For 18 years, Northern Ireland has suffered a changing pattern of civil disorder. Early years were marked by widespread sectarian rioting, shootings, and bombings, which heightened community tension and caused much social and commercial disruption. However, in recent years, terrorist organisations have been more selective in their acts of violence. There are methodological difficulties in assessing the psychological impact of civil disorder and terrorism. But, as well as can be judged from community surveys, hospital admissions and referral data, psychotropic drug usage, suicide and attempted suicide rates, and from assessment of the actual victims of violence, society has not ‘broken down’ nor has the impact been judged considerable. Possible explanations are discussed.

Clinicians who deal with patients with anorexia nervosa are well acquainted with their patients' inability to recognise their emaciation. The patients' insistence that they are normal weight or even overweight, against clear evidence to the contrary, led Bruch (1962) to state that the misperception reaches “delusional proportions”. Studies of body size perception in anorexia nervosa that have used the ‘body part’ method have invariably found that the patients overestimate their body size (Slade & Russell, 1973; Crisp & Kalucy, 1974; Pierloot & Houben, 1978; Garner et al, 1976; Button et al, 1977; Fries, 1977; Casper et al, 1979) but the majority have not found any significant difference in size estimation between patients and controls (Slade, 1985).

The chemical structure of fluoxetine, (±)-N-methyl-3-phenyl-3-[(α,α,α-trifluoro-p-tolyl)oxy]propylamine, as shown in Fig. 1, lacks the three-fused ring system contained in tricyclic antidepressant drugs (TCAs) such as imipramine and amitriptyline. The p-trifluoromethyl substituent on the phenoxy ring of fluoxetine is an important determinant of its potency and its specificity as a serotonin-uptake inhibitor, e.g. the analogue having an o-trifluoromethyl substituent on that ring is only about one-hundredth as potent as fluoxetine in inhibiting serotonin uptake (Wong et al, 1975a). Nisoxetine (Wong et al, 1975b) and tomoxetine (Wong et al, 1982) are analogues differing from fluoxetine only in having an o-methoxy or an o-methyl substituent respectively, in place of the p-trifluoromethyl substituent on the phenoxy ring. Nisoxetine (LY94939) and tomoxetine (LY 139603) are potent and highly selective inhibitors of norepinephrine uptake (Wong et al, 1975b, 1982), differing strikingly from fluoxetine in specificity of uptake inhibition.

Fluoxetine has been shown to be a potent and selective inhibitor of serotonin uptake in laboratory animals; it is orally effective and has a long duration of action. This compound has been a valuable pharmacological tool to study the mechanisms of serotonergic neurotransmission and physiological functions of brain serotonin neurons (Fuller & Wong, 1977; Wong et al, 1985a; Fuller & Wong, 1987). The present paper summarises some of the pre-clinical studies which have characterised fluoxetine as a selective inhibitor of serotonin uptake.

Chronically ill day patients were followed up 3 years after identification in the catchment areas of 13 psychiatric hospitals serving 54% of the Scottish population. Five per cent had died, 6% were in-patients, 56% remained day patients and 14% were supported by community psychiatric nurses or attended an out-patient clinic; contact had been lost with 19%. Over 3 years, 32% had had at least one admission to in-patient care; a wide range of other services was also used. There was little change in the level of disability; a typical patient in contact at follow-up was single, schizophrenic, and rather disabled.

Ninety-two Danish manic–depressive patients with a first psychiatric admission between 1969 and 1983, who committed suicide before 1 July 1986, were considered. Information on any prophylactic or continuation treatment at the time of the suicide was obtained. In 64 of the patients, every precaution seems to have been taken: 28 patients committed suicide during ongoing treatment; 10 while not receiving prophylactic treatment (not indicated); 7 while not in prophylactic treatment because the patients refused or did not tolerate such; and 19 while in prophylactic treatment with antidepressants (10), or lithium (6), or both (3), in usually adequate dosage. In 28 of the patients, suicide might have been obviated. Guidelines for improvement of suicide prevention in manic–depressive illness are presented.

