The attempt to define psychotherapeutic skills appropriate for psychiatrists has aroused an interest in supportive psychotherapy, a previously undervalued and underdeveloped member of the psychotherapeutic family. This has been coupled with an increasing recognition of the importance of support within formal psychotherapies, especially when working with highly disturbed patients.

A review of supportive psychotherapy (ST) was performed, based on a Medline literature search.

It is argued that, from the perspective of attachment theory, support is an integral part of all psychotherapies. ST is also a specific mode of treatment suitable for some patients suffering from psychotic illnesses and borderline personality disorder. ST is an eclectic treatment drawing on many theoretical approaches. A common theme based on a narrative co-constructionist perspective, the search for positive meaning, is identified.

Supportive psychotherapy is an essential component of good psychiatric practice. Further research is needed to define its benefits and limitations.

Suicide pacts are rarely discussed in the medical literature. We report here the medical and social aspects of a consecutive series of double or pact suicides.

Coroners' records were examined for 722 consecutive suicides. Data were extracted from them and from medical and psychiatric records.

Nine pacts (2.5% of suicides) were located: 11 of the 18 people appeared to have been mentally ill at the time of death and three more had a history of mental illness. Five had a significant medical history (three cancer).

Mental disorder is common in those who enter suicide pacts (mainly depression, with alcohol dependence rare). Motivations for suicide appear to be relief of mental disorder and pain.

Little is known about the natural history and evolution of behaviour symptoms and patterns in severely and profoundly mentally retarded adults. This paper reports a cohort study of 100 such adults.

Abnormal behaviour symptoms and patterns have been followed, using a carer rating scale and the Modified Manifest Abnormality Scale of Goldberg's Clinical Interview Schedule (1970) by the same two consultant psychiatrists in 1975, 1981 and 1992.

Emotional withdrawal, stereotypies and eye avoidance are particularly persistent. Carer ratings of noisiness and social withdrawal, and psychiatrist ratings of suspiciousness, overactivity and hostile irritability, are also persistent but to a lesser degree. Overall ratings of psychiatric disorder are persistent and act against successful community placement.

Abnormal behaviour patterns in severely and profoundly mentally retarded adults show only a modest degree of abatement over time. Care staff need a good understanding of clinical psychiatric and behaviour management techniques.

In the search for population-based indicators of need for mental health services, psychiatric admission rates have been correlated with sociodemographic variables. We explored such correlations for different diagnostic groups.

Admissions data for the 19 districts in the North West Region were derived from the Korner Episode System for 1992/3 and divided into eight broad diagnostic groups using ICD–9 codes. Admission rates per 1000 were correlated with measures of deprivation derived from the 1991 census data and with standardised mortality ratios. For the two largest diagnostic groups, correlations with age-standardised admission rates were also calculated.

For schizophrenia/delusional disorder, eight of the 10 sociodemographic measures were significantly correlated with admission rates (Pearson's r 0.52–0.79). On all measures these correlations were greater than those seen for total mental illness. Significant positive correlations of a lower order were seen for organic brain syndromes and mania. Admission rates for depression, personality disorder and substance misuse were not significantly correlated with any of the sociodemographic measures. Admission rates for neurotic illness were negatively correlated with all deprivation measures, with the negative correlation statistically significant at the 5% level for ethnic composition and overcrowding. Standardising admission rates for age and repeating the analysis after removal of influential data points did not greatly alter these findings.

The association between psychiatric admission rates and measures of deprivation varies considerably with diagnosis. Measures of social deprivation may indicate need for services for patients with psychotic disorders; admission rates for non-psychotic illnesses may reflect the availability of beds rather than need.

A previous cross-national epidemiological study of first admission rates in London and in Aarhus, Denmark, found that the incidence of mania was virtually identical for both centres. This study sought to examine the corresponding rate for a defined catchment area in Dublin, Ireland, and to establish whether the impression of a higher rate could be validated.

The study combined a six-year retrospective review and one-year prospective collection of first-admission cases of mania from a defined catchment area. Diagnosis was according to ICD criteria and the Syndrome Check List of the Present State Examination (PSE). Cross-national comparisons were made using standardised incidence rate ratios (SIRs).

The crude incidence rate for Dublin in the age range 18–60 years was established at 4.5 per 100 000 per year. A comparison of SIRs for the three centres showed the Dublin rate to be higher than expected (P < 0.02). Age-specific analysis indicated that this increase came mainly from the age range 18–29 (χ2 = 9.08, P = 0.01).

The study confirmed the impression that the local incidence of mania in Dublin is higher than that reported from two other North European centres. A variation in rates from contrasting socioeconomic districts within the catchment area points to some caution in the interpretation of the results and suggests further study from wider catchment areas.

It was hypothesised that the size of the season-of-birth effect may have decreased in tandem with the apparent decline in the incidence of schizophrenia.

