Randomised trials remain the gold standard for evaluating health interventions. This applies to the criminal justice system as well as to health.

To identify and survey randomised trials relevant to forensic mental health services.

We searched 29 electronic bibliographic databases and acquired randomised trials involving sex offenders, arsonists or people clearly and actively aggressive, or abusive of children or spouse. Two researchers reliably extracted data.

Of 409 studies found, we were able to acquire 300 for further inspection. They all involved particularly violent people (total n=28 669), mostly adult men; the mean study size was 197 (median 52, mode 60, range 1–1200). In these 300 randomised trials over 700 interventions were evaluated and short-term outcomes were recorded on 345 different scales.

Wider collaboration, rationalising treatments and simplifying outcomes could further strengthen the tradition of trialling in forensic psychiatry. Systematic reviews of these studies are overdue.

We know little about the degree to which comorbidity, so commonly seen among psychiatric disorders, arises from variation in normal personality.

To study the degree to which variation in normal personality accounts for the comorbidity of eight common psychiatric and substance use disorders.

Internalising disorders (major depression, generalised anxiety and panic disorders, phobias), externalising disorders (alcohol and drug dependence, anti-social personality and conduct disorders) and personality dimensions of neuroticism, extraversion and novelty seeking were assessed in 7588 participants from a population-based twin registry. The proportion of comorbidity explained by each personality dimension was calculated using structural equation modelling.

Neuroticism accounted for the highest proportion of comorbidity within internalising disorders (20–45%) and between internalising and externalising disorders (19–88%). Variation in neuroticism and novelty seeking each accounted for a modest proportion (10–12% and 7–14%, respectively) of the comorbidity within externalising disorders. Extraversion contributed negligibly

High neuroticism appears to be a broad vulnerability factor for comorbid psychiatric disorders. Novelty seeking is modestly important for comorbid externalising disorders.

Hippocampal volume reduction has been reported inconsistently in people with major depression.

To evaluate the interrelationships between hippocampal volumes, memory and key clinical, vascular and genetic risk factors.

Totals of 66 people with depression and 20 control participants underwent magnetic resonance imaging and clinical assessment. Measures of depression severity, psychomotor retardation, verbal and visual memory and vascular and specific genetic risk factors were collected.

Reduced hippocampal volumes occurred in older people with depression, those with both early-onset and late-onset disorders and those with the melancholic subtype. Reduced hippocampal volumes were associated with deficits in visual and verbal memory performance.

Although reduced hippocampal volumes are most pronounced in late-onset depression, older people with early-onset disorders also display volume changes and memory loss. No clear vascular or genetic risk factors explain these findings. Hippocampal volume changes may explain how depression emerges as a risk factor to dementia.

Decreased metabolic activity in the prefrontal cortex during cognitive activation is a recurrent finding and a likely functional marker of schizophrenia.

To investigate the occurrence of hypofrontality in patients with first-episode psychosis, with or without evolution to schizophrenia.

We used fluorodeoxyglucose positron emission tomography during the performance of an attention task and magnetic resonance imaging to study the dorsolateral prefrontal region in 13 men with a first episode of psychosis. Data from patients who progressed to schizophrenia were compared with those of patients who did not meet criteria for this diagnosis after 2 years.

Patients who developed schizophrenia demonstrated a significant hypofrontality in the dorsolateral prefrontal cortex in comparison with the non-schizophrenia and control groups.

Our results suggest that hypofrontality could be a marker of schizophrenia at the time of the first psychotic episode, in agreement with neurodevelopmental theories of schizophrenia.

The production of grammatically complex sentences is impaired in schizophrenia. It has been suggested that impaired syntax processing reflects a risk for the disorder.

To examine the neural correlates of syntax production in people with schizophrenia using functional magnetic resonance imaging (fMRI).

Six patients with schizophrenia and six healthy volunteers spoke about seven Rorschach inkblots for 3 min each while correlates of brain activation were measured with fMRI. Participants produced varying amounts of syntactically simple and complex sentences during each 3 min run. The number of simple and complex sentences was correlated separately with the BOLD contrast.

In the comparison between the control group and the patient group, the number of complex sentences produced was correlated with activation in the posterior portion of the right middle temporal (Brodmann area 21) and left superior frontal (BA 10) gyri in the control group but not in the patients.

The absence of activation in the right posterior temporal and left superior frontal cortex in patients with schizophrenia might contribute to the articulation of grammatically more simple speech in people with this disorder.

Smoking may have a beneficial effect on either schizophrenic symptoms or antipsychotic side-effects, but studies are hampered by the lack of control of confounding factors.

To explore the self-medication hypothesis in a large sample of stable out-patients with schizophrenia.

Symptoms, assessed with the Positive and Negative Syndrome Scale (PANSS), and number of hospitalisations were compared in 250 out-patients with DSM–IV schizophrenia classified into three categories: highly dependent smokers, mildly dependent smokers and non-smokers. Log-linear analysis was used to control for potential confounding and interacting variables.

