The effects of neuroleptic medication on schizophrenic patients are both positive (reduction in symptoms) and negative (adverse side-effects). Given that altered cognitive functioning may be a feature of schizophrenia, the use of neuroleptics raises important ethical and legal issues.

A selective review was carried out of papers addressing ethical arguments for and against obtaining consent from schizophrenic patients, and the ethical and legal requirements which must be met for consent to occur.

Although a balance must be met between arguments for and against obtaining consent, clinicians should seek informed consent in all but exceptional circumstances. Obtaining consent depends on the adequate presentation of information, the absence of duress and the patients' capacity to consent. Various tests of capacity to consent have been proposed.

It is proposed that clinicians employ a proforma to record attempts to obtain informed consent during routine clinical practice.

An earlier study of 291 world famous men had shown that only visual artists and creative writers were characterised, in comparison with the general population, by a much higher prevalence of pathological personality traits and alcoholism. Depressive disorders, but not any other psychiatric conditions, had afflicted writers almost twice as often as men with other high creative achievements. The present investigation was undertaken to confirm these findings in a larger and more comprehensive series of writers, and to discover causal factors for confirmed high prevalences of affective conditions and alcoholism in writers.

Data were collected from post-mortem biographies and, where applicable, translated into DSM diagnoses. The frequencies of various abnormalities and deviations were compared between poets, prose fiction writers, and playwrights.

A high prevalence in writers of affective conditions and of alcoholism was confirmed. That of bipolar affective psychoses exceeded population norms in poets, who in spite of this had a lower prevalence of all kinds of affective disorders, of alcoholism, of personality deviations, and related to this, of psychosexual and marital problems, than prose fiction and play writers.

A hypothesis is developed, which links the greater frequency of affective illnesses and alcoholism in playwrights and prose writers, in comparison with poets, to differences in the nature and intensity of their emotional imagination. This hypothesis could be tested by clinical psychologists collaborating with experts in literature on random samples of different kinds of writers.

There have been many reports of a higher incidence of ‘obstetric complications’ in the histories of schizophrenics than of controls, but because of the methodological shortcomings of most of these comparisons the relationship remains controversial.

Comprehensive records covering all psychiatric hospital admissions and all hospital deliveries in Scotland since 1971 made it possible to identify the obstetric records of people born in 1971–74 who were subsequently admitted to hospital with a diagnosis of schizophrenia, and then to compare their standardised obstetric records with those of closely matched controls.

One hundred and fifteen schizophrenic/control pairs were compared. The former showed a highly significant (P < 0.001) excess of complications of both pregnancy and delivery. In particular, there was a significant excess of pre-eclampsia (10 v. 2) and of infants detained in hospital for neonatal care (18 v. 6).

The raised incidence of obstetric complications often reported in people with schizophrenia is genuine and probably contributes to the aetiology of the condition.

A complementary approach to defining symptomatic subtypes of schizophrenia is to identify characteristic patterns of ‘problem behaviours’ associated with the capacity of patients to function in the community.

In a large epidemiological survey, patients fulfilling Feighner criteria for schizophrenia were identified by key informants and assessed using the MRC Social Behaviour Schedule (SBS) and the Manchester Scale. An exploratory factor analysis was used to extract behavioural syndromes from the SBS data in order to compare the syndrome profiles in community, acute and long-stay subgroups and to examine their associations with symptoms and social functioning.

Four behavioural syndromes were identified: Thought disturbance, ‘Social withdrawal’, ‘Depressed behaviour’ and ‘Anti-social behaviour’, which distinguished between the patient subgroups and had significant differential relationships to symptoms and social functioning variables.

The evaluation of disability in schizophrenia and effectiveness of treatment interventions is incomplete without an assessment of problem behaviours.

We investigated whether antagonism of α2 adrenergic receptors would augment treatment response in schizophrenia, by administering idazoxan, an α2 antagonist drug, to treatment-resistant patients on typical neuroleptics.

Seventeen hospitalised treatment-resistant patients with DSM–III–R schizophrenia or schizoaffective disorder were studied on typical neuroleptic treatment, on treatment with idazoxan plus typical neuroleptic, and after discontinuation of idazoxan, in fixed, non-random order, and under double-blind, placebo-controlled conditions.

