With genetic and neurochemical findings pointing to a biological aetiology, considerable effort has been devoted to finding direct evidence of brain abnormality in schizophrenia.

T, MRI, post-mortem and functional imaging studies are reviewed to assess which structural and/or functional brain abnormalities have been consistently demonstrated.

The only well-established structural abnormality in schizophrenia is lateral ventricular enlargement; this is modest and there is a large overlap with the normal population. There is no consensus on the presence of any localised structural abnormality from MRI and post-mortem studies, but the most promising findings concern temporal lobe limbic structures. Hypofrontality is not a well-replicated finding in schizophrenia under resting conditions, but the evidence is stronger for a selective association with negative symptoms. A number of studies have found hypofrontality under conditions of neuropsychological task activation. However, findings in these studies are divided and a recent methodologically sophisticated study has failed to confirm it, although this study suggested a decoupling of prefrontal and temporal function.

Schizophrenia is characterised by minor structural abnormality which, in the case of lateral ventricular enlargement, may be better understood as a risk factor than a causative lesion. The functional imaging findings are not transparent but suggest that, as a disorder, schizophrenia shows complex alterations in regional patterns of activity rather than any simple deficit in prefrontal function.

Dysthymia has been reconceptualised in recent years from a personality disorder to a chronic affective disorder. It is incorporated into both the DSM and ICD diagnostic systems. Method. The members of the WPA Dysthymia Working Group combined the results of their manual literature searches with a search using Medline.

Available data are summarised under the headings of classification, epidemiology, validity, comorbidity, course and outcome, pharmacotherapy and psychotherapy. The coexistence of major depressive disorder, constituting ‘double depression’ is of particular importance.

Improved knowledge of this disorder has led to a more positive approach to treatment, in which antidepressants can usefully be complemented by psychosocial measures. A high proportion of cases remain unrecognised in most populations, leading to prolonged morbidity and distress, much of which is now treatable.

The prescription of psychotropic drugs for children is a sensitive and highly contentious subject which may explain the apparent lack of uniformity and consistency in clinical practice.

This review is based on Medline and manual search of the literature.

More than 1000 relevant references were found, and information has been culled from all these. Fifty particularly relevant articles have been selected for the reference list.

Recent years have seen considerable research in this field, and a clearer picture of the benefits and limitations of drug use in children is emerging.

Clinicians practising in the UK are generally conservative in their prescribing of psychotropic drugs for children. This cautious approach is generally justified by concern about toxic side-effects, the potential effects on growth and development, and the paucity of relevant clinical research.

It was proposed to explore the longitudinal relationship between adverse experience and mental health; in particular, whether particular adverse experiences influence the form of subsequent expression of morbidity.

Three groups of women were selected: 64 whose marital partner had recently died, 143 whose husbands had recently experienced a myocardial infarction and a third group of 32 women who had sought protection in a Women's Aid refuge. An initial interview assessed psychiatric status according to the RDC for the six months before the event and up to the time of interview, and a second interview was completed four months after the event had occurred. The course was assessed using the Longitudinal Interval Follow-up Evaluation.

For the coronary group, the prevalence of psychiatric disorder doubled following the experience of the event, and was most pronounced for anxiety disorder. For the bereaved, rates increased over eight times for major depressive disorder and more than twice for anxiety disorder, following the loss; for the refuge group, prevalence rates were lower after entering the refuge than those before. Analyses that took account of the timing of the onset of disorders showed that in almost half of those experienced by the coronary group, and about 40% of the bereaved group, onset pre-dated the timing of the event.

The results further advance knowledge of the evolution and form of psychiatric conditions following the experience of severe adversity.

Computer-supported neural network models have been subjected to diffuse, progressive deletion of synapses/neurons, to show that modelling cerebral neuropathological changes can predict the pattern of memory degradation in diffuse degenerative processes such as Alzheimer's disease. However, it has been suggested that neural models cannot account for more detailed aspects of memory impairment, such as the relative sparing of remote versus recent memories.

The latter claim is examined from a computational perspective, using a neural associative memory model.

The neural network model not only demonstrates progressive memory deterioration as diffuse network damage occurs, but also exhibits differential sparing of remote versus recent memories.

Our results show that neural models can account for a large variety of experimental phenomena characterising memory degradation in Alzheimer's patients. Specific testable predictions are generated concerning the relation between the neuroanatomical findings and the clinical manifestations of Alzheimer's disease.

Torture, with its personal, cultural, political and psychosocial effects, is presented as a complex trauma. The efficacy of different treatment modalities for those survivors who need assistance is examined critically.

