Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment.

To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI.

One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected.

A significantly lower incidence of violent behaviour occurred in subjects with ⩾6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse.

OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.

Improved risk assessment has been stressed as the way to reduce homicides by people with mental illness. The feasibility of predicting rare events needs examining.

To examine the findings of public inquiries into homicides by people with mental illness to see if they support the claim that better risk assessment would have averted the tragedy.

Analysis was made of the findings of the public inquiries between 1988 and 1997 in relation to the predictability and preventability of the homicides.

Of the homicides considered by the inquiry panels, 27.5% were judged to have been predictable, 65% preventable and 60% of the patients had a long-term history containing violence or substantial risk factors for violence.

Improved risk assessment has only a limited role in reducing homicides. More deaths could be prevented by improved mental health care irrespective of the risk of violence. If services become biased towards those assessed as high risk, then ethical concerns arise about the care of both violent and non-violent patients.

There have been no large-scale prospective studies evaluating the transfer of care from psychiatric hospitals to district-based services.

We aimed to compare the quality of life of patients in two north London hospitals scheduled for closure with that in the community homes to which they were discharged.

The total long-stay population of Friern Hospital and several hundred long-stay patients in Claybury Hospital were assessed with a batch of eight schedules while in hospital. They were followed up after one year in the community and then at five years.

Of the 670 discharged patients, 126 died before the five-year follow-up. Data were obtained on 523 (97%) of the survivors. There was no change in the patients' clinical state or in their problems of social behaviour. However, they gained domestic and community living skills. They also acquired friends and confidants. They were living in much freer conditions and the great majority wanted to remain in their current homes.

Community care has enhanced the quality of life of this group of patients, involved in a well-planned and adequately resourced reprovision programme.

Medicine is rapidly becoming molecular medicine, and little escapes the grasp of modern genetics. Most disorders associated with learning disability have at least a genetic component influencing their expression; in many disorders, disturbances of genetic mechanisms play a pivotal role.

Dynamic mutations, imprinting mechanisms and gene-dosage effects are explained with reference to genetic disorders that lead to learning disability.

A review of recent important studies in the genetics of learning disability.

A host of new genetic connections to conditions associated with learning disability have been made.

A basic understanding of these genetic connections is important for all learning disability psychiatrists if they are to follow the rapid changes – already beginning to influence our practice – that hold immense promise for the future.

Unlike schizophrenia, little interest has been taken in the incidence of obstetric complications in affective psychoses.

To find out whether obstetric complications are more common in affective psychoses than matched controls.

Two hundred and seventeen probands with an in-patient diagnosis of affective psychosis who had been born in Scotland in 1971–74, and a further 84 born in 1975–78, were closely matched with controls and the incidence of obstetric complications in the two compared using obstetric data recorded in a set format shortly after birth.

Abnormal presentation of the foetus was the only complication significantly more common in the affective probands in the 1971–74 birth cohort and artificial rupture of the membranes was the only event more common in the probands in the 1975–78 cohort. Both are probably chance findings.

It is unlikely that the incidence of obstetric complications is raised in people with affective psychoses of early onset.

Direct comparisons of the prognosis for treated depression in adult and elderly cohorts are few, but suggest higher morbidity and mortality in the elderly.

To examine outcome in two such groups after 4.5 years and compare results with those reported elsewhere.

Fifty-six adults (aged under 65) and 54 elderly people (over 65) with primary depression were assessed 4.5 years after receiving hospital treatment, and factors influencing the outcome were explored.

Recovery rates were higher in the adults than in the elderly (42.8% v. 24%), largely due to higher rates of death (33%) and dementia (14.8%) in the latter group, who also suffered more serious health problems (62.9% v. 28.5%). Survival analysis showed no difference in the recovery time between cohorts, with over 90% recovered after 25 weeks. After deducting the natural deaths, melancholic illness proved a poor outcome predictor in the adults.

The outlook for elderly depressed patients is poorer than for younger patients because of concurrent physical disease, a higher death rate and the development of dementia.

As the availability of mental hospital beds has fallen, so the number of people in prison has risen.

To review current policy trends in British forensic psychiatry and put them in an international context.

Literature on the prevalence rates of psychiatric disorder in prisons and jails has been examined for the USA, England & Wales and New Zealand.

