The 20th century has seen the globalisation and homogenisation of substance misuse problems, blurring traditional boundaries between producer and consumer countries and forcing the international community to consider new responses to substance misuse.

To highlight the importance of the principles of illicit drug demand reduction and related activities in tackling global drug problems and to discuss the commitment made by United Nations (UN) Member States at the highest political level towards meeting the objectives set in their Declaration on the Guiding Principles.

A review of international responses to substance misuse.

Traditionally, the focus has been on reducing the supply of controlled drugs, while maintaining adequate supplies of narcotic and psychotropic drugs for clinical and scientific purposes. However, it has become apparent that supply reduction in isolation is insufficient and demand reduction is now receiving greater emphasis – culminating in the UN General Assembly adopting the Declaration on the Guiding Principles of Demand Reduction in 1998.

This declaration offers a genuinely holistic approach to the complexities of substance misuse. To be successful, it requires the commitment of governments at the highest level and the willing participation of small communities.

This is the first long-term follow-up of patients discharged from a medium secure unit.

To describe the short– and long-term outcomes of admission for all patients discharged during a 14-year period.

A longitudinal cohort study of all 234 patients discharged from the Denis Hill Unit, Bethlem Royal Hospital, between 1980 and 1994, followed for an average 6.6 years.

Although 48% of admissions were from prison, only 8% returned there, with most being transferred to another psychiatric bed. One-fifth of patients spent none of the follow-up time in the community; 75% of patients had at least one readmission; only 24% were convicted of further offences.

Re-offending rates are comparable with those for patients discharged from high-security hospitals, and much lower than those for released prisoners. The high readmission rates indicate the need for a range of services to maintain former patients in the community.

A follow-up of patients discharged from medium secure psychiatric units is used to compare outcome in patients of different ethnic origin.

To test the hypothesis that there are systematic differences in clinical outcome between ethnic groups.

A descriptive, longitudinal cohort study of discharges from a medium secure unit is used to compare the 125 patients of White/European ethnic origin and the 104 patients of Black/African–Caribbean origin.

Patients of African – Caribbean origin were admitted at three times the rate of White patients, had a higher prevalence of psychosis and a lower prevalence of personality disorder. There was no difference in outcome as measured by location at follow-up, readmission or re-offending.

The higher rate of admission of African–Caribbean patients is consistent with a higher level of demand. There is a need for studies of the pathways by which patients from ethnic minorities reach medium-security accommodation, with a view to early intervention.

There have been few large-scale studies of long-term suicide risk in mental disorders in the UK.

To estimate the long-term risk of suicide in psychiatric patients.

A sample of 7921 individuals was identified from the Salford Psychiatric Case Register. Mortality by suicide or undetermined external cause during a follow-up period of up to 18 years was determined using the NHS Central Register; suicide risks were estimated as rate ratios.

Suicide risk was increased more than ten-fold in both genders: the rate ratio for males was 11.4; for females it was 13.7. The risk was highest in young patients, but high risk continued into late life. The diagnoses with the highest risk were schizophrenia, affective disorders, personality disorder and (in males) substance dependence. Risk was also associated with recent initial contact and number of admissions but not comorbidity.

The suicide risks estimated in this study are generally higher than those previously reported, notably in schizophrenia and personality disorder, and in previous in-patients. Patients with these high-risk diagnoses, an onset of illness within the previous 1–3 years, or more than one previous admission should be regarded as priority groups for suicide prevention by mental health services.

The Care Programme Approach (CPA) and supervision register policies in England are intended to prioritise patients to receive specialist mental health care.

To describe and evaluate the practical application of the policies.

A questionnaire survey of key informants in mental health provider trusts and an analysis of aggregated data collected by health authorities using the Mental Illness Needs Index as a measure of population need.

On average, 1175 per 100 000 total population are subject to the CPA (95% Cl=1055–1309) and 8.6 per 100 000 (95% Cl=7.5–9.9) are on supervision registers. Wide local variations in the number of people subject to the CPA and supervision registers are not explained by variations in population need.

Prioritisation to receive specialist mental health services is carried out inconsistently, and inequitable use of resources may result.

Previous studies have suggested that cognitive therapy is effective in modifying delusions.

To assess the effectiveness of cognitive therapy on patients seen in routine clinical work.

