect. Systolic hypertension was associated with positive affect. Use of antihypertensive medication was independently associated with lower positive affect.

Diastolic hypotension shows a specific association with low positive affect. This association may explain the weak and inconsistent results of earlier studies relating hypotension to depression.

Many factors influence the type and quantity of services received by patients and, thus, the total cost of care. Knowledge of these factors can aid budgetary and service-planning decisions.

To investigate factors that influence the cost of caring for patients with severe psychotic illness.

Univariate and multivariate analyses were used to examine associations between baseline characteristics and subsequent 2-year total direct costs in 667 patients from the UK700 case management trial.

Significantly more money was spent on younger patients, those with longer duration of illness, those who had spent less time living independently and those who had spent longer in hospital for psychiatric reasons.

Total costs of caring for patients with severe psychotic illness appear to be influenced to a large extent by age, duration of illness and past levels of dependence on statutory services. The strength of these relationships is greater than the impact of illness severity.

It is unclear whether intensive case management influences the prevalence of suicidal behaviour in patients with psychosis.

To compare the effect of intensive case management and standard care on prevalence of suicidal behaviour in patients with chronic psychosis.

Patients with established psychosis (n=708) were randomised either to intensive case management or to standard care. The prevalence of suicidal behaviour was estimated at 2-year follow-up and compared between treatment groups. Suicide attempters and non-attempters were compared on multiple socio-demographic and clinical variables to identify predictors of suicidal behaviour.

There was no significant difference in prevalence of suicidal behaviour between treatment groups. Recent attempts at suicide and multiple recent hospital admissions best predicted future attempts.

Intensive case management does not appear to influence the prevalence of suicidal behaviour in chronic psychosis. Predictors identified in this study confirm some previous findings.

Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects.

To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients.

A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living.

Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors.

Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

Many women may suffer psychological symptoms after stillbirth and in the subsequent pregnancy. Stillbirth has not been demonstrated previously to be a stressor for post-traumatic stress disorder (PTSD).

To assess incidence, correlates and predictors of PTSD during and after the pregnancy following stillbirth.

A cohort study of pregnant women whose previous pregnancy ended in stillbirth.

PTSD symptoms were prevalent in the pregnancy following stillbirth. Case-level PTSD was associated with depression, state-anxiety and conception occurring closer to loss. Symptomsgenerally resolved naturally by 1 year postpartum (birth of healthy baby).

Women are vulnerabe to PTSD in the pregnancy subsequent to stillbirth, particularly when conception occurs soon after the loss.

The increasing use of the methods of evidence-based medicine to keep up-to-date with the research literature highlights the absence of high-quality evidence in many areas in psychiatry.

To outline current uncertainties in the maintenance treatment of bipolar disorder and to describe some of the decisions involved in designing a large simple trial.

We describe some of the strategies of evidence-based medicine, and how they can be applied in practice, focusing specifically on the area of bipolar disorder.

One of the key clinical uncertainties in the treatment of bipolar disorder is the place of maintenance drug treatments and their relative efficacy. A large-scale study, the Bipolar Affective Disorder: Lithium Anticonvulsant Evaluation (BALANCE) trial, is proposed to compare the effectiveness of lithium, valproate and the combination of lithium and valproate.

Providing reliable answers to key clinical questions in psychiatry will require new approaches to clinical trials. These will need to be far larger than previously appreciated and will therefore need to be collaborative ventures involving front-line clinicians.

The increasing complexity of psychiatric research, including recent attempts to evaluate mental health legislation, suggests legal advice may be valuable in a wide range of research contexts.

We aim to illustrate both the legal pitfalls of research in psychiatry and the potential for solutions if the methods are carefully chosen.

Two examples of research are subject to legal analysis, one involving advance directives, the other the random discharge of compulsory out-patients.

This analysis illustrates that participation in research may expose clinicians to additional forms of liability, but the legal risks can be minimised through changes in the methods or additional safeguards.

Collaboration between academic law and psychiatry can enrich research agendas and avoid serious legal pitfalls. We argue that sound legal advice should be sought at the planning stage of research in psychiatry, but the fear of liability should not lead to overly defensive research practices. The aim should be to strike the right balance between avoiding unacceptable exposure to liability and stifling innovative research.

Twenty per cent of patients with bipolar affective disorder suffer an illness that responds inadequately to treatment and has a poor outcome. Many patients, but not all, with bipolar disorder show white matter abnormalities on T2-weighted magnetic resonance imaging (MRI).