All studies show a high prevalence of mental disorder in prisons and jails. Authors in the USA suggest that prisons are replacing mental hospitals. In England & Wales rates of psychosis are reported as 4–10% for remanded prisoners and 2–7% for sentenced prisoners. Substance misuse among prisoners is a major problem. Prison is the preferred place of disposal for large numbers of mentally disordered people. Does this matter? Why should this be the case? Is this the cheapest option? Politicians are considering new powers to direct more people into institutions (presumably prisons) on the grounds of public protection.

We need more information about attitudes and their formation. We need more interprofessional dialogue about the best arrangements for people with mental disorders, and inter-disciplinary education.

Research has demonstrated increased mortality rates in adolescent psychiatric in-patients.

To investigate this excess mortality by calculating standardised mortality ratios (SMRs) relative to cause of death, diagnosis, cohort and age.

A nationwide Norwegian sample of 1095 former adolescent psychiatric in-patients were followed up 15–33 years after first hospitalisation by record linkage to the National Death Cause Registry.

The SMR was significantly increased for almost all causes of death investigated. In males, all psychiatric diagnoses had significantly increased SMRs, whereas in females, organic mental disorder, anxiety disorder and affective disorder had non-significantly increased SMRs. The SMR was significantly elevated for all age-spans and cohorts investigated.

A broad prevention strategy is needed to combat the increased mortality rates found in adolescent psychiatric in-patients.

The rapid increase in research endeavour has not kept pace with the advent of well-publicised theories and treatments for autism.

To explore some of the newer developments in biological research into autism.

A review of recent publications and presentations.

The concept is shifting from the narrow perception of aloof autism, described by Kanner, to a wider one that includes a spectrum extending to a broader, subclinical phenotype. The genetic basis has been established; now we need to discover the location and interaction of the relevant sites. There is considerable interest in the bowel as a pathogenetic agent, particularly in the effects of exogenous opioids and multiple viral infection (the latter posing a public health problem). Also of concern is the role of (potentially treatable) epilepsy, analogous to the Laudau-Kleffner syndrome.

In the absence of a cure, the implementation of ideas will continue to outstrip factual evidence. Clinicians are challenged by the availability of information (and misinformation), particularly on the internet.

Most prior studies of panic-depression comorbidity have been limited methodologically by use of small clinical samples and incomplete analyses.

General population data were used to study the association of lifetime and recent (12 months) panic–depression comorbidity with symptom severity, impairment, course and help-seeking in the National Comorbidity Survey (NCS).

The NCS is a nationally representative survey of the prevalences and correlates of major DSM–III–R disorders in the US household population.

Strong lifetime and current comorbidity were found between panic and depression. Comorbidity was associated with greater symptom severity, persistence, role impairment, suicidality and help-seeking, with many findings persisting after controlling for additional comorbid diagnoses. Findings did not differ according to which disorder was chronologically primary.

Both lifetime and current panic–depression comorbidity are markers for more severe, persistent and disabling illness. Neither additional comorbid diagnoses nor the primary–secondary distinction were important moderators of these associations.

This paper reviews current research on workplace violence in the USA and offers suggestions concerning the roles that mental health professionals with forensic expertise can play in this expanding field.

To clarify the role of the mental health professional in evaluating issues related to workplace violence.

Manual and computer literature searches were performed.

The incidence of reported workplace violence is on the rise and can be devastating beyond the immediate injury. Forensically oriented mental health professionals can assist companies by providing pre-employment screenings, fitness-for-duty evaluations and threat assessment by using the results of current research on potentially violent individuals.

With the growing interest in workplace violence come many opportunities for mental health professionals to assist companies in assessment, intervention and prevention.

Ageing is a continuation of the developmental process and is influenced by genetic and other biological factors as well as personal and social circumstances.

To identify some key biological, psychological and social issues relevant to how ageing might particularly effect people with learning disabilities.

This selected review considers the extent to which there are similarities and differences relative to people without learning disabilities.

There is a convergence, in later life, between people with a learning disability and those without, owing to the reduced life expectancy of people with more severe disabilities. People with Down's syndrome have particular risks of age-related problems relatively early in life.

The improved life expectancy of people with learning disabilities is well established. There is a lack of a concerted response to ensure that the best possible health and social care is provided for people with learning disabilities in later life.