Eighteen patients with chronic delusions were treated using cognitive therapy, after the method of Chadwick and Lowe. A single-case multiple-baseline experimental design was used, including a control treatment. Each subject was used as their own control.

Six patients reduced conviction in their delusions during cognitive therapy and not during the control treatment. Seven patients' conviction ratings did not change. Five patients showed a variable response. Degree of conviction did not fall to zero in any patient. All patients reported that the therapy had been helpful; six spontaneously mentioned changes in psychotic thinking.

One-third of patients with chronic delusions whom we treated responded to delusion modification with a reduction in degree of belief. Change within therapy sessions predicted outcome, as did variation in the conviction during baseline. Cognitive therapy with delusions should aim at reducing distress as well as conviction.

Rates of, and risk factors for, lithium-associated clinical hypothyroidism are uncertain.

To determine prevalence of and risk factors for clinical hypothyroidism in patients treated with lithium carbonate.

Retrospective case-note review of 718 patients who had undergone serum lithium estimation during a 15-month period. Patients on thyroxine had a more detailed review.

The prevalence of clinical hypothyroidism during lithium treatment was 10.4%. The main risk factor was female gender (women 14% v. men 4.5%). Women were at highest risk during the first two years of lithium treatment, and women starting lithium aged 40–59 years had the greatest prevalence (> 20%). No equivalent risk factors emerged in men, although, like women, their prevalence of hypothyroidism was substantially higher than community rates.

The high rates of clinical hypothyroidism identified may call for a review of the drug information given to women, particularly to those starting lithium in middle age. Consideration should be given to screening for thyroid antibodies before treatment in high-risk cases. Monitoring of thyroid function should take into account gender, age and stage of lithium treatment.

Risk factors of depression in later life, particularly for sub-cases and for psychotic and neurotic types of depression, are unclear.

To identify such risk factors.

Over 5200 older people ($65 years), randomly selected from Liverpool, were interviewed using the Geriatric Mental State (GMS)and the Minimum Data Set (MDS). The computer-assisted diagnosis AGECAT identified 483 cases and 575 sub-cases of depression and 2451 with no mental problems. Logistic regression was employed to examine factors relevant to caseness.

In multiple logistical regression, odds ratios (ORs) were significantly high for being female (2.04, 95% CI 1.56–2.69), widowed (2.00, 1.18–3.39), having alcohol problems (4.37, 1.40–2.94), physical disablement (2.03, 1.40–2.94), physical illness (1.98,.1.25–3.15), taking medications to calm down (10.04, 6.41 −15.71), and dissatisfaction with life (moderate 4.54, 3.50–5.90; more severe 29.00, 16.00–52.59). Good social networks reduced the ORs. If sub-cases were included as controls, the statistical significance was reduced.

Age was not associated with depression in later life whereas gender, physical disablement and dissatisfaction with life were. The sub-cases shared many risk factors with cases, suggesting that prevention may need to be attempted at an early stage.

This paper reports on the follow-up of a cohort of parentally bereaved adults with learning disabilities.

To investigate whether significant psychopathology, present up to 2.1 years after the death, had resolved five years later.

Of an original sample of 50 adults with learning disabilities, 41 were reassessed. The Aberrant Behaviour Checklist and the Psychopathology Instrument for Mentally Retarded Adults were re-administered to carers.

At follow-up, there was a small increase in the measures of aberrant behaviour. Measures of psychopathology showed improvement, and in particular there was a reduction in anxiety.

The response to bereavement by adults with learning disabilities is similar in type, though not in expression, to that of the general population. Learning disability is a significant predictor of mental health problems following bereavement. Participants adapted more easily when basic emotional needs had been constructively met by carers.

Subsequent to initial exposure to the use of a psychoactive substance, psychoactive substance use disorder (PSUD) may or may not develop.

To investigate the relationship between the risk factors for initiation and the subsequent misuse of psychoactive substances.

The lifetime history of illicit substance use and misuse was obtained by telephone interview with 1934 members of female–female twin pairs. We apply a novel model, which estimates the role of genetic and environmental risk factors that influence initiation and those specific to misuse, to three classes of illicit psychoactive substances.