High PANSS total scores and positive symptoms were less frequent in mildly dependent smokers than in non-smokers or highly dependent smokers. The highly dependent smokers had the worst outcome.

The data do not generally support the self-medication hypothesis but rather suggest a complex interaction between nicotine dependence and schizophrenic symptoms.

Selective serotonin reuptake inhibitors are effective in the treatment of social anxiety disorder and are currently regarded as the pharmacotherapy of choice.

To investigate the efficacy and tolerability of escitalopram in the treatment of generalised social anxiety disorder.

Patients with generalised social anxiety disorder were randomised to receive placebo (n=177) or 10–20 mg escitalopram (n=181) in a 12-week, double-blind trial. The primary outcome measure was the mean change from baseline to last assessment in the Liebowitz Social Anxiety Scale (LSAS) total score.

The study showed a statistically superior therapeutic effect for escitalopram compared with placebo on the LSAS total score (P=0.005). There were significantly more responders to treatment for escitalopram than for placebo (54% v. 39%; P < 0.0 1). The clinical relevance of these findings was supported by significant reduction in the work and social components of the Sheehan Disability Scale and by the good tolerability of escitalopram treatment.

Escitalopram was efficacious and well tolerated in the treatment of generalised social anxiety disorder.

Personality pathology constitutes a major form of psychopathology in adolescents.

To examine the reliability and validity of a Q-sort instrument for assessing adolescent personality pathology designed for clinically experienced informants.

A sample of 294 randomly selected psychiatrists and psychologists each provided data on a current patient, aged 14–18 years. Clinicians completed several measures, including the Shedler–Westen Assessment Procedure for Adolescents (SWAP–200–A).

Factor analysis identified II dimensions of adolescent personality: psychopathology/malignant narcissism, dysphoria/inhibition, psychological health, histrionic sexualisation, schizotypy, sexual conflict, emotional dysregulation, anxious obsessionality, peer rejection, delinquent behaviour and attentional dysregulation. These correlated in predicted ways with a range of criterion variables, including measures of adaptive functioning, Axis II pathology, the Five Factor Model and the Child Behavior Checklist.

The SWAP–200–A shows promise as an instrument for assessing personality pathology in adolescents. Trait dimensions such as delinquent behaviour and emotional dysregulation may prove useful additions to a classification of personality.

There is a need for reliable assessment tools that are suitable for the counselling and the psychological therapy services in primary and secondary care settings.

To test the suitability and utility of the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE–OM) and CORE–Assessment (CORE–A) assessment tools.

Service intake data were analysed from counselling and psychological therapy services in 32 primary care settings and 17 secondary care settings.

Completion rates exceeded 98% in both of the settings sampled. Intake severity levels were similar but secondary care patients were more likely to score above the risk cut-off and the severe threshold and to have experienced their problems for a greater duration.

The CORE–OM and CORE–A are suitable assessment tools that show small but logical differences between psychological therapy services in primary- and secondary-based care.

Established legal mandates and high expectations for psychiatric advance directives are not matched by empirical evidence documenting their actual implementation.

To explore the interests, concerns and planning activities of informed mental health service users contemplating such directives.

Standard qualitative research techniques were used: field observations, interviews, focus groups, archival research and key informant interviews; 33 persons participated in the interviews and focus groups. Transcripts were coded and analysed for thematic content, and results were member-checked.

Training set in motion labour-intensive projects: conceptualising how a psychiatric advance directive would work in one's life, mobilising resources, reviewing past experiences and assessing risks. Especially meaningful was the prospect of being treated as a responsible agent in future interactions with the mental health system.

Advance directives are best thought of as complex planning tools for future psychiatric crisis management, rather than focal interventions to enhance compliance. Research is needed to explore the institutional response to this prospective decision-sharing initiative.

Prediction of suicide risk is difficult in clinical practice.

To identify changes in clinical presentation predictive of suicide in patients treated for repeated episodes of self-poisoning.

A nested case–control study used the Hunter Area Toxicology Service database to identify exposure variables and the National Death Index to identify suicide. Cases were patients who had hospital treatment on more than one occasion between 15 January 1987 and 31 December 2000.

There were 31 cases, for which 93 controls were selected. Study variables associated with an increased risk of subsequent suicide were an increase in the number of drugs ingested (odds ratio 2.59, 95% CI 1.48–4.51), an increase in the dose ingested (OR1.33, 95% CI 1.01–1.76), an increase in coma score (OR 1.71, 95% CI 1.11–2.66), a decrease in Glasgow Coma Score (OR 1.21, 95% CI 1.03–1.43) and an increase in drug or alcohol misuse (OR 2.33, 95% CI 1.06–5.10).

Patients who have escalating severity of self-poisoning episodes are at high risk of completed suicide.