The onset of psychotic illness in the reproductive phase of life with a decrease in fecundity (and approximately constant incidence across populations) requires an evolutionary explanation. What is the survival value of the predisposing gene or genes?

Evolutionary theories, including the author's, are reviewed and critically compared.

Some theories (e.g. Huxley et al, 1964) postulate an advantage outside the nervous system: such theories fail to explain either the characteristic age distribution or constant incidence. More plausible are theories that relate the advantage to diversity of personality structure or social ability, or even to general intelligence, i.e. to the areas of function in which the phenomena of psychosis arise.

It is argued that psychosis arises as the boundary of a distribution of variation in cerebral structure generated in the course of hominid evolution. Language played a central role, with the critical changes taking place on the basis of a mutation that allowed the two cerebral hemispheres to develop with a degree of independence. Sexual selection (differing criteria in females and males in choosing a mate) acting on this genetic innovation has generated a dimension of competence in social interaction in relation to which there has been a progressive increase in cerebral size by delayed maturation (neoteny). A sexual dimorphism in cerebral asymmetry and the sex difference in age of onset of psychosis can be parsimoniously explained if a gene regulating the relative growth of the two hemispheres is X–Y homologous.

Factors that determine geographical differences in incidence rates of ‘probable’ presenile Alzheimer's disease (AD PSD) may help to clarify the possible role of the environment in its aetiology.

We have ascertained the treated incidence of AD PSD in Scotland by scrutiny of hospital casenotes and searched for cases outside hospital settings. Small area geographical analysis compared the observed distribution of cases (each allocated to one of Scotland's 898 postcode sectors) with the estimated random distribution of cases.

There was non-random geographical distribution of AD PSD but not of the comparison conditions (vascular dementia (VaD), motor neurone disease, prostatic or ovarian cancers). Substantial differences between Scottish regions were probably not attributable to methodological artefact, as other techniques of case finding showed the same regional differences.

The observed differences in incidence of AD PSD between Scotland's regions are real and some localities have a higher incidence, mostly in central Scotland.

The selective serotonin reuptake inhibitors (SSRIs) are now widely used in the treatment of depressive illness. Interest has grown in the use of SSRIs as alternatives to tricyclic antidepressants (TCAs) and in the therapeutic use of combinations of SSRIs and TCAs in refractory depression.

MEDLINE and PSYCLit literature searches were conducted. Reference sections from papers retrieved were scrutinised for other relevant reports.

Of 41 relevant articles identified, 35 were selected for review.

Fluoxetine, fluvoxamine, paroxetine and sertraline may substantially increase TCA plasma levels when given concurrently. Such interactions may give rise to adverse effects. The effect of sertraline may be less profound than that of fluoxetine, fluvoxamine and paroxetine. Limited data suggest that citalopram may not affect TCA serum levels. There is scant literature evidence to support the use of SSRIs in combination with TCAs as a treatment for refractory depression.

Nuclear magnetic resonance is a non-destructive and non-invasive technology that is highly suited for research in psychiatry. It is establishing itself as a versatile means of studying brain morphology, chemistry and function and is finding a place in the diagnosis of disease, monitoring of treatment and the study of basic brain processes.

A literature review was undertaken.

Magnetic resonance spectroscopy has been shown to distinguish between psychiatric disorders, and has provided evidence of their pathophysiological mechanisms.

Spectroscopy in particular opens a window, for the first time, on the study of in vivo brain chemistry.

The treatment of sexual dysfunctions underwent a great change when sex therapy was developed more than 25 years ago. Since then the treatment programme has been modified in various ways, the response to treatment evaluated and other treatment approaches introduced.

A review of the literature concerning the application and outcome of sex therapy and other treatments for sexual dysfunction was conducted.

The format of effective conjoint sex therapy is now fairly clear and there is good understanding of the sexual dysfunctions that respond best to this treatment and the couples most likely to benefit. Less is known about the effects of treatment of individuals without partners, bibliotherapy and combining sex therapy with marital therapy and with physical methods of treatment.

Sex therapy is now a well-established form of treatment. It should be more widely available for patients seen in psychiatry departments.

We evaluated integrated, multidisciplinary, community-based care for a cohort of people with treated long-term mental illness over two years in a field trial set in a semi-rural setting. The aim was to organise local psychiatric services on an extramural basis with general practitioner teams as the key element.

Trained research workers used a structured interview to collect standardised baseline and three-monthly socio-demographic, clinical, social, family adjustment and burden, and treatment measures from patients, informants, and key-workers. Analysis included descriptive statistics and, for longitudinal data, analysis of best-fitted straight lines.

We studied 34 patients (14 with schizophrenia, 11 with major affective disorders, and 9 with minor (non-major) affective disorders and anxiety disorders) who had a mean of 12 years continuous illness. At baseline, they were mainly characterised by research workers as mildly ill with fair social adaptive functioning, and by lay informants as having moderate target symptom severity and disturbance of social performance. Over two years, there were statistically significant, slight improvements in clinical global impressions ratings by research workers, and in informants ratings of target symptoms and social performance. Most patients continued to receive prescriptions for psychotropic drugs throughout follow-up, and they had a mean of 47 therapeutic contacts, mainly from nurses. Two patients were admitted to psychiatric hospital. There were few differences between patients in different diagnostic groups.

Integrated, multidisciplinary, community-based psychiatric care for people with treated long-term mental illness is feasible in a semi-rural setting: patients receiving pharmacotherapy and regular psychosocial treatments remained relatively stable on clinical and social measures over two years. The unique way in which the service was monitored, by making regular, systematic assessments of patients and carers, serves as an example for other services.

