Community care has been criticised as a hazardous policy associated with high rates of adverse events. There is little research evidence as to the truth of this claim.

Best available evidence from public records, interviews, case notes, key workers and general practitioners was assembled to establish: (a) which of the 514 subjects initially identified as having psychotic illnesses had died during an average follow-up of 4.9 years; (b) care currently received by all 286 subjects originally selected for interview; and (c) rates of major adverse events and of admission for these 286 individuals.

Twenty-eight natural and 11 unnatural deaths had occurred. Among subjects still living at the end of the follow-up, 84% were in contact with specialist mental health services and 11% only with primary care services. Rates of serious violence, imprisonment and homelessness were relatively low. Forty-one per cent had been admitted at least once during a mean follow-up of 3.2 years and 20% at least once under the Mental Health Act. After adjustment, there were no significant differences between standard and intensive care sectors.

Rates of adverse events and slipping through the net’ are relatively low among individuals receiving community-based services, whether intensive or standard care.

Childhood autism is a developmental disorder with distinctive clinical features and characteristic cognitive deficits. Neuroimaging techniques have been extensively used in the study of autism and related disorders.

Recent important literature reported on structural and functional neuroimaging in autism was reviewed and discussed in the context of other neurobiological research findings.

Various abnormalities of brain structure and function have been proposed, but no focal defect has been reliably demonstrated. Important findings, so far, include increased brain volume, structural abnormality in frontal lobe and corpus callosum in a proportion of autistic individuals. Functional neuroimaging findings emphasised the imbalance in interregional and inter-hemispheric brain metabolism and blood flow as well as abnormality in the anterior cingulate gyrus.

The research to date has been hindered by methodological difficulties. However, hypothesis-driven research, particularly involving activation studies and neurotransmitter/neuroreceptor activities, using functional neuroimaging will be very useful in unravelling the enigma associated with this intriguing and distressing condition.

Community care for people with psychosis can be provided via several different service models. The study compared two models: standard community treatment with high patient:staff ratios, and intensive community treatment in which there was more of an emphasis on community involvement and lower patient:staff ratios.

All people fulfilling diagnostic criteria for psychosis and living in two defined geographical areas in south London were identified. These people were provided with either an intensive or standard service depending on their address. Their social behaviour and symptoms were measured at the beginning of the study and after two years.

There is little evidence of any effects of the two service models on levels of symptoms. However, the standard service did seem to be advantageous in reducing social disability for those with medium or low levels of disability.

The effect of intensive community services was the opposite to that predicted. Despite improvements in outcomes (e.g. hospital admission), there were no advantages for this type of service in the measures of disability or symptoms. In fact, the standard service was effective in reducing disability, whereas in the intensive service there was no change.

A randomised controlled trial of cognitive — behavioural therapy (CBT) for people with medication-resistant psychosis showed improvements in overall symptomatology after nine months of treatment; good outcome was strongly predicted by a measure of cognitive flexibility concerning delusions. The present paper presents a follow-up evaluation 18 months after baseline.

Forty-seven (78% of original n=60) participants were available for follow-up at 18 months, and were reassessed on all the original outcome measures (see Part I). An economic evaluation was also completed.

Those in the CBT treatment group showed a significant and continuing improvement in Brief Psychiatric Rating Scale scores, whereas the control group did not change from baseline. Delusional distress and the frequency of hallucinations were also significantly reduced in the CBT group. The costs of CB Tappear to have been offset by reductions in service utilisation and associated costs during follow-up.

Improvement in overall symptoms was maintained in the CBT group 18 months after baseline and nine months after intensive therapy was completed. CBT may be a specific and cost-effective intervention in medication-resistant psychosis.

Data on eight specific fears representing DSM–III–R simple phobia were analysed to evaluate: (a) their prevalence and (b) the validity of subtypes of specific phobia defined by DSM–IV.

A modified version of the Composite International Diagnostic Interview was administered to a probability sample of 8098 community respondents. Correlates of responses to questions concerning these fears were analysed.

The most prevalent specific fears were of animals among women, and of heights among men. Slight evidence was found for specific phobia subtypes. Number of fears, independent of type, powerfully predicted impairment, comorbidity, illness course, demographic features, and family psychopathology.

Number of specific fears may mark a general predisposition to psychopathology. More detailed information is needed to resolve the question of specific phobia subtypes.

Symptoms of schizophrenia known as nuclear’ or ‘first-rank’ are found in all populations. The genetic variation that gives rise to them must be as old as modern Homo sapiens.