To explore the hypothesis that white matter abnormalities on MRI are seen more frequently in subjects whose illness has a poor outcome compared with those with a good outcome or controls.

Two groups of age- and gender-matched patients with bipolar disorder (14 with a good outcome and 15 with a poor outcome) and 15 controls, aged 20–65 years, were studied. Axial T2-weighted MRI scans were examined for the presence and severity of white matter abnormalities.

Significantly more poor outcome group members had deep subcortical punctate, but not periventricular, white matter hyperintensities than the good outcome group (P=0.035) or controls (P=0.003) and these abnormalities were of greater severity (P=0.030 and P < 0.014, respectively).

Subcortical white matter lesions are associated with poor outcome bipolar disorder.

The mechanism by which rapid tryptophan depletion (RTD) paradigm induces depressive relapse in recently remitted patients with depression is unknown.

To determine the effects of RTD on brain 5-HT2 receptors using positron emission tomography (PET) and 18F-labelled setoperone.

Ten healthy women underwent two PET scans. Each scan was done 5 h after the ingestion of either a balanced or a tryptophan-deficient amino acid mixture, and the two test sessions were separated by at least 5 days.

The RTD decreased plasma free tryptophan levels significantly but it had no significant effects on mood. Subjects showed a significant decrease in brain 5-HT2 receptor binding in various cortical regions following the RTD session.

When taken with the evidence that antidepressant treatment is associated with a decrease in brain 5-HT2 receptors, these findings suggest that a decrease in 5-HT2 binding following RTD might be an adaptive response that provides protection against depressive symptoms.

There is some evidence that genetic effects on the likelihood of experiencing stressful life events (SLEs) are mediated by heritable traits such as cognitive ability (CA) and neuroticism (N).

To examine whether the association between CA, N and mental ill-health is driven in part by a predisposition to experience depressogenic SLEs.

Childhood measures of N and CA were available in a birth cohort of 5362 individuals. At ages 36 and 43 years, mental state and occurrence of SLEs in the previous year were assessed. Using a path-analytic approach, models with and without a hypothesised influence of N and CA on the occurrence of SLEs were compared.

The fit of the model with childhood N having a direct influence on SLEs was good with χ2=5.72, d.f.=4, P=0.22 at age 36 years and χ2=3.50, d.f.=5, P=0.62 at age 43. The fit of the model was significantly worse without this path at both ages (36 years: χ2=42,5, d.f.=1, P<0.001; 43 years χ2=15.3 d.f.=1, P<0.001). No consistent differences were seen in comparisons of models with CA.

The results are congruent with the suggestion that genetic effects on SLEs are mediated by personal characteristics. Part of the well-established association between N and minor psychiatric disorder may be mediated by an indirect effect of N on the likelihood of experiencing SLEs.

The study arises from the need for good quality of life (QOL) assessment and a new comprehensive generic QOL profile for cross-cultural use.

To examine changes in the QOL of patients receiving antidepressants from a general practitioner, and to assess the validity and sensitivity of a new QOL measure, the World Health Organization Quality of Life Assessment (100-item version) (WHOQOL–100).

Patients with moderate depression (n=106) completed the WHOQOL–100 and Beck Depression Inventory at the start of treatment and again after 6 weeks.

Depression decreased significantly over 2 months and 74% reported feeling better. WHOQOL–100 scores increased in 24 of the 25 facets, demonstrating that QOL improves significantly in the 8 weeks following the start of antidepressant treatment. It also shows the instrument's validity and sensitivity to changes in clinical condition.

The UK WHOQOL–100 is confirmed as excellent to good. Antidepressants significantly and comprehensively improve QOL.

The short-term course of schizophrenia is reported to be better in some developing country settings. The long-term course in such settings, however, has rarely been studied.

To examine the long-term course and mortality of schizophrenia in patients with a poor 2-year course.

The report is based on two incidence cohorts of first-contact patients in urban and rural Chandigarh, India, originally recruited for the World Health Organization Determinants of Outcome of Severe Mental Disorders study. Patients were assessed using standardised instruments at 2- and 15-year follow-ups.

Ninety-two per cent of the patients with a poor 2-year course had a poor long-term course and 47% died – a nine times higher mortality rate than among patients with other 2-year course types.

In this developing country setting, a poor 2-year course was strongly predictive of poor prognosis and high mortality, raising questions about the adequacy of care for such patients.

Brain serotonin (5-HT) function is abnormal in major depression, but the involvement of different 5-HT receptor subtypes has been little studied. The availability of selective ligands now makes it possible to test the sensitivity of 5-HT1D receptors in patients with depression.