The study was carried out on 25–34-year-old, British-born, married women, living on a south-east London housing estate. The reported early and current family relationships of 50 depressed and 40 non-depressed women were compared. Significantly more of the depressed women reported a poor early relationship with their mothers, but not with their fathers. This finding was confirmed by corresponding low care and high overprotection scores (for mothers only) on the Parental Bonding Instrument. On the basis of what the women and their husbands said, the marriages of the depressed women were rated as much poorer. This was confirmed by the women's and their husbands' scores on a Partner Rating Questionnaire and the Ryle–Scott-Heyes Marital Patterns Questionnaire. The depressed women reported a poorer current relationship with their mothers and a much poorer relationship with their husbands' mothers and fathers. Significantly more depressed women reported four or more poor family relationships.

An increasing number of psychiatric services have non-seclusion policies. Evaluation of a policy of using specified observation levels instead of seclusion was made over a two-year period. The number of violent incidents recorded in health service facilities was low (exactly 50). Community responses elicited from police, probation, and prison services were not generally critical of the policy. Medication levels used were not excessive as determined by peak levels of major tranquilliser and anti-Parkinsonian drugs used. No patient was excluded from the unit because of his or her level of actual or potential aggression, but two were transferred from it for this reason.

A two-stage screening strategy was used to study psychiatric morbidity and social problems in a consecutive series of out-patients with insulin-dependent diabetes mellitus. The prevalence of psychiatric morbidity was 18%, and consisted of depression, anxiety, and attendant symptoms. Patients reporting major social problems had significantly higher levels of psychiatric symptoms. Psychiatric morbidity was not associated with the presence of complications of diabetes.

A sample of psychiatrists was asked to read a case vignette and indicate likely management and attitudes to the patient on a number of semantic-differential scales. Patients given a previous diagnosis of personality disorder (PD) were seen as more difficult and less deserving of care compared with control subjects who were not. The PD cases were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts. PD therefore appears to be an enduring pejorative judgement rather than a clinical diagnosis. It is proposed that the concept be abandoned.

The Present State Examination was conducted upon 328 recently admitted psychotic patients, of whom 23 were later found to have underlying organic illness. The phenomenology in these 23 was compared with that of 92 matching controls drawn from the parent sample who conformed to DSM-III criteria for schizophrenia, mania and depression. Few significant differences were present and there was considerable overlap between the diagnostic groups.

For many decades thinness has been a desirable attribute for women in prosperous northern European and American cultures. Over the last 20 years or so the acceptable female shape has become even slimmer (Garner & Garfinkel, 1980). The increased emphasis on thinness among women is also apparent from the rising number of articles on slimming in women's magazines in recent years.

The tremendous increase in interest in childhood and adolescent depression that has occurred since the early 1970s has resulted in a large and contradictory literature. Development of the concept of childhood depression, and the many clinical studies of depression and its concomitants, both psychosocial and biological, are critically reviewed. A number of methodological and theoretical problems are discussed.

The paper describes a special hospital-based treatment programme for male mentally handicapped offenders, comprising a package of practical and personal skills training coupled with a socialisation programme based on token-economy strategies within a controlled and structured environment. Twenty patients admitted to the programme and followed up after discharge for an average of 3.3 years were studied in detail. All had committed serious or persistent offences and showed a high level of psychosocial pathology. A good or fair response to the treatment programme was made by 85%, and 65% were judged well adjusted or reasonably well adjusted at last follow-up contact. A good outcome was associated with more than two years' in-patient care, a good response to the treatment programme and stable residential placement, regular occupation and regular supervision and support in the community. Offenders against the person (sex and assault) had a better prognosis than and showed other interesting differences from property offenders (property and arson).

Drugs are discovered by a variety of approaches, which include a systematic evaluation of synthetic compounds, using extensive structure activity relationships. After a lead compound which possesses desirable pharmacological properties is found, through the exhaustive screening of a variety of compounds, a number of congeners are then synthesised and tested, using specific physiological or biochemical models of therapeutic agents. The discovery of fluoxetine involved this complex process, and led to the description in the literature of one of the first selective serotonin uptake inhibitors (Wong et al, 1974); it was subsequently tested clinically, and these studies demonstrated its effectiveness and safety as an antidepressant drug (Chouinard, 1985). This paper reviews the published information relevant to fluoxetine's pharmacology and pharmacokinetics in man.

