We consider how far it is possible to predict a chronic course of a depressive disorder from psychosocial and clinical material available at the point of onset.

A population survey found 404 working-class mothers living in an inner-city area of London. The majority were interviewed three times over a 3-year period.

Chronicity (more than 12 months' duration) was strongly related to both childhood adversity (parental indifference, family violence or any sexual abuse) and current adult interpersonal difficulties. The lack of positive events during the course of the episode was also independently related to chronicity, but to a lesser degree. Clinical characteristics were relatively unimportant compared with psychosocial factors.

The childhood risk factors were particularly important (judged by a path analysis), and a challenge for future research will be to establish the intervening processes involved with this distal link.

This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort.

Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18–64 on admission, who had been in hospital for between six months and three years.

Two particular sub-groups were observed. Younger NLS patients (aged 18–34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55–67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm.

Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.

There is pressure on acute admission services in inner-city areas. Two deprived London districts with markedly different acute bed ratios but similar sociodemographic backgrounds were compared to test the hypothesis that more facilities mean better service.

An instrument for auditing the use of short-stay hospital beds was constructed to collect information concerning admissions to, and short-stay patients in, the chosen districts during a three-month period.

There was a higher admission rate and substantially greater use of beds per unit population in south Southwark than in Hammersmith & Fulham. Much of the difference was attributable to a higher rate of admission of patients with affective disorders in south Southwark.

The results are not explained by variations in population need, longer in-patient stay, or poorer aftercare leading to early relapse. The question of whether there is over-provision of services compared with real need in south Southwark, or under-provision (particularly for people with affective disorders) in Hammersmith & Fulham, is considered but left open for discussion following a study of ethnic issues and the reasons for admission.

This investigation sought to determine the prevalences of various psychopathologies in outstandingly creative individuals, and to test a hypothesis that the high prevalence of mental abnormalities reported in prominent living creative persons would not be found in those who had achieved and retained world status.

The family background, physical health, personality, psychosexuality and mental health of 291 famous men in science, thought, politics, and art were investigated. The membership of the six series of scientists and inventors, thinkers and scholars, statesmen and national leaders, painters and sculptors, composers, and of novelists and playwrights was determined by the availability of sufficiently adequate biographies. Extracted data were transformed into diagnoses in accordance with DSM–III–R criteria, when appropriate.

All excelled not only by virtue of their abilities and originality, but also of their drive, perseverance, industry, and meticulousness. With a few exceptions, these men were emotionally warm, with a gift for friendship and sociability. Most had unusual personality characteristics and, in addition, minor ‘neurotic’ abnormalities were probably more common than in the general population. Severe personality deviations were unduly frequent only in the case of visual artists and writers. Functional psychoses were probably less frequent than psychiatric epidemiology would suggest, and they were entirely restricted to the affective varieties. Among other functional disorders, only depressive conditions, alcoholism, and, less reliably, psychosexual problems were more prevalent than expected in some professional categories, but strikingly so in writers.

Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.

The association was examined between reporting child sexual abuse (CSA) and a range of social, interpersonal and sexual difficulties in adult life.

A random sample of 2250 women were posted a questionnaire exploring a range of abuse experiences. All 248 reporting CSA were invited for interview, together with an equal number of controls. At interview a detailed inquiry was made into the CSA and into current interpersonal, social and sexual function.

Significant associations emerged between reporting CSA and a decline in socioeconomic status, increased sexual problems, and the disruption of intimate relationships by difficulties with trust as well as a propensity to perceive their partners as uncaring and overcontrolling. CSA was more common in those from disturbed and disrupted families and in those who also reported physical and emotional abuse. This explained part, but not all, of the apparent association between CSA and negative outcomes.

Those reporting CSA are more likely to suffer social, interpersonal and sexual difficulties in adult life.

Twenty-six per cent of patients in two Inner London districts were admitted to acute wards under the provisions of the Mental Health Act. Compared with those not under compulsion, they were young, male, more likely to be of black Caribbean origin, and to have a diagnosis of schizophrenia of short duration. The hypothesis is tested that ethnicity determines rates of compulsory admission independently of the other factors.

Sampling and data collection methods were described in the first paper. Statistical analyses included a log-linear analysis of six key variables: compulsory admission, challenging behaviour, diagnosis, ethnicity, age, and sex.

There were no substantial differences between districts. Analysis provided two similar statistical models. In both, admission under the Act was strongly associated with challenging behaviour and diagnosis of schizophrenia. In the model of best fit there was no significant interaction term for ethnicity and compulsion. In the second model there was a weak association.

Ethnicity did not appear to be of outstanding importance in decisions to use the Mental Health Act. There was a strong link between ethnicity and diagnosis, independent of compulsion. Differences between the districts made no major contribution to the rates of compulsory admission.

