From a first clinical description of a complete resident sample of special (high security) hospital patients, we examined the association between mental disorder and violence.

A record survey of all 1740 patients resident at any time between 1 January and 30 June 1993. inclusive, and, for most, the official criminal record.

1015 patients (58%) had functional psychosis, one-quarter of whom also had an independent personality disorder: 461 (26%)had personality disorders uncomplicated by psychosis, and 264 (16%) had learning disabilities. Pre-admission substance misuse, which was probably under-recorded, had been most common among those with psychosis and an independent personality disorder. Less than 10% had never been convicted of a criminal offence, although 25% had been admitted directly from other hospitals. Direct personal violence was more common among men, and fire-setting among women. Schizophrenia was most strongly associated with personal violence. More than 75% of those with a psychosis were recorded as being driven to offend by their delusions. In the absence of delusions, hallucinations had no such effect.

For people with personality disorder better clinical descriptions seem essential. For people with a pure psychosis, as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health.

The risk of recurrence in affective disorder has been found to increase with each new episode. It is unclear whether it is universal without regard to gender, age and type of disorder.

Survival analysis was used to estimate the risk of recurrence in a case-register study including all hospital admissions with primary affective disorder in Denmark from 1971–1993. In this period 20 350 first-admission patients had been discharged with a diagnosis of affective disorder, depressive or manic/cyclic type.

The risk of recurrence increased with the number of previous episodes regardless of the combination of gender, age and type of disorder. Initially in the course of illness, unipolar and bipolar women experienced an equal greater risk of recurrence than men. The risk of recurrence after the first episode was increased for middle-aged and older unipolar women compared with the risk for younger women, while after all other episodes younger age at first episode increased the risk of recurrence.

The course of severe unipolar and bipolar disorder seems to be progressive in nature irrespective of gender, age and type of disorder.

The Joint Working Group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners (1996) recommended graded exercise and antidepressants for patients with chronic fatigue syndrome. We assessed efficacy and acceptability of these treatments.

Six-month prospective randomised placebo and therapist contact time controlled trial with allocation to one of four treatment cells: exercise and 20 mg fluoxetine, exercise and placebo drug, appointments only and 20 mg fluoxetine, appointments and placebo drug. Drug treatment was double blind and patients were blind to assignment to exercise or appointments.

Ninety-six (71%) of 136 patients completed the trial. Patients were more likely to drop out of exercise than non-exercise treatment (P=0.05). In an intention to treat analysis, exercise resulted in fewer patients with case level fatigue than appointments only at 26 weeks (12 (18%) v. 4 (6%) respectively P=0.025) and improvement in functional work capacity at 12(P=0.005) and 26 weeks (P=0.03). Fluoxetine had a significant effect on depression at week 12 only (P=0.04). Exercise significantly improved health perception (P=0.012) and fatigue (P=0.028) at 28 weeks.

Graded exercise produced improvements in functional work capacity and fatigue, while fluoxetine improved depression only.

In schizophrenia, disturbances in the development of physiological hemisphere asymmetry are assumed to play a pathogenetic role. The most striking difference between hemispheres is in language processing. The left hemisphere is superior in the use of syntactic or semantic information, whereas the right hemisphere uses contextual information more effectively.

Using psycholinguistic experimental techniques, semantic associations were examined in 38 control subjects, 24 non-thought-disordered and 16 thought-disordered people with schizophrenia, for both hemispheres separately.

Direct semantic priming did not differ between the hemispheres in any of the groups. Only thought-disordered people showed significant indirect semantic priming in the left hemisphere.

The results support: (a) a prominent role of the right hemisphere for remote associations; (b) enhanced spreading of semantic associations in thought-disordered subjects; and (c) disorganisation of the functional asymmetry of semantic processing in thought-disordered subjects.

Psychological approaches to working with people with learning disabilities who self-injure have developed over the past 30 years.

The major literature is reviewed and an ecological framework is described which emphasises the importance of environmental, interpersonal and intrapersonal dynamics to understanding the multi-factorial nature of self-injury. Case examples are given.

Self-injury is seen as essentially communicative and functionally adaptive; it is the person's best attempt to deal with abusive, neglecting or traumatic environments or events.

The persistence of self-injurious behaviour once established, requires an interdisciplinary approach which addresses comprehensively the variety of factors which have contributed to the development and maintenance of self-injury.

Unblinding effects may-introduce bias into clinical trials. The use of active placebos to mimic side-effects of medication may therefore produce more rigorous evidence on the efficacy of antidepressants.

Trials comparing antidepressants with active placebos were located. A standard measure of effect was calculated for each trial and weighted pooled estimates obtained. Heterogeneity was examined and sensitivity analyses performed. A subgroup analysis of in-patient and out-patient trials was conducted.

