There are interesting parallels between sleep disorders and the epilepsies. Firstly, both terms refer to a group of conditions differing in cause, clinical manifestation, natural history and impact on the lives of patients and their relatives. Secondly, the investigation and management of both sets of conditions require a combined physical and psychological approach. Thirdly, neither field is usually covered systematically (if at all) in medical education, although some initiative has been taken in the USA for the introduction of these areas into the curriculum of medical schools (Medical School Curriculum Task Force, 1988). This relative neglect no doubt explains the fourth parallel – that in both sleep disorders and the epilepsies misdiagnosis or inadequate diagnosis appears to be common.

It is probable that all schizophrenics have abnormalities in the medial temporal lobe, which differ in degree but not in kind. The structures of the medial temporal lobe are believed to have a crucial role in the integration and processing of the output from the association cortex. Dysfunction of this system could result in the clinical symptoms that form the core of the schizophrenia syndrome. The structural differences appear to fit the profile of a disturbance in the normal pattern of brain development. The asymmetrical patterns of normal brain development explain how such a disturbance simultaneously affecting both hemispheres could, disproportionately, affect the left (dominant) hemisphere. Epidemiological and pathological evidence points to aberrant genetic mechanisms as being the cause of the developmental anomaly in the majority of cases; environmental factors probably play a minor role. Despite the great progress made in solving the enigma of the structural changes in the brains of schizophrenics, the cause(s) of the changes – the aberrant genetic mechanism controlling brain development – may prove difficult to define.

Psychoanalytical ideas are used to outline how poor narcissistic development can lead to poor regulation of self-esteem. This in turn often underlies domestic violence, the short-term treatment of which can be aided by psychodynamic understanding.

The effectiveness of day care versus out-patient care in the treatment of persistent severe anxiety and depression was compared in a controlled clinical trial. Of 96 consecutively referred patients meeting the entry criteria, 92 were followed up for six months. Patients were randomised to day care or out-patient care, and assessed at entry and at six months using the Standardised Psychiatric Interview and in terms of their time structuring and socialisation. Marked improvement in all three measures was seen for most of the day patients, but for few of the out-patients: this difference was highly significant for each measure. Day patients also rated themselves as coping more effectively and as more satisfied with their treatment. These differences could not be explained by differences in use of medication. Day treatment should remain an option for patients with persistent anxiety and depression resistant to outpatient treatment.

Thirty-five people who had suffered a recent onset of symptoms of depression and/or anxiety were interviewed soon after being seen by a clinician, and again six months later. Symptom scores at the second interview were predicted by whether any plans subjects had formed by the first interview had gone wrong, by major non-health difficulties, and by internal, stable and global attributions made at the first interview about the event or difficulty that was most distressing before symptoms became severe.

The hypothesis that the sociodemographic distribution of minor affective disorder can be explained by high-risk groups experiencing more psychosocial stress, defined in terms of life events and chronic difficulties, was tested. Linear logistic analysis of data from 275 subjects identified in a community psychiatric survey provided little support for this. Although high-risk groups uniformly experienced more psychosocial adversity, and adversity was strongly associated with disorder, this did not provide an adequate explanation for the increased risk of disorder. This must therefore be explained in other ways.

Data from a two-stage survey of the general population were used to test the proposition that the over-representation of minor affective disorders among women was restricted to those who had had children, independently of current involvement in childcare. Initial analyses supported this proposition strongly. Subsequent linear logistic analyses were largely in favour of an effect of marriage rather than of parity, but it remains possible that part of the gender differences in rates of depression arises because of the effect of parity in raising female prevalence. If substantiated, the parity effect could operate through social or biological mechanisms; although its nature is unclear, it merits further investigation.

The study was based on an index group of 49 mothers who had had depressive disorders in the post-natal year, and 49 control mothers who had been free from any psychiatric disorder since delivery. Nineteen months after childbirth, the interaction between mother and child was assessed by blind assessors using defined observational methods. Compared with controls, index mother-child pairs showed a reduced quality of interaction (e.g. mothers showed less facilitation of their children, children showed less affective sharing and less initial sociability with a stranger). Similar but reduced effects were seen in a subgroup of index mothers and children where the mother had recovered from depression by 19 months. Social and marital difficulties were associated with reduced quality of mother-child interaction.

Forty-six patients with recurrent affective disorders, who began prophylactic treatment with lithium an average of 20 years previously, were followed up prospectively after a ten-year observation period to assess renal function. Nineteen patients had maintained lithium therapy, and eight patients had died. Tubular function was almost unchanged and patients who had continued lithium had not shown increasing urine volumes, but patients who had received lithium in a single daily dosage at night had a significantly lower urinary output than those on a multiple-dosage schedule. The GFR decreased significantly, but the decline was essentially dependent on increasing age, except in two patients who had developed renal insufficiency. Renal function during chronic lithium treatment is related to age, lithium intoxication episodes, pre-existing renal disease, and treatment schedule rather than to duration of prophylactic lithium therapy.

The CSF concentrations of CRF, somatostatin and β-endorphin were determined in nine patients who fulfilled DSM–III criteria for major depression with psychotic features. CSF samples were obtained at baseline in the depressed state, and again after a course of ECT. Concentrations of both CRF and β-endorphin decreased after ECT, while the concentration of somatostatin increased, although the latter difference did not attain statistical significance. The increase in CSF concentrations of CRF and β-endorphin in depressed patients is therefore seen to be state-dependent.