The addition of idazoxan to fluphenazine treatment resulted in significant reductions of global psychosis and total, positive and negative symptoms on the Brief Psychiatric Rating Scale, compared to neuroleptic treatment alone. Symptom improvement significantly correlated with idazoxan-induced changes in indices of noradrenergic function. In a subgroup of patients, idazoxan plus typical neuroleptic treatment compared favourably with clozapine treatment, when both were compared to typical neuroleptic treatment alone.

The antagonism of α2 receptors augmented therapeutic response to typical neuroleptic treatment in treatment-resistant patients with schizophrenia. This antagonism may contribute to clozapine's superior antipsychotic effects.

Findings that the EE level of a relative may change over time support the idea that EE may represent the circumstances of the relationship between patient and caregiver. The present study examines to what extent EE levels in relatives are related to relatives' burden of care and their perceptions of patients' deficits in social role performance.

Fifty patients recently admitted to hospital with DSM–III–R diagnoses of schizophrenia or schizophreniform disorder were assessed for positive and negative symptoms. Fifty relatives who were living or were in close contact with these patients were interviewed for the assessment of EE and burden of care, and to provide information about patients' social role performance and social and behaviour problems.

High-EE relatives had considerably higher mean scores for burden of care than low-EE relatives (12.5 v. 6.8, respectively, P=0.002), and perceived more deficits in patients' social functioning than low-EE relatives (means: 16.2 v. 6.9, respectively, P=0.004). The employment status of relatives was the only socio-demographic characteristic of relatives and patients associated with EE levels, those who were working being less likely to be high EE. Patients' psychopathology was not associated with EE levels and burden of care.

This study shows that EE and the burden of care are related. EE and burden both measure aspects of the relationship between relatives and patients. These findings suggest that EE and burden of care are more dependent on relatives' appraisal of the patient condition than on patients' actual deficits.

Although a cognitive–behavioural formulation of morbid jealousy has been described there is little empirical research into the practical usefulness of this model. This study evaluated the effectiveness of treating non-psychotic morbid jealousy using a cognitive approach.

Cognitive–behavioural and emotional measures of jealousy were calibrated by comparison with 40 non-jealous normal controls. These instruments were used as measures of change to assess the effectiveness of cognitive therapy in altering cognitive errors in 30 morbidly jealous out-patient referrals, divided into delayed and immediate treatment subgroups to assess the stability of the condition. Both groups completed all measures immediately before and after treatment, and at follow-up.

The instruments demonstrated significant differences between jealous and non-jealous subjects on cognitive–behavioural and emotional aspects of jealousy. The delayed treatment group showed no significant alteration in scores on any of the instruments after 12 weeks on the waiting list, confirming the stability of the condition. In the majority of cases cognitive therapy aimed at the modification of dysfunctional cognitive processes resulted in a significant improvement on all jealousy measures, immediately after treatment and at follow-up. The improvement reported by patients was supported by the partner's ratings.

The results support the postulation of the cognitive model that modification of cognitive schema by a schema-focused treatment package results in a significant reduction in disturbance in all aspects of the jealousy syndrome.

The Hamilton Depression Rating Scale retains its primacy in research. There have been recent important critiques. It is clear that instructions provided by its author are widely overlooked.

A survey of the present use of the HDRS was conducted by inspection of five major journals publishing studies in the field of psychiatry. Note was especially made of whether a recognised version of the Scale was quoted; also of whether authors had selected specific scores on one or other of the versions to indicate a criterion for inclusion of a subject in a study, and likewise whether a specific score had been selected as an indication of recovery following some procedure or treatment.

One hundred and fourteen articles were reviewed in which 71 had used a depression scale. This was the HDRS in 66% of the studies. There was considerable evidence that the instruction that the HDRS was only to be used in situations where the patient had received a diagnosis of a primary depressive illness had been ignored. There was considerable degree of arbitrary selection of Scale scores.

The survey causes concern about the methodology of much research in the field of assessment of severity of psychiatric disorder. The rationale of assessment by the rating scale method is considered and suggestion made for improvement in research practice.

Long-stay patients with learning disabilities (n=214) were assessed in hospital and 12 and 24 months after discharge in order to examine the effects of relocation.