The individual-specific environment and family environment influenced the probability of initiation, but only individual-specific environment had an impact on the probability of subsequent misuse. Genetic factors which influence the risk of initiation and of misuse were identified.

Aetiological factors that influence drug initiation and subsequent misuse are correlated but not identical. Family environment is an important determinant of risk for drug experimentation. Two classes of genetic risk factors act on the liability to PSUD: those that influence the probability of initiation and those that influence the risk of misuse.

Genetic studies in schizophrenia are hampered by the complex heterogeneous clinical phenotype. Biological variables identified as trait markers of risk could clarify the mode of inheritance, define clinical subgroups and provide clues about aetiology.

To use single photon emission computed tomography (SPECT) to compare brain perfusion maps in patients with schizophrenia (n=19), their asymptomatic ‘high-risk’ relatives (n=36) and control subjects (n=34) and to examine the relationships between imaging, memory and P300 event-related potential.

SPECT, memory tests and P300 recording were carried out.

In the patients with schizophrenia and their relatives, perfusion was reduced in left inferior prefrontal and anterior cingulate cortex and increased bilaterally in a subcortical region. Perfusion significantly correlated with verbal memory and P300 amplitude in left inferior prefrontal cortex and with P300 latency in anterior cingulate cortex.

Medication– and symptom-free relatives had altered regional perfusion intermediate between subjects with schizophrenia and controls. Impaired perfusion, verbal memory and P300 appear to be related traits associated with an increased risk of illness.

Positron emission tomography (PET) studies have revealed functional left superior temporal gyrus (STG) abnormalities in symptomatic schizophrenia during word generation.

To discover if this dysfunction is present in asymptomatic schizophrenia. To determine whether, without concurrent symptomatology, schizophrenia and bipolar affective disorder (BPD) are distinguishable by differing regional cerebral blood flow (rCBF) patterns during word generation.

A PETverbal fluency protocol was applied to six patients with BPD in remission and six patients with asymptomatic schizophrenia. Analysis included 10 control subjects from a contemporaneous study.

All groups showed relative reduction of rCBF in both superior temporal cortices. There were no quantitative differences in any group comparison. All groups exhibited negative covariation between rCBF in left prefrontal and right (but not left) temporal regions.

Abnormal patterns of left STG function cannot be regarded as a trait marker for schizophrenia. Functional abnormalities may reflect aspects of mental state.

Transcranial magnetic stimulation of the motor cortex may not only elicit excitatory responses in hand muscles contralateral to the stimulated hemisphere, but may also suppress tonic voluntary electromyogram activity in muscles ipsilateral to the stimulation. This inhibition is mediated between the motor cortices via the corpus callosum.

To investigate motor excitability and interhemispheric (transcallosal) connections in patients with schizophrenia.

Transcallosal inhibition and motor conduction parameters were investigated in ten patients with schizophrenia and in ten age- and gender-matched healthy subjects.

Transcallosal conduction time (TCT) and duration of the inhibition were significantly longer in patients with schizophrenia (mean (s.d.)): TCT, 12.4 (2.9) ms in normal subjects and 15.3 (2.6) ms in patients (P=0.03); mean duration, 34.1 (4.9) ms in normal subjects and 51.9 (16.8) ms in patients (P=0.01).

Magnetic motor conduction parameters are unaltered in schizophrenia, but transcallosal inhibition is significantly delayed and prolonged. This may indicate abnormal function of the corpus callosum in these patients.

The parenting environment provided by mothers with schizophrenia is likely to contribute to the cognitive impairment observed in their offspring.

To assess the relative contribution of maternal schizophrenia, obstetric factors and mothers' lifestyle to the cognitive development of infants in their first year.

The Bayley Scales of Infant Development were administered to 19 infants of mothers with schizophrenia, 34 with non-psychotic depression in the mother, 29 with affective psychosis in the mother and 24 normal controls when the babies were two and seven months of age.

At two months, infants of mothers with schizophrenia and of those with affective psychosis had lower mental development index (MDI) scores than controls. At seven months, infants of mothers with schizophrenia had lower MDI scores than all other groups. When infant birth weight and mothers' social class were taken into account there was no effect of maternal schizophrenia on infants' MDI scores.

Infants of mothers with schizophrenia are likely to have impaired cognitive development. This may be due in part to environmental factors such as the mother's lifestyle.