The 50th anniversary of the inauguration of the NHS provided the occasion to review the evolution of mental health services and of psychiatry itself in Britain during that period.

The principal themes to be followed were the decline of a mental hospital system that had existed for over a century, the development of an alternative policy of ‘community care’, the emergence of a numerous and well-trained psychiatric profession, and the interaction between political and legal processes and mental health care.

An examination of Ministry of Health and Department of Health and Social Security files in the Public Record Office, interviews with influential figures, examination of the secondary literature, and personal experience of events described.

The material has been analysed, in the light of the expressed aims, and important trends have been described. The current situation is assessed.

The replacement of one system of care and treatment in Britain by another has been a process fraught with overwhelming difficulties. While adhering to the aim of ‘community care’, governments have been reluctant to provide the means for achieving this. The psychiatric profession is now faced with very large but ill-defined responsibilities.

About one-third of patients fail to respond to initial antidepressant therapy, which suggests a need for more effective drugs.

To compare the efficacy and safety of venlafaxine and paroxetine in 122 patients with non-chronic treatment-resistant depression.

In-patients or out-patients satisfying DSM – III – R criteria for major depression in evolution for less than eight months, having a baseline HAM–D score 18 and a HAM – D Item 3 score < 3 were eligible. Patients were required to have a history of resistance to two previous antidepressant treatments and a CGI improvement score of 3 at the beginning of treatment. Doses were adjusted to 200–300 mg/day for venlafaxine and 30–40 mg/day for paroxetine.

For the observed-case analysis, the response rate was 51.9% for venlafaxine and 32.7% for paroxetine (P=0.044), and a remission was achieved in 42.3% of venlafaxine-treated and 20.0% of paroxetine-treated patients (P=0.01). The incidence of adverse effects was comparable between treatment groups.

Venlafaxine showed some evidence of superiority to paroxetine in this difficult-to-treat patient population.

Most pharmacotherapy trials in post-traumatic stress disorder (PTSD) have been conducted upon male combat veterans. Outcome studies relating to civilians are therefore needed.

To demonstrate that fluoxetine is more effective than placebo in treating PTSD.

Civilians with PTSD (n=53) were treated for 12 weeks with fluoxetine (up to 60 mg/day) or placebo. Assessments of PTSD severity, disability, stress vulnerability, and high end-state function were obtained.

Fluoxetine was more effective than placebo on most measures at week 12, including global improvement (much or very much improved: fluoxetine 85%, placebo 62%, difference 0.24, 95% CI 0.01–0.47; very much improved: fluoxetine 59%, placebo 19%, difference 0.40, 95% CI 0.16–0.64), and high end-state function (fluoxetine 41%, placebo 4%, difference 0.37, 95% CI 0.17–0.57)

Fluoxetine was superior for measures of PTSD severity, disability, stress vulnerability, and high end-state function. The placebo-group response was low when viewed as a broad outcome based on a portfolio of ratings, but was higher with a traditional global rating criterion.

No interventions have been shown to be effective in reducing deliberate self-harm (DSH) repetition in this group of patients as a whole.

To investigate the effect on repetition of offering emergency telephone support in a group of hospital-admitted DSH patients.

Atotal of 827 DSH patients admitted to medical wards were randomly allocated to either control or intervention (green card) groups. In addition to treatment as usual, the intervention group was offered telephone support should any further crises occur. The main outcome measure was DSH repetition within six months of the index event.

The intervention had no significant effect on the overall DSH repetition rate (odds ratio 1.20, 95% CI 0.82–1.75). Sub-group analysis suggested that response to the intervention differed according to the past history of DSH – subjects with a previous history repeating more often and first-timers appearing to benefit.

No overall effect of the intervention was shown. Conclusions concerning sub-groups must be regarded as speculative, but they suggest that further assessment of the value of telephone support in first-timer DSH patients is indicated.

The incidence rate for broad schizophrenia among second-generation African–Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors.

To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997)

A12-month study of all persons in the 18–54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using World Health Organization screening and measurement instruments.

On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10 000 (95% CI 1.97–3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10 000 (95% CI 2.3–4.1), which is significantly lower than the comparable rate for London's African–Caribbeans of 6.6/10000 (95% CI 4.5–8.7)

The very high rate for broad schizophrenia among African–Caribbean people in the UK is probably due to environmental factors.

An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.

To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.

A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.

Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.

The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

An increased incidence of psychotic disorders has repeatedly been reported among African–Caribbeans in the UK.