International literature searches using MEDLINE and Psych-Info, books and relevant book chapters were examined.

One hundred and twenty-five articles were selected for analysis; 30 of the most relevant are discussed.

Discrete approaches to treatment have been developed, but many have yet to be evaluated critically. Common therapeutic elements are outlined. It is recommended that an integrated, flexible, client-centred approach utilising several techniques is most likely to achieve best results. Wider socio-political aspects should be taken into account, and treatment must be consistent with cultural expectations. Future directions for research are outlined and the role of primary prevention is stressed.

People with obsessive–compulsive disorders (OCD) are widely treated with a combination of medication and behavioural techniques. The success rate is 50–85%, but both relapse and drop-out rates appear high. The use of cognitive therapy (CT) for the treatment of OCD has been suggested. The empirical evidence supporting the use of CT for OCD is examined.

A manual and computer (Medline) literature search was performed.

Fifteen empirical studies were found: ten non-controlled, and five controlled.

There are few controlled CT studies, and these show little evidence of improvement when CT is added to existing therapeutic techniques.

Appraisal of the future of adolescent psychiatry is required urgently, in view of the increasing scrutiny of mental health service priorities and the need for informed planning of psychiatric training and manpower requirements.

Future developments are set in the context of the changing concept and connotations of adolescence, the history and present position of adolescent psychiatry, and the rationale for separate services.

Predictions are derived using trend extrapolation, in relation to a number of factors likely to determine the future. These include the social value attached to adolescence and youth, the status of adolescent medicine, the definition of clinical boundaries, the upper age-limit of services, investment in prevention, postgraduate training, research, the evaluation and marketing of adolescent psychiatry and, finally, its recognition as a separate sub-speciality.

Predictions suggest that adolescent psychiatry will assume an expanding clinical role and increasing academic influence in the 21st century.

This study was performed in order to evaluate the short-term efficacy and safety of fixed risperidone doses compared to haloperidol.

In a multi-national, parallel-group, double-blind study, patients with chronic schizophrenia (DSM–III–R) were randomly assigned to risperidone 1, 4, 8, 12 or 16 mg or haloperidol 10 mg daily for 8 weeks. Efficacy was assessed by the Positive and Negative Syndrome Scale for schizophrenia (PANSS) and clinical global impression (CGI), and safety primarily by the Extrapyramidal Symptom Rating Scale (ESRS).

One thousand three hundred and sixty-two patients were evaluated. The optimum risperidone doses were 4 mg and 8 mg, with response rates of 63.4% (56.8%; 69.7%) and 65.8% (59.2%; 71.9%) respectively. Response rate in haloperidol-treated patients was 58.7% (52.0%; 65.3%); the 95% confidence intervals (CI) of the differences between risperidone 4 mg or 8 mg and haloperidol were (–4.3%; 13.7%) and (–1.9%; 16.0%) respectively. There were no significant differences in CGI scores at endpoint between risperidone 4 mg, 8 mg, 12 mg and 16 mg and haloperidol (3.0, 3.0, 3.2, 3.1 and 3.1 respectively); the 95% CI of the differences between risperidone 4 mg or 8 mg and haloperidol were (–0.4; 0.1) and (–0.3; 0.2) respectively. Mean shifts to the maximum total ESRS scores versus baseline (mean (confidence interval)) were significantly greater in haloperidol-treated patients (5.1 (4.0; 6.2)) than in the risperidone 1, 4, 8 and 12 mg groups (1.1 (0.3; 1.9); 1.8 (0.9; 2.7); 2.7 (1.8; 3.6) and 3.2 (2.3; 4.1) respectively (P< 0.05)).

Risperidone is an effective antipsychotic for the treatment of chronic schizophrenia; doses of 4 and 8 mg seem to be optimal and have a lower incidence of side-effects than haloperidol.

The White Paper The Health of the Nation targets a reduction in suicide rates. Preventive strategies must be guided by an understanding of the demography and antecedents of suicide. These issues are examined in relation to suicide by old people in Manchester.

One hundred consecutive coroners' inquisitions on people aged over 65 occurring between 1980 and 1991 in which the verdict was suicide were scrutinised and related to Health Service notes.

Suicides were rare, numbers ranging from 0 to seven per annum per Health District. Rates did not vary between district but did within smaller sub-populations. Most individuals died at home; 65% were physically ill, of whom 23% had been hospitalised within the previous year. At least 60% were clinically depressed, with 25% being prescribed antidepressants. A total of 43% had seen their general practitioner in the previous month but only 14% were in contact with psychiatric services.