Each resident acted as his/her own control in a prospective repeated-measures design. Skills and behavioural problems were assessed by keyworkers. Self-perceived quality of life was obtained during interviews with researchers who also completed an environmental checklist of the residents' accommodation.

There was little or no change in peoples low pre-discharge skill levels. Certain aspects of problem behaviour improved after 12 months, although socially unacceptable behaviour increased slightly. People were less depressed (P ⩽ 0.01) 12 months after discharge (n=119) and were more satisfied (P ⩽ 0.05) with their new ‘homes’ (n=108). There were few changes in the pattern of activities or the social networks of people 12 months later. Little or no further change in outcomes was reported 24 months after discharge.

The implementation of the deinstitutionalisation policy in Northern Ireland has been limited by the predominance of residential and nursing homes and the lack of ‘ordinary’ accommodation. There is a need for purchasers and providers to give more attention to ways in which the principles of normalisation could be incorporated in the process of contracting and delivering services.

Postnatal depression follows 10% of live births but there is little consensus on the risk factors associated with its development. Previous smaller studies have been unable to quantify the impact of independent risk factors as relative and attributable risks.

The Edinburgh Postnatal Depression Scale (EPDS) was used to screen a systematic sample of 2375 women, six to eight weeks after delivery. Information on socio-demographic and obstetric variables was collected at the screening interview. The risk factors associated with high EPDS scores (>12) were determined and entered stepwise into a regression model.

Four independent variables were found to be associated with an EPDS score above this threshold. These were an unplanned pregnancy (OR 1.44); not breast-feeding (OR 1.52), and unemployment in either the mother, i.e. no job to return to following maternity leave (OR 1.56), or the head of household (OR 1.50). These four variables appeared to explain the risk associated with other risk factors.

Although a direct aetiological role for these risk factors is not certain, they may indicate strategies for the prevention of affective morbidity in postnatal women. These may include reducing unwanted pregnancy and employment for women after childbirth.

High rates of comorbid alcohol and drug disorders have previously been found among individuals with severe mental illnesses such as schizophrenia and bipolar affective disorders. Clinical and social outcomes have been reported to be worse in this group and service costs greater than in individuals with severe mental illness only. These ‘dual diagnosis’ patients have mainly been investigated in the USA, and there has been very little research in Europe, where patterns of substance abuse may be different.

All patients with psychotic illnesses who had any contact with the mental health services in a geographically defined sector in South London over a specified period were studied. Individuals with problems related to alcohol or drugs were identified using standardised interviews with subjects and their keyworkers. Data on psychiatric service use during the previous 2 years were also obtained.

One hundred and seventy-one subjects with psychotic illnesses were interviewed (response rate: 78.4%). The one-year prevalence rate for any substance problem was 36.3% (95% CI=29.1–43.5), for alcohol problems it was 31.6% (95% CI=24.6–38.5), and for drug problems 15.8% (95% CI=10.3–21.3). Young male subjects were at higher risk of having substance problems. Patients with substance problems had spent almost twice as many days in hospital as those without such problems over the previous two years (difference=26.3 days, 95% CI=3.8–48.7).

The prevalence of substance problems among people suffering from severe mental disorders is high, and seems to be associated with greater use of in-patient services. This is a significant clinical problem, with cost implications. Further investigation is needed for adequate service provision.

It has been suggested that in schizophrenia an association exists between family history of schizophrenia and poor outcome on the one hand, and family history of affective disorders and good outcome on the other.

We tested for associations between four-year outcome and familial loading for psychotic disorders in a mixed sample of 150 consecutively admitted patients with functional psychosis (schizophrenia, psychotic affective disorders, other psychotic disorders) of recent onset. For each proband, a familial loading score for (i) broadly defined psychotic disorder, (ii) schizophrenia, and (iii) affective disorder was calculated using information on relatives obtained through the Family History Research Diagnostic Criteria method and direct interviews of relatives with the Schedule for Affective Disorders and Schizophrenia.