To test whether the increased incidence of psychotic disorders in first-and second-generation African–Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.

Thirty-three patients of African–Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.

There was a trend for better outcomes in African–Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio=0.9 (–0.50 to –2.00)). Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio=0.59 (–0.21 to –1.66)). Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African–Caribbean group.

Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African–Caribbeans.

A recent review showed that opioid users' deaths from suicide were 10 times as common as expected on the basis of age and gender. Surveys showing prisoners' high prevalence of injecting or opioid dependence have led to a new statistical approach to prison suicides.

To estimate the expected number of UK prison suicides annually, having taken account of inmates' age, gender and opioid dependence.

By gender, estimate the effective number of individuals (in terms of community-equivalent suicide risk) for whom prisons have a duty of care as 10 times the number of opioid-dependent inmates plus the number of non-opioid user inmates. Apply the gender and age-appropriate national suicide rates to work out the expected number of prison suicides.

The Scottish Prison Service can expect 7.1 suicides per annum, and annual totals up to 12 without exacerbation of suicides due to incarceration. For the Prison Service in England and Wales, 19.3 suicides per annum can be expected in prisons, and annual totals may range up to 28 without indicating incarceration; the total of self-inflicted deaths was 47 in 1993–94

Prisons cannot prevent all suicides. An alert may be warranted if prison suicides exceed 12 per annum in Scotland, or 28 in England and Wales.

Family members of patients with schizophrenia frequently report burdens associated with caring for their relatives.

We evaluate the impact of illness beliefs on the burden reported by family care-givers of people with bipolar illness.

The multivariate relationships between patient symptomatology and family illness beliefs and report of burden were examined at baseline among care-givers of 266 patients with Research Diagnostic Criteria-diagnosed bipolar illness who were subsequently followed for 15 months.

At baseline, 93% of care-givers reported moderate or greater distress in at least one burden domain. As a group, care-giver illness beliefs (illness awareness, perception of patient and family control) explained an additional 18–28% of variance in burden experienced beyond the effects of the patients clinical state and history.

Care-givers of patients with bipolar illness report widespread burden that is influenced by beliefs about the illness.

The use of MDMA (‘ecstasy’) is common among young people in Western countries. Animal models of MDMA toxicity suggest a loss of serotonergic neurons, and potentially implicate it in the development of significant psychiatric morbidity in humans.

To test whether long-term use of MDMA can produce abnormalities in cerebral serotonin, but not dopamine, transporter binding measured by single photon emission computed tomography (SPECT)

Ten male regular ecstasy users and 10 well-matched controls recruited from the same community sources participated in SPECT with the serotonin transporter (SEPT) ligand [123I]-CIT. Dopamine transporter binding was determined from scans acquired 23 hours after injection of the tracer.

Ecstasy users showed a cortical reduction of SERT binding, particularly prominent in primary sensory-motor cortex, with normal dopamine transporter binding in lenticular nuclei.

This cross-sectional association study provides suggestive evidence for specific, at least temporary, serotonergic neurotoxicity of MDMA in humans.

This study evaluates two in-patient units attached to community mental health centres (CMHCs) that were designed to supplement acute in-patient care and to integrate with community-based after-care services.

To examine the comparative outcome of patients with severe mental illness (SMI) admitted to the two units.

All patients with SMI admitted to the acute psychiatric wards serving the two CMHCs, those transferred to the community in-patient units and those admitted directly to these units (n=110) were compared with patients (n=67) admitted to acute wards serving two similar catchment areas without associated community beds. Baseline clinical and social measures were made and repeated at six and 12 months. Satisfaction with services was assessed at 12 months.

The experimental group showed significantly better outcomes, significant reduction in unmet need and better satisfaction with services.

The use of the community beds appears to have significant benefits for patients with SMI.

Innovative approaches to the provision of psychiatric care must justify their ability to improve the quality of life within the resource constraints imposed on psychiatry.

To examine the average costs per patient of the experimental and control group services.

An individual patient costing methodology that identified, measured and valued all public and private resources.

The experimental group was more likely to remain in contact with services over a 12-month period, had fewer acute readmissions and spent less time in acute in-patient units. There were significantly different levels and patterns of resource consumption between the groups and between the two separate catchment areas.

The cost analysis should be assessed in the context of the previous outcome analysis. It is likely, but not inevitable, that such units will increase the overall costs of care provision; this largely depends on the effectiveness with which such units are integrated into existing care provision.