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Background: The Clinical Standards Advisory Group was asked by UK health ministers to advise on the standards of clinical care being achieved for people with schizophrenia. A subcommittee commissioned a review of standards, followed by research into how far these were reflected in contracts and met by providers., Method: No comprehensive but practical set of standards was found. A protocol of 143 items of good service practice was constructed, and applied by teams visiting services in II UK districts. The team appraisals were summarised in 20 key points, each scored 0 (absent) to 4 (excellent performance). Seven points were used to assess standards of commissioning and 13 for standards of service provision., Results: When placed into rank order, the mean key point scores for commissioners and providers in the same district tended to be very similar. Total district scores were then used to assign districts to one of three groups. Four performed reasonably well, five were moderate and two were poor., Conclusions: One of the key elements associated with these differences was the local level of morale. After wide consultation, a revised protocol of 26 key points for direct rating was drawn up and has since been further tested.

Work in the 1980s has shown that the high incidence of schizophrenia in British Caribbean men is restricted to those born after 1950. Data from a study of admissions in three London health districts suggested that the greater part of this excess risk may be confined to those born before 1966. This suggests that the group of British Caribbean men experiencing a high frequency of schizophrenia could be a tightly delineated birth cohort. If confirmed in wider studies, this could have important implications for the elucidation of the causes of one type of schizophrenia.

During the past 25 years psychiatry has increased its understanding of the social context of schizophrenia in four major areas. Reasonable reliability can now be achieved in describing and recognizing many of the acute and chronic syndromes, so that comparability can be achieved between different research teams. Much is now known about the proximate social causes of symptoms and disabilities. The relationship between social and pharmacological treatments is now better understood. A more rational approach to the planning and prescription of services and to the counseling of patients and relatives can be made. Each of these lines of advance promises to lead to further progress in the future.

Schizophrenia is recognized by the presence of one or more clinical syndromes, but there is disagreement as to how far the boundaries of the concept should be extended. During the course of a World Health Organization study, using the Present State Examination and a computerized classification program, a nuclear schizophrenic syndrome was nearly always (95.1%) associated with a diagnosis of schizophrenic or paranoid psychosis. The only substantial exception was that 13 out of 79 patients diagnosed as manic were said to show the nuclear syndrome. The computer classification was concordant with a clinical diagnosis of schizophrenic or paranoid psychosis, manic psychosis, or depressive disorder, in 90% of cases. If appropriate precautions are taken, many of the sources of noncomparability in epidemiological, therapeutic, and prognostic studies can be brought under control.

British contributions to theoretical and applied social psychiatry have been determined in large part by a traditional empiricism and by developments in social welfare legislation over the past 70 years. The establishment of a national health service covering the whole population and the attempt to provide comprehensive social services have created special opportunities for epidemiological research and for practical community psychiatry. These developments have by no means been uniform throughout the country, and there has been plenty of scope for individual initiative. Open-door policies, domiciliary visiting, social and occupational rehabilitation, therapeutic communities, and long-term continuity of care were first introduced in pioneering centers and subsequently adopted elsewhere. The idea that disorders such as schizophrenia not only have the character of acute illnesses but can also take the form of chronic disabilities has led to recognition of the fact that services must be tailored to the needs of individuals, and to an emphasis on the importance of the family and other social environments. There is a readiness to capitalize on successes and to learn from mistakes, assisted by a wide range of evaluative studies, which promises well for the future.

Diagnostical problems are of importance for the organization of mental health services. The WHO data show that criteria for diagnosing schizophrenia are rather broader in Moscow than in London and this must be borne in mind, when comparing services. The rehabilitation system is more thorough in Moscow and Leningrad than in the U. K. So far as the central syndromes of schizophrenia are concerned the basic approach in two countries is practically similar. Both assume an interaction between a biological abnormality which is liable to be chronically handicapping and a social environment.

Among the many technical issues dealt with in this symposium, two clinical problems are preeminent--how is schizophrenia defined and what is meant by outcome? Each problem is highly complex. Even given adequate designs, sampling, and analysis, the generalizability of the results depends on the extent to which the diagnostic and outcome criteria are independent of each other and reproducible. The authors amply demonstrate how far we are from achieving such comparability. Schizophrenia, at the moment, is diagnosable only on its manifestations, which can be influenced for better or worse by environmental conditions. Several standardized diagnostic systems are available but they recommend different sets of rules. It is premature, therefore, to speak of a "natural" long-term course. It is even doubtful whether further long-term studies (except perhaps of birth cohorts) should be attempted until more discriminating and reliable methods have been found. Short-term studies, however, focused on specific hypotheses, still hold out promise of yielding fruitful results.

A double-blind, placebo-controlled trial was carried out to determine the value of maintenance therapy with phenothiazines in a population of outpatients who had recently recovered from an acute episode of schizophrenia. The drug was shown to be significantly more effective than the placebo in preventing relapse. The relationship of the trial patients to the population from which they were selected was defined in terms of clinical, historical, and social data. Maintenance therapy seems of little value in patients with a good prognosis and in the severely ill, but it is of value in the indeterminate group between these two extremes.

A double-blind placebo trial of fluphenazine decanoate, a long-acting phenothiazine, was carried out to determine its value in maintenance therapy of chronic schizophrenic outpatients already established on the drug for a minimum period of eight weeks. In low doses it was significantly more effective than placebo in preventing relapse and admission to hospital. Relapse was accompanied by a resurgence of specifically schizophrenic symptoms and by an increase in abnormalities described by the relatives. There was no difference between the experimental and control groups in the treatment required for depression. The group on active medication required more treatment for Parkinsonism, but this difference did not reach statistical significance.In the context of a well-run special clinic for outpatient follow-up of chronic schizophrenic patients these results confirm the usefulness of long-acting fluphenazine. By inference, the benefit of this treatment highlights the need for adequate community services to deal with the residual chronic disabilities which are characteristic of these patients.

The article comments on the first-rank symptoms (FRS) developed by Kurt Schneider for the diagnosis of schizophrenia. Research by Schneider and other psychiatrists gives hope that few special manifestations of psychopathology will distinguish true cases of schizophrenia from other psychoses that only resemble the condition. Schneider's FRS, however, belong only to the reality-distortion domain of schizophrenia symptoms and lack prognostic significance. The issues' implications for psychiatry are also cited.

Background: 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.Method: Sampling and data collection methods were described in the first paper.Results: 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: 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.Method: 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.Results: 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: 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.Method: 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.Results: 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]