In our sample of psychotic patients, familial loading for psychotic disorder predicted persistent negative symptoms over the follow-up period (OR 1.5; 95% CI 1–2.2), especially in schizophrenia, and was also associated with more time hospitalised (P > 0.05), and more social disability at follow-up (P < 0.05). Greater familial loading for schizophrenia predicted a greater likelihood of non-recovery (OR 2.2; 95% CI 1.1–4.4) and a greater likelihood to have had persistent negative symptoms over the follow-up period (OR 1.7; 95% CI 0.9–3.1). No association was found between outcome and familial loading for affective disorder.

We conclude that familial loading may be a continuous risk factor for some dimensions of clinical outcome in the functional psychoses. This suggests that there is a continuum of genetic liability not only to the emergence of psychotic illness, but also the subsequent chronicity of the disorder.

The study was designed to investigate whether seasonal mood and behavioural changes are detectable prospectively in a non-clinical population in the way they have been reported in retrospective studies. The specificity of any seasonal fluctuation in affective state was also investigated by measuring anxiety as well as depression.

To measure seasonal fluctuations in affect and behaviour prospectively, 25 women were interviewed every month for one year using four scales (depression, anxiety, stress, and behavioural change). Retrospective accounts of mood and behaviour at the end of the year were collected with the Seasonal Pattern and Assessment Questionnaire (SPAQ).

Seasonal depression peaked in winter as did atypical behaviour when measured either prospectively or retrospectively, but the difference between winter and summer was much more pronounced in the retrospective data. No seasonal effect was found for anxiety or psychosocial stressors.

The results obtained by retrospective techniques have limited reliability. In future, more prospective studies with unbiased, standardised instruments are recommended to measure seasonal variations in affect and behaviour.

It has been suggested that mass hysteria can be divided into two syndromes; one with predominant features of anxiety and the other with predominant abnormalities of motor behaviour. In the former condition, prior tension is absent and spread is by visual contact In the latter, prior tension is present, initial cases can be identified and spread is gradual.

The development and resolution of neurological symptoms in 156 Nigerian school girls were studied and a diagnosis of ‘mass hysteria’ made.

The signs and symptoms manifested by the school girls during the outbreak of illness had features of both ‘anxiety’ and ‘motor’ predominant forms of mass hysteria.

Although there may be two patterns of symptom presentation in mass hysteria, other supposedly discrete features overlap. This weakens the argument that there are two separate syndromes.

We aimed to validate the Eating Disorders Inventory (EDI) in Arabic.

Subjects were chosen randomly from female school students. Only healthy Saudi students were included. They were asked to fill the EDI and undergo a semi-structured interview by a psychiatrist who was unaware of the EDI scores. Of 146 students approached 12 did not meet our criteria and were excluded; 16 other students were excluded for incomplete responses.

The difference between the two diagnostic methods in the proportion of caseness was statistically significant (P < 0.0001). The scores on Perfectionism, Maturity Fears and Interoceptive Awareness were significantly higher in the Saudi students compared with Canadians (P < 0.05).

The EDI-DT subscale has a sensitivity of 100% and a specificity of 85%. Despite its low positive predictive value of 5%, it may be useful for screening large non-clinical groups for eating disorders.

Measurement of the quality of psychiatric care including assessment of patients' views have become increasingly important as expectations of the standard of care rises.

Attitudes and satisfaction of acute psychiatric in-patients were investigated using a questionnaire looking at satisfaction, patients' views on personal and professional qualities of psychiatrists, empowerment and insight.

The response rate was 79.2% (137 out of 173). Patients with a diagnosis of a non-affective psychotic illness, particularly those lacking insight were significantly less satisfied with their care. Respondents were more satisfied with the personal rather than the professional qualities of the doctors, and less satisfied with their empowerment and doctors' availability.

In-patients' attitudes towards their psychiatric care involves a complex relationship between clinical and sociocultural characteristics. Satisfaction studies can serve as an important monitor and reminder of patient dissent.

An investigation of the relationship between bipolar affective disorder and schizophrenia, following a severe head injury and removal of the left prefrontal cortex.

A single case report.

An individual with past history of bipolar affective disorder suffered traumatic damages to the left prefrontal cortex with a second lesion in the left temporal lobe. The patient developed typical schizophrenia nine months later. The relevance of his brain lesions in determining the schizophrenic symptoms is discussed.

We propose that the specific pattern of brain injury in this patient was sufficient to change the phenotype from bipolar affective disorder to schizophrenia.