This paper reviews research on the psychological treatment of depression in children.

Manual and computer literature searches were performed.

The most promising psychological interventions for depression in children are individual rather than family therapies. Cognitive – behavioural therapy seems to be an effective treatment for depressive symptoms and mild depressive disorders. It may also be a useful preventive intervention, though this remains to be conclusively demonstrated. There have been no systematic studies comparing psychological treatments with medication.

Studies comparing psychological treatments and medication are now required.

Childhood autism is a developmental disorder with distinctive clinical features and characteristic cognitive deficits. Neuroimaging techniques have been extensively used in the study of autism and related disorders.

Recent important literature reported on structural and functional neuroimaging in autism was reviewed and discussed in the context of other neurobiological research findings.

Various abnormalities of brain structure and function have been proposed, but no focal defect has been reliably demonstrated. Important findings, so far, include increased brain volume, structural abnormality in frontal lobe and corpus callosum in a proportion of autistic individuals. Functional neuroimaging findings emphasised the imbalance in interregional and inter-hemispheric brain metabolism and blood flow as well as abnormality in the anterior cingulate gyrus.

The research to date has been hindered by methodological difficulties. However, hypothesis-driven research, particularly involving activation studies and neurotransmitter/neuroreceptor activities, using functional neuroimaging will be very useful in unravelling the enigma associated with this intriguing and distressing condition.

Symptoms of schizophrenia known as nuclear’ or ‘first-rank’ are found in all populations. The genetic variation that gives rise to them must be as old as modern Homo sapiens.

The hypothesis was formulated that language evolved, under constraints on callosal transmission, by a process of hemispheric specialisation. One component, the phonological output sequence, became localised to the dominant hemisphere whereas its associations (the signifieds) were lateralised in part to the non-dominant hemisphere. Concepts (‘thoughts’) are translated through a bi-hemispheric interaction into phonemes (‘speech’) by the speaker in frontal association areas, and decoded back into concepts (‘meanings’) by the hearer in occipito-temporo-parietal association areas.

The first-rank symptoms demonstrate that an integral component is a system of ‘indexicality’ that distinguishes those phonemic signals generated by the hearer, from his own thoughts, and from signals that he receives from an interlocutor.

Language, as Buehler proposed, is cast in a coordinate system orientated at its origin, in the dominant hemisphere, to the self of the speaker. Thus conceived, the phenomena of the illness called schizophrenia are key to the neural organisation of the human characteristic of language.

Diagnostic comorbidity is prevalent in psychiatry and may be inadequately captured by the DSM-III/III-R nosology.

The lifetime presence of 11 psychiatric diagnoses was determined by structured personal interviews of a population-based sample of 1898 female twins. We used latent class analysis to derive an empirical typology.

Six classes provided the best fit to the data. Their mnemonics were: minimal disorder (60% of the sample), major depression -generalised anxiety disorder (19%), alcohol–nicotine (7%), highly comorbid major depression (5%) and eating disorders (3%). The validity of this typology was strongly supported by demographic, health, personality and attitudinal validators along with the significant monozygotic twin concordance for class membership. The typology superficially resembled DSM-III-R, but contained many differences. Major depression appeared in three forms (alone, with generalised anxiety disorder and with considerable comorbidity). Alcoholism-nicotine dependence and the various anxiety disorders formed discrete classes, but were also prominent in other classes. Bulimia and anorexia were exceptional in their appearance in a single class.

The DSM-III-R and closely related DSM-IV nosology did not capture the natural tendency of these disorders to co-occur. Fundamental assumptions of the dominant diagnostic schemata may be incorrect.

Farmers in the UK have an elevated risk of suicide. It has been suggested that this may be related to their ease of access to dangerous means for suicidal behaviour. The extent to which farmers use these means and changes in their use may be relevant to suicide prevention.

Data on 719 deaths in farmers of both genders in England and Wales between 1981 and 1993 in which a verdict of suicide or undetermined cause (open verdict) was recorded were analysed.

Of 702 deaths in male farmers, farms were involved in 40.0%, hanging in 29.6%, carbon monoxide in 16.4%, poisoning in 8.0% (over half of which involved agricultural or horticultural poisons) and other methods in 6.1%. There was a considerable excess of deaths due to firearms compared with the distribution of methods of suicide and open verdict deaths in males in the general population. Hanging was also somewhat more frequent. During the study period there was a reduction in firearm death rates, particularly after 1989 when there was national legislation on firearm ownership, registration and storage. There were also fewer farming suicides after this date. By the end of the study period hanging was more frequent than deaths involving firearms.

Farmers who commit suicide tend to use methods to which they have easy access. Restriction of the ready availability of such methods, particularly in farmers known to be depressed or otherwise at risk, might prevent some suicides.