Through the Aberdeen Psychiatric Case Register, subjects were identified who had been diagnosed as schizophrenic and had been born between 1900 and 1969. The ratio of winter/spring to summer/autumn births was compared across the seven decades for both sexes together, for men, and for women.

For the 1935 men, but not for the 1620 women, there was a highly significant increase (P = 0.0009) in season-of-birth effect.

Non-seasonal factors have contributed to a declining incidence of schizophrenia in both sexes. ‘Seasonal’ factors to which female foetuses are more susceptible than male foetuses (such as infection or malnutrition) have also decreased in frequency, severity, or both, but this has not happened with factors affecting males, leading to an increase of their season-of-birth effect.

This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia.

Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication.

Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome.

Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population.

Dysphoric reactions to antipsychotic medication are well recognised in association with akathisia, but can also occur independently.

Fifty-one healthy volunteers were given haloperidol 5 mg in two consecutive pharmacokinetic studies.

Dysphoria occurred in about 40% of the subjects on both occasions, but akathisia was only detected in 8% (first study) and 16% (second study). All adverse effects were transient and were abolished in nine of the ten subjects given procyclidine.

While dysphoria is a well-recognised reaction in healthy volunteers, it is probably insufficiently recognised in patients, particularly if it occurs in the absence of akathisia. Better detection could improve compliance in patients.

Cyproheptadine, an antiserotonergic agent, was used to treat neuroleptic-induced akathisia.

In an open clinical trial 17 neuroleptic-treated patients with akathisia were administered cyproheptadine (16 mg/day) over 4 days. Assessment of akathisia, psychosis and depression were monitored by BAS, BPRS and HAM-D.

All subjects showed improvement in the severity of akathisia, which in the majority (15/17) was of a marked degree. There was no aggravation of psychosis or depression. Symptoms of akathisia returned when cyproheptadine was discontinued.

Cyproheptadine may be useful in neuroleptic-induced akathisia.

This study investigates the naturalistic course of panic disorder over four years and attempts to identify predictors for outcome.

423 DSM–III–R panic disorder patients who had taken part in an international multicentre drug trial were selected for follow-up; we were able to re-interview 367 (87%). For panic attacks, phobic avoidance and disabilities the same rating scales were administered as had been used for the clinical trials.

While 61 % of all patients experienced at least occasional panic attacks at follow-up, few suffered from serious phobic avoidance (16.7%) or serious disabilities (work 7.9%; family 8.7%; social 13.9%). Panic attack frequency at baseline, original trial medication and continuous use of psychotropic medication during follow-up are not related to outcome, whereas longer duration of illness and more severe phobic avoidance at baseline are unfavourable.

The course of panic disorder is not uniform. Since long duration of illness and severe phobic avoidance at baseline are predictors for an unfavourable outcome, more rigorous efforts should be undertaken to detect and treat panic disorder at an early stage.

The Royal Air Force Wroughton Post-Traumatic Stress Disorder (PTSD) Rehabilitation Programme is described. It comprised a 12-day structured in-patient ‘course’ of group psychotherapy and day-case group follow-up sessions over a one-year period. Psychological debriefing was the main therapeutic technique employed.

This is a ‘before and after’ open outcome study. A comprehensive assessment protocol confirmed the presence and severity of PTSD and measured co-morbid psychopathological status, occupational and social function longitudinally.

A highly significant global response to treatment is demonstrated in the 34 subjects included in the study, with 85.3% not fulfilling the DSM–III–R criteria for PTSD at one year after treatment.

Further controlled studies assessing the value of psychological debriefing techniques in the treatment of established PTSD are required.

Different definitions of chronic fatigue syndrome (CFS) have different psychiatric exclusion criteria and this affects the type and frequency of associated psychiatric morbidity found. The operational criteria for neuraesthenia in ICD–10 vary in this and other respects from the Centers for Disease Control and Prevention (CDC) criteria for CFS. Neuraesthenia and associated psychiatric morbidity in CDC-defined CFS are evaluated.

CFS subjects and controls were interviewed with the Schedule for the Clinical Assessment of Neuropsychiatry (SCAN). The computerised scoring program for SCAN (CATEG05) facilitates the assignment of operational definitions according to DSM–III–R and ICD–10. Subjects were re-interviewed with SCAN an average of 11 months later. No specific treatments or interventions were given during this period.

The majority of subjects fulfilled ICD–10 operational criteria for neuraesthenia and had two and a half times the rate of psychiatric morbidity as the healthy comparison group according to the CATEG05 Index of Definition (ID). Approximately 80% of subjects fulfilled both DSM–III–R and ICD–10 criteria for sleep disorders. There was a significant fall in the number of subjects fulfilling criteria for depression and anxiety disorders and a significant increase in the number of subjects with no diagnosis for DSM–III–R criteria over time. There were no significant changes over time for any diagnosis according to ICD–10 criteria or for overall levels of psychopathology as reflected in CATEG05 ID levels.