Only two of the nine studies examined produced effect sizes which showed a consistent significant difference in favour of the active drug. Combining all studies produced pooled effect size estimates of between 0.41 (0.27–0.56) and 0.46 (0.31–0.60) with high heterogeneity due to one strongly positive trial. Sensitivity analyses excluding this and one other trial reduced the pooled effect to between 0.21 (0.03–0.38) and 0.27 (0.10–0.45).

Meta-analysis is very sensitive to decisions about exclusions. Previous general meta-analyses have found combined effect sizes in the range 0.4–0.8. The more conservative estimates produced here suggest that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos.

This is the third large-scale audit in the past 20 years and compares the practice of electroconvulsive therapy (ECT) in England and Wales with the standards derived from the Royal College of Psychiatrists' 2nd ECT handbook.

Facilities, equipment, practice, personnel and training were systematically evaluated during visits to all ECT clinics in the former North East Thames and East Anglia regions and Wales. All other English ECT clinics were surveyed with a postal questionnaire. Information was obtained for 184 (84%) of the 220 ECT clinics identified.

Although some aspects of ECT administration had improved since the last audit in 1991, overall only one-third of clinics were rated as meeting College standards. Only 16% of responsible consultants attended their ECT clinic weekly and only 6% had sessional time for ECT duties. Fifty-nine per cent of all clinics had machines of the type recommended by the College and 7% were still using machines considered outdated in 1989. Only about one-third of clinics had clear policies to help guide junior doctors to administer ECT effectively.

Twenty years of activity by the Royal College of Psychiatrists and three large-scale audits have been associated with only modest improvement in local practice.

There have been few prospective studies of the long-term outcome of psychosis in people of Afro-Caribbean origin in the UK.

We followed-up a population-based, consecutive series of 34 Afro-Caribbean and 54 White people with psychosis who had been extensively investigated during their first admission in 1973/74. Diagnoses were made by direct interview using the Present State Examination at both first admission and follow-up.

Ninety-seven per cent of the original sample were traced. A slightly greater proportion of the Afro-Caribbean people were assigned to the S+ Catego class (schizophrenia), both on first assessment and at follow-up. No difference was found between the two groups in the consistency of diagnosis over the 18 years or in the proportion of patients considered psychotic but Afro-Caribbean people tended to have fewer negative symptoms at follow-up. There were striking differences between the two groups in their experience of psychiatric care; Afro-Caribbean people were more likely to have been readmitted, to have experienced longer hospitalisations, and to have undergone more involuntary admissions than their White counterparts.

Afro-Caribbean people who met clinical and research criteria for schizophrenia had a less satisfactory experience of, and response to, psychiatric care over 18 years than their White counterparts.

The lifetime risks of suicide are generally quoted as 15% for affective disorder and alcoholism and 10% for schizophrenia, based on data from 1921–1975 and on calculations performed before computerised modelling techniques became available. This study recalculates the risk using contemporary data and modern techniques.

Twenty-seven mortality studies provided data for affective disorder, 27 for alcohol dependence and 29 for schizophrenia. The proportion of the cohort who had died was plotted against the proportion of deaths from suicide. Modelling techniques fitted curves through the data points extrapolating them to cohort extinction, thus estimating the lifetime risk of suicide for each disorder.

The lifetime risk was estimated at 6% for affective disorder, 7% for alcohol dependence and 4% for schizophrenia.

The lifetime suicide risk figures often quoted in the literature appear to be too high.

Two studies tested whether subjects with obsessive-compulsive disorder could successfully use BT STEPS, a computer-aided system, to perform self-assessment for self-treatment of obsessive-compulsive disorder by exposure and ritual prevention.

Subjects were given a self-guiding manual and could use a touch-tone telephone to access computer-controlled Interactive Voice Response interviews at their convenience from home. Using the BT STEPS system, patients rated themselves and worked out a plan for individually tailored self-exposure therapy.

Outcomes were similar in the two studies. Of the 63 subjects who used BT STEPS, 84% completed the self-assessment module. Most calls were made outside usual office hours. As expected, subjects did not improve merely by completing self-assessment. However, completion of self-assessment predicted later improvement with self-exposure therapy.

Most subjects successfully completed self-assessment using BT STEPS from their homes.

Factors associated with aggression among psychiatric in-patients are still poorly understood. Inconsistent published findings are partly attributable to methodological problems. Much previous research has been undertaken in specialist settings, where conditions are likely to differ from those in acute admission wards.

Levels of aggression were ascertained weekly by staff report, using a reliable measure, for every patient on five acute admission wards and one locked intensive care ward at two hospitals prospectively over a five-month period.

Levels of aggression varied considerably among the admission wards. Aggression was more common on the locked ward and among younger patients. Factors associated with aggression changed with time since admission (seldom examined in previous studies). Complex associations were found with gender, ethnic group and diagnosis.

Some of the findings might be explicable by differences in ward environment, and staff–patient interactions. Further investigation into these is warranted.