The aim of the study was to use the 5-HT1D receptor agonist, zolmitriptan, to test the sensitivity of 5-HT1D receptors in patients with depression before and after treatment with selective serotonin reuptake inhibitors (SSRIs).

We measured the growth hormone response to zolmitriptan (5 mg orally) in patients with major depression before and after SSRI treatment. A matched sample of healthy subjects acted as a control group.

The growth hormone response to zolmitriptan was blunted in patients with a melancholic depressive syndrome. SSRI treatment produced a marked reduction in zolmitriptan-induced growth hormone release.

Patients with melancholic depression have impaired sensitivity of the post-synaptic 5-HT1D receptors that mediate growth hormone release. The reduction in 5-HT1D receptor sensitivity following SSRI treatment is probably an adaptive response to increased levels of synaptic 5-HT.

Both subjective and objective information is necessary to assess quality of life (QOL).

To explore the role of subjective and objective QOL dimensions and their cross-sectional and longitudinal predictors.

The relationship between QOL, as measured by the Lancashire Quality of Life Profile (LQL), and demographic variables, diagnosis, psychopathology, disability, functioning, affect balance, self-esteem, service use and service satisfaction was investigated at two points in time, using factor analysis and multiple regression techniques.

One subjective and two objective LQL factors with strong face validity were identified. Cross-sectional predictors of the subjective factor were primarily subjective measures; longitudinally, few predictors of this factor were identified. The cross-sectional and longitudinal predictors of the objective factors were primarily demographic and observer-rated measures.

Subjective and objective data are distinct types of information. Objective measures may be more suitable in detecting treatment effects. Subjective information is necessary to complete the QOL picture and to enhance the interpretation of objective data.

Previous reports on the incidence of schizophrenia in immigrant groups to The Netherlands were based on hospital data.

To compare the incidence of psychotic disorders in the immigrant groups to that in natives.

Two-year first-contact incidence study in The Hague.

The risks of schizophrenia, schizophreniform or schizoaffective disorder (DSM–IV criteria) were increased for subjects born in Morocco (gender and age-adjusted relative risk=4.5; 95% CI 1.4–8.5), Surinam (relative risk=3.2; 1.8–5.7), The Netherlands Antilles (relative risk=2.9; 0.9–9.5) and other non-Western countries (relative risk=2.4; 1.3–4.7). This risk was also increased for Moroccans (relative risk=8.0; 2.6–24.5) and Surinamese (relative risk=5.5; 2.5–11.9) of the second generation. The risks for Turkish immigrants, first or second generation, and for immigrants from Western countries were not significantly increased.

This study indicates that the incidence of schizophrenia is increased in several, but not all, immigrant groups to The Netherlands. It is possible that factors associated with a process of rapid westernisation precipitate schizophrenia in people who are genetically at risk.

Previous investigations into the impact of birth complications and social environment have generally followed their subjects only at young ages.

To assess the long-range impact of socio-economic status (SES) and birth risks on the development of emotional and nervous conditions through adulthood.

The Johns Hopkins Pathways Study interviewed 1824 subjects born between 1960 and 1965. The median household income of the children at age 7–8 years was used to divide the cohort into high and low income categories. Differences in lifetime prevalence of emotional and nervous conditions through adulthood between the two income groups were identified.

Children in the lower income group were 1.86 times more likely to report an emotional or nervous condition in adult life. Boys in the lower income group at age 7–8 years were 3.2 times more likely to do so. The risks of difficult birth for adult mental disturbance were accentuated in the low-income group.

Children who experience birth complications are at increased risk of developing adult mental disturbances; this increase is mitigated by higher SES.

Little research on the value of Health of the Nation Outcome Scales (HoNOS) has occurred in out-patient settings, particularly psychotherapy services.

To determine whether HoNOS provides an adequate assessment for psychotherapy services which is sensitive to change.

HoNOS ratings from 1688 patients from eight out-patient psychotherapy services were collected. Of these, 362 also had ratings post-treatment. Mean scores, pre- to post-treatment differences, and reliable and clinically significant change criteria were calculated for HoNOS items and for total scores.

The mean total HoNOS rating was 8.93, which is comparable to psychiatric out-patients. Only three items showed sufficient variability to use in assessing pre- to post-treatment change.

Significant limitations were found in rating items that commonly present to psychotherapists. The lack of variability in most items limits HoNOS's usefulness in this population.