The 12–month outcome of 103 elderly depressed patients treated by psychiatrists in Perth, Western Australia, was good in 32–47% of cases, depending upon the stringency of the outcome criteria used. A higher than expected mortality was found, especially in men. No clear association was found between 12–month outcome and a variety of clinical variables at index admission, including chronic physical illness, severity of depression, and severe life events during follow-up. As the statistical power of this and other studies is small, it would be unwise at present to draw definite conclusions about the role of possible risk factors in the prognosis of depressed elderly. Vigorous treatment of the depressive illness and adequate after-care are important.

A prospective study of male in-patients over 55 years old who met Feighner criteria for non-bipolar depression was performed to determine if a previous history of alcoholism significantly influenced treatment or response to treatment. Among 58 subjects with complete follow-up information, the 16 who had a history of alcoholism had a presentation at index which differed from that of the non-alcoholics, and on follow-up they clearly had more chronic illness. This elderly sample with alcoholism resembles ‘neurotic-reactive’ depressives described in younger samples, and supports a past history of alcoholism as being a risk factor for chronicity of depression on follow-up in the elderly population.

Twenty-four patients who developed their first psychotic episode after the age of 45 were studied with MRI and comprehensive neuropsychological testing and compared with 72 healthy elderly subjects. The patients demonstrated more clinical abnormalities on MRI, were more likely to have large white-matter lesions or metabolic illness, and did more poorly on many neuropsychological tests, particularly those testing frontal-lobe and memory abilities. We conclude that structural brain injury is commonly associated with the late onset of psychosis. Neuroimaging investigations are a valuable component in the evaluation of this patient group.

An unselected community sample of 128 patients were studied over the 12 months after their first stroke, and compared with a control sample of subjects from the general population. Psychiatric status was assessed using the PSE and BDI. Symptoms of mood disorder were commoner in the stroke patients than the controls, but the differences were not substantial and had largely disappeared by 12 months. Psychiatric problems encountered included agoraphobia, social withdrawal, apathy and self-neglect, irritability and pathological emotionalism. While there was a high cumulative incidence of psychiatric disorder, little of it persisted: only two cases of major depression were present for the whole 12 months. We believe undue emphasis has been placed in the recent literature on major depression as a specific syndrome following stroke.

A retrospective study of referrals to a child psychiatry liaison service was carried out in order to assess the impact of the reorganisation of the service. A total of 55% of referrals were of in-patients on the paediatric ward; other in-patients made up 12.5%. Of all referrals, 67% were from paediatricians. Of the children who had not harmed themselves, most were referred either for help with the management of physical illness or for investigation of a non-organic physical complaint. The main finding was that liaison referrals increased significantly in contrast to both the total number of referrals and the number of cases of deliberate self-harm.

Among 236 in-patients in one hospital for the mentally handicapped, there was a significant relationship between the amount of motor disorder (rated using a comprehensive check-list) and the severity of mental handicap, the presence of associated psychiatric disorder and the use of neuroleptic medication. The population was fairly evenly divided between those currently, previously and never having received neuroleptic medication. All categories of motor disorder, including abnormal movements, were present in all three subgroups. Neuroleptic medication appeared to modify the expression of motor disorder rather than producing it de novo. The range and frequency of motor disorders was comparable with that in patients with severe psychiatric illness. A common cerebral basis for the motor disorders of patients with mental handicap and severe psychiatric illness is suggested.

Twenty-five patients with mild mental retardation were compared with 26 schizophrenic patients of normal intelligence. The patients with retardation had suffered an earlier onset and were less likely to have been married or employed. However, the clinical phenomena exhibited by the two groups, as elicited by a SADS–L interview, were very similar. Thus, standardised interviews and criteria for schizophrenia can be readily applied to those with an IQ between 50 and 70.

The diagnostic concept and classification of chronic depressions has long been a matter of controversy. Kraepelin (1921) considered chronic depression to be a ‘rudiment’ of fully developed manic-depressive insanity, and this view was shared by Slater & Roth (1969), who cited occasional dramatic improvement in patients with neurasthenic disorder when they received convulsive therapy.

Sixty-three relatives of 52 schizophrenics living at home were offered a package of treatments by professionals working in an everyday NHS setting: educational seminars, relatives' groups, and family meetings. Thirty-two relatives refused intervention. Of the 31 relatives who agreed, 14 attended neither the educational seminars nor the relatives' groups. Seventeen relatives had a mean of ten treatment sessions, but there was little change in their level of expressed emotion after intervention. The number of patients who relapsed was the same in the 18 months before and after intervention, although the total number of relapses fell after intervention.

British Journal of Psychiatry (1991), 158, 110–113

Eighteen long-stay patients from an old county asylum moved into hospital hostels. After 12–24 months, there were significant reductions in overall symptoms, as rated by the CPRS and the Krawiecka scale, as well as in deviant but not general behaviour, rated by the REHAB scale. Six later moved to live in supported accommodation. All relatives and patients who expressed an opinion to an independent assessor were satisfied with their present accommodation or wished to move to more independent living.