The hypercortisolaemia and dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis associated with mood disorders have been attributed to a breakdown in the glucocorticoid-receptor-mediated negative feedback mechanism regulating HPA activity. Reinstating normal feedback may be therapeutic in mood disorders.

To review the evidence for the involvement of the glucocorticoid receptor in the pathogenesis and treatment of mood disorders.

Medline and hand searches were carried out, selecting literature relevant to psychiatrists and psychopharmacologists.

A dysfunction in glucocorticoid receptors is integral to the HPA abnormalities of mood disorders. Antidepressant and mood-stabilising drugs can up-regulate glucocorticoid receptors, restoring glucocorticoid function. Preliminary clinical studies targeting the glucocorticoid receptor are encouraging.

Drugs designed specifically to up-regulate glucocorticoid receptors may be integral to future strategies in treating mood disorders.

Although the benefits of public knowledge of physical diseases are widely accepted, knowledge about mental disorders (mental health literacy) has been comparatively neglected.

To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area.

A narrative review within a conceptual framework.

Many members of the public cannot recognise specific disorders or different types of psychological distress. They differ from mental health experts in their beliefs about the causes of mental disorders and the most effective treatments. Attitudes which hinder recognition and appropriate help-seeking are common. Much of the mental health information most readily available to the public is misleading. However, there is some evidence that mental health literacy can be improved.

If the public's mental health literacy is not improved, this may hinder public acceptance of evidence-based mental health care. Also, many people with common mental disorders may be denied effective self-help and may not receive appropriate support from others in the community.

Functional imaging studies indicate that delusions and hallucinations in schizophrenia are associated with overactivity of the left hippocampus and ventral striatum. Hippocampal neuronal firing modulates feedback to cortex via cortico–striato–thalamic loops.

To test the hypothesis that recovery from psychosis is associated with decrease in activity in cortico–striato–thalamic circuits, and, furthermore, that reduction in hippocampal activity predicts the degree of alleviation of delusions and hallucinations.

Positron emission tomography (PET) was used to measure the effects of the atypical antipsychotic, risperidone, on glucose metabolism in eight first-episode schizophrenia patients.

A single dose of risperidone produced decreases in metabolism in ventral striatum, thalamus and frontal cortex. The magnitude of decreases in left hippocampus predicted subsequent reduction in delusions and hallucinations. After six weeks' treatment with risperidone, the decreases in frontal metabolism were more extensive.

The mechanism of antipsychotic action of risperidone entails reduction of hippocampal activity together with reduced feedback via cortico–striato–thalamic loops.

Selective action at limbic cortical dopamine D2-like receptors could mediate atypical antipsychotic efficacy with few extrapyramidal side-effects.

To test the hypothesis that quetiapine has ‘limbic selective’ D2/D3 receptor occupancy in vivo.

The high-affinity D2/D3 ligand [123I]-epidepride and single photon emission tomography were used to estimate D2/D3 specific binding and an index of relative percentage D2/D3 occupancy in striatal and temporal cortical regions for quetiapine-treated patients (n=6). Quetiapine-, and previously studied typical-antipsychotic- and clozapine-treated patients were compared.

Mean (s.d.) relative percentage D2/D3 receptor occupancy by quetiapine was 32.0% (14.6) in striatum and 60.1% (17.2) in temporal cortex (mean daily dose 450 mg: range 300–700 mg/day). Quetiapine treatment resulted in limbic selective D2/D3 blockade similar to clozapine and significantly higher than typical antipsychotics.

Preliminary data suggest that limbic selective D2/D3 receptor blockade is important for atypical drug action.

Those with schizophrenia often give a history of premorbid non-psychotic psychiatric disorder.

To investigate the association between non-psychotic psychiatric disorders and the later development of schizophrenia.

Men aged 18 or 19 years, conscripted to the Swedish army in 1970 (n=50 054) were linked to the Swedish National Psychiatric Case Register.

There was an increased risk of schizophrenia in those with ICD–8 diagnoses of neurosis (OR=4.6,95% CI 3.2–6.9), personality disorder (OR=8.2, 95% CI 5.4–12.3), alcohol abuse (OR=5.5, 95% CI 1.7–17.5) or substance abuse (OR=14.0, 95% CI 7.8–25.0) at age 18. Of those who developed schizophrenia, 38% (95% CI 32–45) received a diagnosis of non-psychotic psychiatric disorder at age 18. Only those with personality disorder had a significantly increased risk of schizophrenia (OR=2.4, 95% CI 1.1–5.2) with onset after age 23.