The result of, and difficulties in, applying a range of existing criteria for mild dementia to a random sample of community elderly aged 70 years and over is examined. By one or more criteria, 25% had mild dementia, and almost 30% of these had additional psychiatric disorders, mostly depression. Prevalence rates for mild dementia varied widely according to the different criteria. Rates of mild dementia increased with age. Poor specification of diagnostic criteria was a major problem. These criteria should be standardised and detailed, and prospective longitudinal studies conducted to elicit the natural history of this condition.

The validity of premorbid IQ estimates provided by the National Adult Reading Test (NART) and Vocabulary sub-test of the Wechsler Adult Intelligence Scale were evaluated, by comparison with matched, healthy control subjects, in Korsakoff psychosis, alcoholic dementia, dementia Alzheimer type (DAT), multi-infarct dementia (MID), Huntington's disease, and closed head injury (CHI). There was no significant difference in NART performance between control subjects and the alcoholic dementia, DAT, MID, and CHI groups. Although there appeared to be a decline in NART performance in the Korsakoff and Huntington's groups, it did provide a significantly higher IQ estimate than the Vocabulary sub-test. All clinical groups, with the exception of the CHI group, performed at a significantly lower level than the control group on the Vocabulary sub-test.

The tricyclic antidepressants (TCAs) were discovered accidentally by pharmaceutical chemists seeking first, better antihistamines and then antipsychotic agents. Careful clinical assessment revealed the antidepressant properties and suggested that the closer the patient resembled the classical textbook description of ‘endogenous’ depression, the more likely was an adequate clinical response to occur (Kuhn, 1958). However, it was quickly realised that the TCAs possess a plethora of side-effects, particularly sedation and symptoms related to their anticholinergic effects.

Despite much research over the past 25 years, it is unclear how TCAs effect clinical improvement. The two main neurotransmitters involved in some way are noradrenaline (Schildkraut, 1965) and 5-hydroxytryptamine (5-HT; serotonin; Van Praag, 1977). It was proposed that TCAs acted by blocking the reuptake of one or other or both of these neurotransmitters, thereby increasing their concentration in the synaptic cleft. However, as well as these acute effects, chronic effects, such as a decrease in the number of central beta-adrenoceptors (‘down-regulation’) occur, and these are probably more relevant to the clinical action.

A study on neurological conditions was performed in the Republic of San Marino, which is the smallest independent state in the world (60 km2, 21 792 people). We personally examined or collected information on all people born in 1898, 1903, 1908, 1913 and 1918 and living in the Republic of San Marino on 31 July 1985. We found 29 people out of 488 with mild to severe dementia. Frequency of dementia increased progressively with age, from 1.8% among 67-year-olds to 25% among 87-year-olds. In women the increase was due mainly to primary degenerative dementia, whereas in men other types of dementia were involved. Our study shows a female/male ratio of more than 2:1 for primary degenerative dementia even considering mild dementia, and this form of dementia represents about 50% of all types of dementia. We found an association between severe auditory loss and primary degenerative dementia.

A retrospective case-note survey was carried out on 31 subjects admitted with temporal-lobe epilepsy to the Maudsley hospital from 1974–1983 inclusive. Fourteen aggressive subjects were compared with the non-aggressive patients on 95 organic, developmental, and social variables. Aggressive behaviour was associated with male sex, early onset of seizures, and a history of long-standing behavioural problems. Aggressive subjects had lower mean IQ scores and poorer occupational records than controls. No relationship was found between aggression and the presence of specific EEG or CAT scan findings, or a history of psychosis. The results demonstrate the complex interplay between organic and socially mediated factors underlying aggressive behaviour in temporal-lobe epilepsy.

Sixty individuals are described who have lifelong eccentricity and social isolation and who have sought psychiatric treatment as a direct or an indirect result. They were predominantly young and, as in other samples of autistic people, male (6M: 1F). Most of them were of normal intelligence. They were all profoundly socially handicapped: few had lived independently, had lasting sexual relationships or spent much time in employment. Nearly a half of the subjects had been involved in antisocial behaviour at some stage. Nearly a quarter had committed a criminal offence. Violence was usually domestic, most often directed against the mother. Forty-eight per cent of subjects had a second psychiatric disorder (11.7% had a psychosis).