We consider how well the psychosocial and clinical factors found to predict a chronic course for depressive episodes in the community, held for female psychiatric patients.

A consecutive series of depressed patients, aged 18 to 60, treated as in-patients, out-patients or day-patients at psychiatric departments of two London hospitals, were interviewed initially and at follow-up two years later.

Indices of childhood adversity and current interpersonal difficulties predicted episodes taking a chronic course (of more than 12 months' duration). Half of the episodes associated with one or the other factor were chronic, compared with 22% of those with neither. The patients were at higher risk than the community series (75% v. 34%) and this explains their much greater rate of chronicity. There was also some evidence that social support reduced risk. Clinical features and the presence of a personality disorder were unrelated to chronicity.

Similar psychosocial factors are important for predicting chronicity in both community and patient series.

This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital.

Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements.

The average point prevalence was 6.1 per 100 000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100 000 population per year. Many English services had very few non-acute psychiatric beds and 31 % of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61 % of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available.

Many NLS patients remain in hospital because their residential needs are not met by existing community provision.

Stereotactic subcaudate tractotomy (SST) is the only type of psychosurgery performed at the Geoffrey Knight Unit, London, where nearly 1300 operations have been done since 1961. Statistically reliable data are not available to prove the effectiveness of SST. A detailed statement about contemporary psychosurgery is given.

Relevant publications from the Unit and via Medline are discussed. The outcome figures are reviewed. The outcome is assessed at the Unit in global and clinical terms, associated with results of self-completed questionnaires.

ST allows 40–60% of patients to live normal or near-normal lives, perhaps with continuation of medication. A reduction in suicide rate to 1% postoperatively, from 15% in cases of uncontrolled affective disorders is seen.

As a treatment of last resort, no controlled trial against a comparable treatment is possible. It appears reasonable to offer SST to patients with suicidal and deluded depression or with frequently swinging moods, not responding to other treatments.

We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8–10 sessions of therapy is as effective as 16–20 sessions, and (c) brief therapist training is as effective as intensive training.

Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM–III–R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up.

Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change.

Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16–20 sessions of treatment is more effective, on average, than 8–10 sessions.

A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London.

Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.)

It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

In this series, rates of admission and daily bed use in south Southwark were 30% higher than in Hammersmith & Fulham, principally because of a higher rate of admission for affective disorders. Factors associated with compulsory admission did not differ between the districts. This final paper examines the severity of symptoms, the reasons given for admission and factors relevant to the judgement to admit, in order to test the hypothesis that more resources mean better service.

Sampling and data collection methods were described in the first paper.

In both districts, major reasons for admission were self-neglect and risk of self-harm, poor adaptive functioning, and poor acceptance of medication. In south Southwark, a group of patients had affective disorders and less severe symptoms but a stated risk of suicide. Rates for, and severity of, schizophrenia were similar in the two districts. Social and preventive reasons for admission were given more frequently in south Southwark, where patients had more often been in contact with services before admission. Staff there, but not in Hammersmith & Fulham, suggested that many could have benefited from alternative forms of residential care.

A ‘buffer’ of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.

Current clinical classifications do not contain specific diagnostic categories for patients with senile dementia of the Lewy body type (SDLT), recently proposed as the second commonest neuropathological cause of dementia in the elderly. This study determines how existing clinical diagnosis systems label SDLT patients and suggests how such patients may be identified.

A range of clinical diagnostic criteria for dementia were applied to case notes of autopsy-confirmed SDLT (n = 20), dementia of Alzheimer type (DAT; n = 21) and multi-infarct dementia (MID; n = 9) patients who had received psychogeriatric assessment. The predictive validity of each set of clinical criteria was calculated against the external criterion of neuropathological diagnosis.

Many SDLT patients erroneously met criteria for MID (35% with Hachinski scores ≥ 7) or for DAT (15% by NINCDS ‘probable AD’, 35% by DSM–III–R DAT and 50% by NINCDS ‘possible AD’). Up to 85% of SDLT cases could be correctly identified using recently published specific criteria.

DLT usually has a discernible clinical syndrome and existing clinical classifications may need revision to diagnose correctly such patients.

The validity of excluding bereavement-related depressive episodes which satisfy all the criteria of major depression is examined in this community study.

A total of 658 subjects were interviewed in their homes using the Diagnostic Interview Schedule. The length of the episodes of depression, the dysfunction they caused, and the frequency of seeking and receiving treatment were assessed.

The risk of recurrence did not differ whether the depressive episodes that satisfy the DSM–III–R criteria of major depression were or were not related to bereavement.

Excluding from the repertoire of depressions all those related to external stressors might need more research, but singling out those related to bereavement does not seem to be supported by our community-based data.