Personality factors could represent an underlying vulnerability to schizophrenia. Other diagnoses occurring before schizophrenia may reflect a prodromal phase of the illness.

It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders.

To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications.

A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years.

At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05).

Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.

To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.

Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.

Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.

The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

Family interventions for schizophrenia have proved to be highly effective in preventing relapse, but it is not clear how they work or how they should be structured.

To examine the effects of a behavioural family intervention and a family support programme on communication, problem solving and outcome in order to determine the impact of structured communication training.

Patients and family members participating in the Treatment Strategies in Schizophrenia study were videotaped engaging in 10-minute problem-solving conversations at baseline and after the conclusion of the family intervention. Tapes were subsequently evaluated for changes in communication patterns.

The intensive behavioural intervention did not produce differential improvement in communication, and change in communication was unrelated to patient outcomes.

The data suggest that intensive behavioural family interventions may not be cost efficient, and that change in family communication patterns may only be important for a subset of families.

About 30% of psychiatric out-patients with major depression demonstrate partial remission.

To explore whether the addition of cognitive therapy (CT) had any differential effect on residual symptoms or social adjustment.

Patients with residual symptoms of major depression (n=158) were randomised to receive clinical management (CM) alone, or CM plus 18 sessions of CT. Subjects' depressive symptoms and social functioning were assessed regularly over 16 months.

The addition of CT produced statistically significant differential effects on: two out of four measures of overall severity of depression; specific psychological symptoms (guilt, self-esteem and hopelessness); and social functioning (including dependency, interpersonal behaviour and friction).

In patients showing only partial response to antidepressants, the addition of CT produced modest improvements in social and psychological functioning. The implications for research on the mechanisms of action of CT are discussed.

Previous studies suggest that brain serotonin neurotransmission may mediate the actions of lithium carbonate. Acute tryptophan depletion reduces brain serotonin and allows the study of this neurotransmitter in patient groups.

To examine the effects of acute tryptophan depletion on mood and suicidal ideation in bipolar patients who were symptomatically stable on lithium.

Nineteen subjects satisfying DSM–IV criteria for bipolar I disorder participated in a within-subject, double-blind, placebo-controlled random-order crossover study. Symptoms were evaluated following acute tryptophan depletion, which was induced by a 100 g amino acid drink following an overnight fast.

Plasma tryptophan fell significantly after the depleting drink, but not after the control drink (P < 0.05, paired t-test, mean reduction 83%). No significant changes in mood or suicidality scores were recorded after acute tryptophan depletion.

Acute tryptophan depletion does not reverse lithium's effects on mood and suicidality in bipolar disorder.

In people with learning disability one of the most frequent reasons for psychiatric referral is challenging behaviour.

To determine what proportion of people with challenging behaviour actually have psychiatric symptoms.

Using an instrument specifically designed for use by informants, a sample of 320 people with administratively defined learning disability, with and without challenging behaviour, was surveyed for the presence of psychiatric symptoms.

Increasing severity of challenging behaviour was associated with increased prevalence of psychiatric symptoms, depression showing the most marked association. Anxiety symptoms were associated with the presence of self-injurious behaviour.

There is clearly the potential for reducing challenging behaviour by improved identification and treatment of coexisting psychiatric disorders. The possibility of modifying diagnostic criteria for depression in people with learning disability, by including aspects of challenging behaviour, merits attention.

Little is known about personality disorders and normal personality dimensions in relatives of patients with obsessive-compulsive disorder (OCD).

To determine whether specific personality characteristics are part of a familial spectrum of OCD.

Clinicians evaluated personality disorders in 72 OCD case and 72 control probands and 198 case and 207 control first-degree relatives. The self-completed Revised NEO Personality Inventory was used for assessment of normal personality dimensions. The prevalence of personality disorders and scores on normal personality dimensions were compared between case and control probands and between case and control relatives.

Case probands and case relatives had a high prevalence of obsessive-compulsive personality disorder (OCPD) and high neuroticism scores. Neuroticism was associated with OCPD in case but not control relatives.

Neuroticism and OCPD may share a common familial aetiology with OCD.

The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour.

To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).

Analysis, using Poisson regression, of the number of suicides and open verdicts (suicides’) in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992–1996. Similar analysis on DSH presentations to a general hospital.

Suicides increased during the month following the Princess's funeral (+ 17.4%). This was particularly marked in females (+33.7%), especially those aged 25–44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.

The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.