Many young people who harm themselves have chronic mental health or social problems or are at risk of future self-harm or even suicide. The accident and emergency (A&E) clinic is an important gateway to treatment.

To describe the psychosocial assessment of 12- to 24-year-old patients attending A&E clinics following deliberate self-harm (DSH) and to identify features of service management and provision which maximise specialist assessment.

A postal questionnaire was sent to a sample of one in three A&E departments in England. In a representative sample of 18 of these hospitals, staff were interviewed and 50 case notes per hospital were examined.

Psychosocial assessment by non-specialist doctors in A&E departments tended to be of variable quality, focused on short-term risk. Around 43% of patients aged 12–24 were assessed by a specialist; specialist assessment was associated with high admission rates and the presence of on-site psychiatric departments and DSH teams.

Young DSH patients at risk often go unidentified; as a result their psychological problems may not be treated. Hospitals are frequently unaware of the proportion of patients discharged without adequate assessment.

Previous meta-analyses of fluoxetine as an antidepressant have many methodological problems, including diagnosis of major depression, validity of outcome measures and lack of intention-to-treat analyses.

To provide an estimate of the effect of fluoxetine compared with placebo and tricyclic antidepressants (TCAs), and to investigate reasons for early discontinuation from acute treatment.

Randomised trials were analysed using both intention-to-treat, efficacy and end-point.

Fluoxetine was superior to placebo but effect size was low. In trials comparing fluoxetine v. TCA, the results for all trials and for the USA trials showed a trend in favour of fluoxetine. Those for the non-USA trials showed a trend in favour of TCA. When combined, the results showed that significantly fewer patients on fluoxetine discontinued treatment because of adverse events.

Fluoxetine is superior to placebo, irrespective of the analytical approach use, whereas the results obtained v. TCAs depend on the approach used. Hence, the results should be interpreted in this light.

Psychological therapies are rarely used in people with learning disabilities. Learning disability is often given as an exclusion criterion. There is insufficient published research to conduct a systematic review. Few outcome studies of psychoanalytic or cognitive psychotherapy have been reported.

To describe recent advances in understanding and practice within the learning disability field which have not received wider recognition within mainstream psychotherapy and psychiatry.

The availability of different psychotherapeutic approaches is discussed. We explore developmental issues including the contribution of attachment theory to our understanding, and the effects of trauma on the lives of people with learning disabilities.

Theoretical and clinical perspectives suggest that many therapeutic opportunities exist.

Practitioners are encouraged to extend their therapeutic repertoire, and to report measurable outcomes.

Epidemiological studies suggest schizophrenia and substance misuse to be associated with a higher rate of violence and crime.

The literature was evaluated to assess whether people with schizophrenia who use substances have an increased risk for violence and disturbed behaviour.

A detailed Medline analysis was performed and relevant studies were reviewed.

A large number of studies have linked substance misuse in schizophrenia with male gender, high incidence of homelessness, more pronounced psychotic symptoms, non-adherence with medication, poor prognosis, violence and aggression. The latter has been proved by clinical, epidemiological and longitudinal prospective studies of unselected birth cohorts. The increased risk for aggression and violent acts cannot be interpreted only as a result of poor social integration. Male gender, more severe psychopathology, a primary antisocial personality, repeated intoxications and non-adherence with treatment are important confounding variables.

Substance misuse has been shown consistently to be a significant risk factor for violence and disturbed behaviour. Future research should try to evaluate possible pharmacological and psychosocial treatment approaches.

Robust evidence that anorexia nervosa is preceded rather than accompanied by high-concern (overprotective) parenting is limited.

To look for evidence of parental high concern occurring before any onset of disorder.

Forty consecutive referrals of adolescent girls with DSM – III – R anorexia nervosa were compared with matched controls using obstetric records and maternal interviews.

Index mothers reported higher rates of: near-exclusive child care (P=0.02), infant sleep difficulties (P=0.018), severe distress at first regular separation (P=0.048), high maternal trait anxiety levels (P=0.008) and later age for first sleeping away from home (P=0.009). More index families had experienced a severe obstetric loss prior to their daughter's birth (P=0.066).

This study lends evidence to the clinical contention that high-concern parenting in infancy is associated with the later development of anorexia nervosa. This may derive, in part, from aspects of unresolved grief.