Psychosocial factors may contribute 25–30% to the outcome variance in bipolar disorders. Sufferers have identified benefits from psychotherapy, but biological models and treatments dominate the research agenda. The author reviews research on psychosocial issues and interventions in this disorder.

Research on adjustment to the disorder, interpersonal stressors and obstacles to treatment compliance were located by computerised searches and the author's knowledge of the literature. All published outcome studies of psychosocial interventions in bipolar disorder are reviewed.

There is an inadequate database on psychosocial factors associated with onset and maintenance of bipolar disorder. While the outcome studies available are methodologically inadequate, the accumulated evidence suggests that psychosocial interventions may have significant benefits for bipolar sufferers and their families.

Given the significant associated morbidity and mortality, there is a clear need for more systematic clinical management that addresses psychosocial as well as biological aspects of bipolar disorder. The author identifies appropriate research strategies to improve knowledge of effective psychosocial interventions.

We related geographical variation of ‘probable’ presenile Alzheimer's disease (AD PSD) to exposures to possible risk factors for AD PSD and vascular dementia (VaD) and to geographical differences in survival times after presentation with AD PSD.

We found that an ecological measure of socio-economic deprivation was related to VaD but not to AD PSD. Among men with AD PSD and VaD, specific occupations conveyed no altered risk but having fathers who were coal miners was associated with AD PSD and VaD in offspring. Increased paternal age was associated with AD PSD but only in men. These factors acted independently of one another and did not distinguish between geographical areas of high and low incidence.

The length of survival after presentation with AD PSD distinguished between these areas, and when migration between these areas was taken into account, a plausible multifactorial model of the harmful effects of environment emerged, which acted independently of risk factors acting earlier in life.

Suicide pacts are rarely discussed in the medical literature. We report here the medical and social aspects of a consecutive series of double or pact suicides.

Coroners' records were examined for 722 consecutive suicides. Data were extracted from them and from medical and psychiatric records.

Nine pacts (2.5% of suicides) were located: 11 of the 18 people appeared to have been mentally ill at the time of death and three more had a history of mental illness. Five had a significant medical history (three cancer).

Mental disorder is common in those who enter suicide pacts (mainly depression, with alcohol dependence rare). Motivations for suicide appear to be relief of mental disorder and pain.

An exploratory study was undertaken of the importance of personality disorder in predicting the long-term outcome for both episodic disorders and social functioning.

In 1966–67, a representative series of patients with children, free of episodic illness for at least one year, was sampled from the Camberwell Psychiatric Register and systematically assessed over a four-year period, using measures of known reliability and validity. Psychiatric disorder was measured using a PSE-compatible instrument. The follow-up after 15–20 years used the PSE and a systematic assessment of social functioning.

Overall outcomes were similar across diagnoses, but an initial categorical diagnosis of personality disorder predicted much poorer outcomes on psychiatric and social measures for patients with unipolar depressive disorders than for those with other diagnoses.

The findings indicate the importance for prognosis of including a systematic assessment of personality disorder in the clinical assessment of patients with depressive disorder.

There is considerable inconsistency in the results of studies of the psychological and sexual sequelae of the menopause and their treatment.

A search of the literature on Medline was made of studies of psychological symptoms in women who were either naturally or surgically menopausal or who were receiving hormone replacement therapy for menopausal symptoms.

There is evidence of a small increase in psychological morbidity (not usually amounting to psychiatric disorder) preceding the natural menopause and following the surgical menopause. Psychosocial as well as hormonal factors are relevant. While the response of psychosocial symptoms to hormone replacement therapy with oestrogens is variable and most marked in the surgical menopause, in some studies the effect is little greater than that for placebo. Where sexual symptoms are present, there is more consistent evidence that hormone replacement therapy is effective.

In the light of the available evidence, the current use of hormone replacement therapy to treat psychological symptoms detected at the time of (but not necessarily therefore due to) the natural menopause must be questioned. It does appear that oestrogen therapy ameliorates psychological symptoms after surgical menopause.

People with severe mental illness often have a complex mixture of clinical and social needs. The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs. There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool. The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services.

A draft version of the instrument was designed by the authors. Modifications were made following comments from mental health experts and a patient survey. Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument.

The mean number of needs identified per patient ranged from 7.55 to 8.64. Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 0.99 and 0.78 respectively. The percentage of complete agreement on individual items ranged from 100–81.6% (inter-rater) and 100–58.1% (test-retest).

The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness. It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes.

Little is known about the natural history and evolution of behaviour symptoms and patterns in severely and profoundly mentally retarded adults. This paper reports a cohort study of 100 such adults.

Abnormal behaviour symptoms and patterns have been followed, using a carer rating scale and the Modified Manifest Abnormality Scale of Goldberg's Clinical Interview Schedule (1970) by the same two consultant psychiatrists in 1975, 1981 and 1992.

Emotional withdrawal, stereotypies and eye avoidance are particularly persistent. Carer ratings of noisiness and social withdrawal, and psychiatrist ratings of suspiciousness, overactivity and hostile irritability, are also persistent but to a lesser degree. Overall ratings of psychiatric disorder are persistent and act against successful community placement.

Abnormal behaviour patterns in severely and profoundly mentally retarded adults show only a modest degree of abatement over time. Care staff need a good understanding of clinical psychiatric and behaviour management techniques.