The hypothesis was formulated that language evolved, under constraints on callosal transmission, by a process of hemispheric specialisation. One component, the phonological output sequence, became localised to the dominant hemisphere whereas its associations (the signifieds) were lateralised in part to the non-dominant hemisphere. Concepts (‘thoughts’) are translated through a bi-hemispheric interaction into phonemes (‘speech’) by the speaker in frontal association areas, and decoded back into concepts (‘meanings’) by the hearer in occipito-temporo-parietal association areas.

The first-rank symptoms demonstrate that an integral component is a system of ‘indexicality’ that distinguishes those phonemic signals generated by the hearer, from his own thoughts, and from signals that he receives from an interlocutor.

Language, as Buehler proposed, is cast in a coordinate system orientated at its origin, in the dominant hemisphere, to the self of the speaker. Thus conceived, the phenomena of the illness called schizophrenia are key to the neural organisation of the human characteristic of language.

The role of viruses in the aetiology of both chronic fatigue syndrome (CFS) and depressive illness is uncertain.

A prospective cohort study of 250 primary care patients, presenting with glandular fever or an ordinary upper respiratory tract infection (URTI).

The incidence of an acute fatigue syndrome was 47% at onset, after glandular fever, compared with 20% with an ordinary URTI (relative risk 2.3, 95% CI 1.3–4.1). The acute fatigue syndrome lasted a median (interquartile range) of eight weeks (4–16) after glandular fever, but only three weeks (2–4) after an URTI. The prevalence of CFS was 9–22% six months after glandular fever, compared with 0–6% following an ordinary URTI, with relative risks of 2.7–5.1. The most conservative measure of the incidence of CFS was 9% after glandular fever, compared with no cases after an URTI. A conservative estimate is that glandular fever accounts for 3113 (95% C11698–4528) new cases of CFS per annum in England and Wales. New episodes of major depressive disorder were triggered by infection, especially the Epstein – Barr virus, but lasted a median of only three weeks. No psychiatric disorder was significantly more prevalent six months after onset than before.

Glandular fever is a significant risk factor for both acute and chronic fatigue syndromes. Transient new major depressive disorders occur close to onset, but are not related to any particular infection if they last more than a month.

Hypochondriasis is generally considered difficult to manage. This study aimed to assess the effectiveness of cognitive therapy and to compare it with an equally credible, alternative treatment.

Forty-eight patients with hypochondriasis were initially randomly assigned to either cognitive therapy, behavioural stress management or a no treatment waiting list control group. At the end of the waiting period, patients in the control group were randomly assigned to one of the two treatments. Assessments were at pre-, mid- and post-treatment or waiting list and at three-, six- and 12-month post-treatment follow-up.

Comparisons with the waiting list group showed both treatments were effective. Comparisons between the treatments showed that cognitive therapy was more effective than behavioural stress management on measures of hypochondriasis, but not general mood disturbance at mid-treatment and at post-treatment. One year after treatment patients who had received either treatment remained significantly better than before treatment, and on almost all measures the two therapies did not differ from each other.

Cognitive therapy is a specific treatment for hypochondriasis. Behavioural stress management is also effective but its specificity remains to be demonstrated.

The costs and the effectiveness of mental health services need to be evaluated if provision is to be efficient. Service use and costs are described for two geographical areas in south London.

Service use was measured comprehensively for clients in both sectors for two six-month time periods using the Client Service Receipt Interview This information was combined with unit costs to calculate service costs. The ‘hidden’ costs of informal care and unsupported accommodation were also calculated.

At baseline significantly more intensive sector clients had in-patient stays but by the follow-up this difference had disappeared. There was significantly more use of supported accommodation in the intensive sector during both time periods. Baseline and follow-up total service costs were significantly higher for the intensive sector. Costs were spread disproportionately and a small number of services accounted for a large proportion of cost.

While the cost at Time 2 was significantly greater in the intensive sector, this was largely due to the high use of supported accommodation. There was some convergence in cost between the sectors over time.

The dose – effect relationships of cumulative trauma to the psychiatric symptoms of major depression and post-traumatic stress disorder (PTSD) in a community study of Cambodian survivors of mass violence were evaluated.

In 1990, a survey of 1000 households was conducted in aThai refugee camp (Site 2) using a multi-stage random sampling design. Trauma history and psychiatric symptoms were assessed for two time periods. Analysis used linear dose – response regression modelling.

993 Cambodian adults reported a mean of 14 Pol Pot era trauma events and 1.3 trauma events during the past year. Symptom categories of depression, PTSD, dissociative and culturally dependent symptoms exhibited strong dose – effect responses with the exception of avoidance. All symptom categories, except avoidant symptoms, were highly correlated.

Cumulative trauma continued to affect psychiatric symptom levels a decade after the original trauma events. The diagnostic validity of PTSD criteria, with the notable exception of avoidance, was supported. Inclusion of dissociative and culturally dependent symptoms increased the cultural sensitivity of PTSD.