The ICD–10 ‘neuraesthenia’ definition identifies almost all subjects with CDC-defined CFS. Fifty per cent of CFS subjects also had depressive or anxiety disorders, some categories of which remit spontaneously over time.

There are many reports of adolescents with periodic episodes each followed by complete remission within 2 weeks, but the nosology and long-term prognosis of such cases have not been elucidated.

A prospective follow-up study on 11 cases (nine girls and two boys) meeting predetermined criteria is reported.

The first several episodes were found to meet ICD–10 symptomatic criteria for recurrent depressive disorder in all cases, and, except for two cases, showed psychotic features. The episodes were linked to one phase of the menstrual cycle in only two of six girls with regular menses. There were no recurrences while on lithium in eight of nine cases. Of eight patients followed up 5–14 years after the first onset, three had been well, three had become bipolar and two were still suffering from brief depressive episodes.

Recurrent brief episodes in adolescence tend to show a near-monthly rhythm and psychotic features. Most of them appear to be manifestations of affective illness and may be treated and prevented as such.

Twenty-six young men admitted to an Accident and Emergency Department for observation following a minor closed head injury (post-traumatic amnesia (PTA) less than 12 hours) were investigated within 24 hours of admission (day 0) and followed up at 10 days, 6 weeks and 1 year after the trauma.

Investigations at day 0 included physical examination, completion of post-concussional symptom and stress-arousal checklists, computerised EEG (CEEG) and auditory brainstem evoked potential (BAEP) recordings. These were repeated at ten days and six weeks. At 12 months follow-up, the Present State Examination (PSE) was carried out and a further post-concussional symptom checklist completed.

Post-concussional symptomatology declined progressively from day 0 but half had residual symptoms at 1 year. Seventy-two per cent ran an acute course with recovery by 6 weeks, 8% a chronic unremitting course and 20% initially improved but had an exacerbation of symptoms between 6 weeks and 12 months. The CEEG alpha-theta ratios decreased significantly between days 0 and 10, reaching a baseline thereafter. Measures of CEEG recovery from all channels correlated with symptom counts at six weeks; the slower the recovery the greater the symptoms. A relative delay in left temporal recovery was associated with residual psychiatric morbidity (PSE ID scores) at 12 months. Prolonged central brainstem conduction times occurred in 27% of patients at day 0. These correlated positively with PTA and degree of psychiatric morbidity (PSE ID scores) at 12 months.

Symptom chronicity was accompanied by continuing brainstem dysfunction, while the degree of transient cortical dysfunction appeared to have a direct influence in the intensity of early organic symptom reaction to the trauma. Levels of perceived stress at the time of the injury, or afterwards, were not related to symptom formation.

The growth hormone (GH) response to apomorphine, thought to reflect central dopaminergic receptor sensitivity, has been reported as enhanced in acute schizophrenia. We investigated this response in relation to the psychotic episodes associated with Parkinson's disease (PD).

The GH response to apomorphine was measured in three groups of patients with Parkinson's disease: those currently psychotic (n = 9), those with a past history of psychosis (n = 7) and those who had never been psychotic (n = 8).

Apomorphine-induced GH response was not related to psychosis but was unexpectedly associated with measures of depression.

Visual hallucinations were a prominent feature in the psychotic patients and the atypical nature of these psychoses might explain why we found no evidence of dopaminergic sensitivity. Serotonergic dysfunction would be in keeping with this. Dopaminergic mechanisms may contribute to the minor depressive symptomatology seen in PD.

Many studies have shown hospitalised mentally ill patients to have a higher mortality risk than the general population.

Data of patients with organic mental disorders of ICD–9 categories 290, 293, 294 and 310 from seven psychiatric hospitals with defined catchment areas were analysed. During an observation period of 2.5 years 1821 treatment periods in these diagnostic categories were recorded.

During hospitalisation 137 patients died from natural causes. The age- and sex-adjusted mortality rates show an increased mortality risk of 7.5 times, compared to the general population. The odds ratio of a logistic regression demonstrate the overwhelming influence of the medical diagnosis.

Medical factors, particularly pneumonias, contribute most to the excess mortality.

The apolipoprotein E (ApoE) ∊4 allele is associated with an increased risk of senile and probably presenile Alzheimer's disease. It is not yet clear whether the ∊4 allele also influences the duration/rate of progress of illness and the severity of the dementia.

We have retrospectively examined a series of ApoE genotyped presenile and senile autopsy cases of Alzheimer's disease (AD) for length of illness and severity of pathology.

We find no evidence that ApoE genotype affects the rate of progress of AD, but the degree of pathology at death may be increased.

It appears that the rate of progress of AD as a whole is independent of the ApoE genotype.