Although increased mortality is one of the most consistent and accepted epidemiological findings in schizophrenia, a high rate of suicide appears unable to account fully for this burden which remains poorly understood.

A cohort of 88 in-patients was followed prospectively over a 10-year period and predictors of survival sought among demographic, clinical and treatment variables.

Over the decade, 39 of the 88 patients (44%) died, with no instances of suicide. Reduced survival was predicted by increasing age, male gender, edentulousness and time since pre-terminal withdrawal of antipsychotics; additionally, two indices of polypharmacy predicted reduced survival: maximum number of antipsychotics given concurrently (relative risk 2.46, 95% C1 1.10-5.47; P=0.03) and absence of co-treatment with an anticholinergic (relative risk 3.33, 95% C1 0.99-11.11; P=0.05).

Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotic polypharmacy. Conversely, over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.

Suicides among people with schizophrenia are commonly believed to be impulsive and to occur unexpectedly.

As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, suicide victims with DSM-III-R schizophrenia (n=86; n=64 in the active illness phase) and others (n=1 109; n=666 without any evidence for psychosis) were compared for communication of suicidal intent (CSI), as well as previous suicide attempts known by the next of kin and/or an attending health care professional during the latest treatment relationship.

More victims with schizophrenia (84%) had a history of previous CSI, and/or had made previous suicide attempt(s) than others (70%). Also, victims with active illness schizophrenia (56%) had more CSI and/or had made suicide attempts during their last three months than victims with no psychosis (41%).

CSI and/or suicide attempts occur at least as often in people with schizophrenia as in those without schizophrenia, even in the active phase of the illness.

The analysis of the costs of schizophrenia and its treatment under different mental health care structures will facilitate the improved allocation of the limited resources available for the treatment of schizophrenia. The research we present compares health service use and total health care costs of three cohorts of subjects with schizophrenia which are representative of three areas of Spain (Burlada in Navarra, Cantabria and the Eixample of Barcelona).

We selected first-time contacts with any psychiatric service who received a diagnosis of schizophrenia. Subjects were evaluated in the third year after onset.

The mean number of out-patient visits per patient per year was 10.7 and the mean in-patient days were 9.5. The mean direct cost per patient in the third year of treatment was US$2243. Costs were higher for single subjects and for people who had a relapse. Costs of subjects with better functioning were lower than costs of subjects with a worse state.

Direct costs of care in Spain were lower than the reported figures from other western European countries. Costs were greater in the two centres with greater community mental health service development. Some of the findings may be explained by service availability.

Previous studies of clozapine pharmacokinetics have shown a wide intra- and inter-individual variability of plasma levels in patients on stable clozapine doses. We investigated dose-plasma level relationships and intra-individual variability of plasma levels during maintenance treatment with clozapine.

Forty-one patients on clozapine were followed for 26 weeks with repeated plasma level measurements and assessments of co-medication and clinical symptoms. In a second step, 15 patients on stable clozapine doses between treatment Weeks 12 and 52 were followed in the same way. Coefficient of variation was used as a parameter of plasma level deviation.

Dose-plasma level correlations stayed significant from Week 6 to Week 26 (n=41). The group of patients followed up to Week 52 showed a mean intra-individual coefficient of variation of 52.8% (s.d. =20.6), and remained stable psychopathologically.

Even though clozapine plasma levels may show a significant degree of variation, this is not necessarily reflected in a change in psychopathology.

Although cocaine use in women has increased substantially over the past half-century, we understand little about the aetiology in women of cocaine use and abuse, and know almost nothing about the role of genetic factors.

We obtained by telephone interview a history of lifetime cocaine use, abuse and dependence from 1934 individual twins from female–female pairs ascertained through a population-based registry, including both members of 485 monozygotic (MZ) and 335 dizygotic (DZ) pairs.

The prevalence of lifetime cocaine use, abuse and dependence were 14.0%, 3.3% and 2.3%. Probandwise concordance rates, in MZ and DZ twins, respectively, were: cocaine use 54% and 42%; cocaine abuse 47% and 8% and cocaine dependence 35% and 0%. In MZ and DZ twins, odds ratios were: cocaine use 14.2 and 6.7 and cocaine abuse 40.8 and 2.7. Biometrical model-fitting suggested that twin resemblance for liability to cocaine use was due to both genetic and familial–environmental factors while twin resemblance for cocaine abuse and symptoms of dependence was due solely to genetic factors. Estimated heritabilities were: cocaine use 0.39, cocaine abuse 0.79 and symptoms of dependence 0.65.

The vulnerability to cocaine use and particularly cocaine abuse and dependence in women is substantially influenced by genetic factors.