Many elderly people who commit suicide are not in close contact with primary care services; those who are may not be prescribed appropriate treatment, and few are referred for specialist care. Specialist services will fail to reduce suicide rates unless they embark upon programmes to increase public awareness of therapeutic possibilities and work more closely with primary care agencies to realise these possibilities.

Decision analysis is an explicit, quantitative approach to examining difficult decisions about course of action. Its applicability to psychiatry is considered.

An example of how decision analysis could be used in psychiatry is given, criticism of the technique is discussed, and previous attempts to apply it to mental illness problems (from a Medline search from 1966 onwards) are reviewed.

The future for decision analysis in psychiatry lies in teaching, audit and research, rather than clinical work.

This paper reports further data from the Stoke study of postnatal depression and examines whether psychosocial characteristics and symptom profiles differ between postnatal and control depression.

Two hundred and thirty-two postnatal and non-postnatal control women were screened with the Edinburgh Postnatal Depression Scale; all high scorers and a sample of low scorers were interviewed with the Standardised Psychiatric Interview and modified Social Maladjustment Schedule. Depression was diagnosed using the Research Diagnostic Criteria.

Postnatal but not control depression was associated with a poor relationship with the woman's own mother and greater occupational instability. Depression in control women was associated with low income, having three or more children, performing manual work and occupational dissatisfaction, but postnatal depression was not. There were no differences in the symptom profiles of the postnatal and control women nor between early and late onset postnatal depression.

Depression is a common and socially disabling disorder affecting mothers of young children. Postnatal depression is more contingent on acute biopsychosocial stresses caused by the arrival of a new family member. Depression in women with older children is more closely related to longer term social adversity.

In a 10-year follow-up of a survey from Oslo, 503 persons were reinterviewed using the same questionnaire.

The questionnaire includes information about social support, ‘locus of control’ and mental health as well as negative life events and long-lasting mental strain during the year prior to the follow-up.

The study confirms the “buffer hypothesis”, that social support protects against the development of mental disorder only when the individual is exposed to stressors, like negative life events. This buffering effect was especially strong for depression.

The buffering effect only applies to the ‘externals’ –those who have personality-related feelings of powerlessness and lack of control over their own lives. The ‘internals’ do not have the same need for social support to cope with life stressors, and have low symptom scores even when negative life events are combined with relative weak social support.

This study explored some of the problems associated with current procedures for the ascertainment of suicide.

A sample of 242 deaths which were known to have been self-inflicted was followed up through the coroners' courts where causes of death were legally established.

Verdicts other than suicide were returned on half of the men, and on one-quarter of the women.

For suicide statistics to become valid indicators of suicide rates it might be more appropriate to apply the civil, rather than the criminal, standard of proof during inquest proceedings.

Prenatal and perinatal factors have been linked to affective disorders. We therefore undertook an exploratory study to determine whether prenatal exposure to severe famine was associated with an increased risk of affective disorders.

Monthly birth cohorts that were exposed and unexposed to the Dutch Hunger Winter of 1944–45 were identified. The cumulative incidences of affective psychoses and neurotic depression (ICD–9 criteria) were compared between exposed and unexposed cohorts during each trimester of gestation.

The relative risk (RR) of affective psychosis (broad and restricted definitions) among persons exposed to famine during the second trimester was significantly increased (broad: RR (95% confidence interval) = 1.62 (1.19, 2.20); restricted: 1.59 (1.14, 2.21)). Separate analysis by gender showed a significant association among males (broad: 2.26 (1.43, 3.57); restricted: 2.40 (1.49, 3.89)), but not females (broad: 1.28 (0.84, 1.94); restricted: 1.17 (0.73, 1.86)). The risk of neurotic depression was not increased after prenatal famine exposure.

These results suggest a possible relationship between prenatal famine during the second trimester and affective psychosis, lending plausibility to reports that have associated affective psychoses with prenatal exposures. Further studies of this relationship are warranted.

It is unclear whether the causative factors of non-psychotic postnatal depression are the same as those of depression at other times.

The course and recurrence of postnatal depression was studied in two groups of primiparous women experiencing an index episode of postnatal depression: those for whom the mood disorder had arisen de novo (n = 34), and those for whom it was a recurrence of previous affective disturbance (n = 21). The mental state of these two groups, together with a psychiatrically well control group (n = 40), was studied for five years.

It was found that those for whom the index episode was a recurrence of depression were at raised risk of further non-postpartum episodes but not postpartum episodes, and that those for whom the index episode had arisen de novo were at raised risk for further episodes of postnatal depression but not for non-postpartum episodes.

These findings suggest a specific nosologic reference for the concept of postnatal depression.