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.

There is a significant gap between the demand for psychological therapy services and the available supply. One proposal to overcome this problem is to increase efficiency of provision through the adoption of briefer ‘minimal interventions' within stepped care models.

To examine the theoretical underpinnings of stepped care, together with the practicalities of the adoption of this system of care.

Narrative literature review.

The potential clinical and economic benefits of stepped care are dependent upon underlying assumptions of equivalence in terms of clinical outcomes, efficiency in terms of resource use and costs, and acceptability of ‘minimal interventions' to patients and therapists. Illustrative studies of these issues are considered.

Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.

The hypothesis that schizophrenia is neurodevelopmental was investigated in a prospective study of young people with a postulated 10–15% risk for the development of schizophrenia.

To determine premorbid variables distinguishing high-risk people who will go on to develop schizophrenia from those who will not.

A high-risk sample of 163 young adults with two relatives with schizophrenia was recruited. They and 36 controls were serially examined. Baseline measures were compared between those who did develop schizophrenia, a well control group, a well high-risk group and high-risk participants with partial or isolated psychotic symptoms.

Of those at high risk, 20 developed schizophrenia within 2½ years. More experienced isolated or partial psychotic symptoms. Those who developed schizophrenia differed from those who did not on social anxiety, withdrawal and other schizotypal features. The whole high-risk sample differed from the control group on developmental and neuropsychological variables.

The genetic component of schizophrenia affects many more individuals than will develop the illness, and partial impairment can be found in them. Highly significant predictors of the development of schizophrenia are detectable years before onset.

There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers.

To verify combat exposure history for a relevant sample through objective historical data.

Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined.

Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam ‘combat’ and ‘no combat’ groups on relevant clinical variables.

A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Previous research has found that African–Caribbean and Black African patients are likely to come into contact with mental health services via more negative routes, when compared with White patients. We sought to investigate pathways to mental health care and ethnicity in a sample of patients with a first episode of psychosis drawn from two UK centres.

We included all White British, other White, African–Caribbean and Black African patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.

Compared with White British patients, general practitioner referral was less frequent for both African–Caribbean and Black African patients and referral by a criminal justice agency was more common. With the exception of criminal justice referrals for Black African patients, these findings remained significant after adjusting for potential confounders.

These findings suggest that factors are operating during a first episode of psychosis to increase the risk that the pathway to care for Black patients will involve non-health professionals.

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.

Neuropsychological abnormalities in schizophrenia are well replicated and are present in unaffected relatives. Cognitive findings in bipolar disorder are less clearly established.

To examine the possibility that these abnormalities may provide a means by which the disorders might be separated and to clarify the associations of phenotypic expression and genetic liability.

A neuropsychological test battery was administered to 50 control participants, 74 patients and 76 unaffected relatives recruited for the study. Patients included those with schizophrenia from families affected by schizophrenia alone, those with bipolar disorder from families affected by bipolar disorder alone and those with bipolar disorder from families affected by both disorders. Unaffected relatives were also recruited.

Current, verbal and premorbid IQ were impaired in people with schizophrenia and in their close relatives. Memory was impaired in all patient and relative groups. Psychomotor performance and performance IQ were impaired in patients, regardless of diagnosis.

This study finds evidence that intellectual abnormalities are related to a genetic liability to schizophrenia. Abnormalities of memory appear to be related to an increased liability to psychosis in general. No impairment was specific to bipolar disorder.

The Helsinki High-Risk Study monitors women treated for schizophrenia-spectrum disorders in Helsinki mental hospitals before 1975, their offspring, and controls.

To compare the development of high-risk and control group children, and investigate which factors predicted future psychiatric disorders.

We examined information from childhood and school health record cards of 159 high-risk and 99 control group offspring. Logistic regression was used to assess whether developmental abnormalities predicted later mental disorders.

Compared with controls, children in the high-risk group had more emotional symptoms before school age, attentional problems and social inhibition at school age, and neurological soft signs throughout. Inthisgroup pre-school socia adjustment problems (OR=9.7, 95% CI 1.8–51.8) or severe neurological symptom: (Fisher's test, P=0.006) predicted future schizophrenia-spectrum disorder. Social adjustment problems and emotional symptoms during school age predicted future non-psychotic psychiatric disorders.

Our study supports the validity of neurological, emotional, social and behavioural markers as vulnerability indicators of psychotic and other mental disorders, particularly among children genetically at high risk of psychosis.

22q11 deletion syndrome is associated with high rates of psychiatric morbidity, especially schizophrenia. If common neurodevelopmental trajectories characterise 22q11 deletion syndrome and idiopathic schizophrenia, then similar ‘premorbid’ features would be predicted.

To define psychopathology in adolescents and young adults with 22q11 deletion syndrome.

Individuals with 22q11 deletion syndrome (n=25) and age- and IQ-matched comparison participants (n=25), along withtheir parents/carers, completed standardised semi-structured assessments.

Psychiatric disorders were more prevalent among those with the syndrome and included attention deficit, depression and anxiety; nearly half reported transient psychotic experiences. Inappropriate emotionality and disrupted social behaviour were also common. Poor functional adjustment was associated with schizotypal symptoms and was more marked in older individuals. Conclusions 22q11 deletion syndrome is associated with significant psychopathology prior to adulthood. Double the proportion expected to develop schizophrenia reported psychotic phenomena. These findings imply a continuum of developmental disruption in 22q11 deletion syndrome, associated with declining mental health in early adulthood.

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.

Despite interest in early treatment of schizophrenia, premorbid and prodromal symptomatology remain poorly delineated.

To compare pre-illness symptomatology in patients at high risk of schizophrenia who progress to illness with that of high-risk subjects who remain well and with normal controls.

Using Present State Examination (PSE) data, symptomatic scales were devised from participants of the Northwick Park Study of first-episode schizophrenia and scores were compared on the first and last PSEs of participants of the Edinburgh High Risk Study.

At entry, when still well, high-risk individuals who subsequently became ill (mean time to diagnosis 929 days; s.e.=138 days) scored significantly higher on ‘situational anxiety’, ‘nervous tension’, ‘depression’, ‘changed perception’ and ‘hallucinations' than those remaining well and normal controls, who did not differ. With illness onset, affective symptomatology remained high but essentially stable.

In genetically predisposed individuals, affective and perceptual disorders are prominent before any behavioural or subjective change that usually characterises the shift to schizophrenic prodrome or active illness.

Many people with mental health problems do not seek professional help but their use of other sources of help is unclear.

To investigate patterns of lay and professional help-seeking in men and women aged 16–64 years in relation to severity of symptoms and sociodemographic variables.

Postal questionnaire survey, including the 12-item General Health Questionnaire (GHQ–12), sent to a stratified random sample (n=15222) of the population of Somerset.

The response rate was 76%. Only 28% of people with extremely high GHQ–12 scores (⩾8) had sought help from their general practitioner but most (78%) had sought some form of help. Males, young people and people living in affluent areas were the least likely to seek help.

Health promotion interventions to encourage appropriate help-seeking behaviour in young people, particularly in men, may lead to improvements in the mental health of this group of the population.

Reduced hippocampal volume is a consistently described structural abnormality in schizophrenia but its cause and timing are not known.

To examine the relationship of duration of schizophrenic illness and treatment effects with hippocampal volumes.

Quantitative 1.5 T magnetic resonance imaging brain scans of young male patients in the early stage of schizophrenic illness were compared with those of chronically ill older patients. Scans were also acquired for controls matched to both patient groups for age and handedness. Duration of illness was recorded and severity of symptoms assessed with the Positive and Negative Syndrome Scale.

The patients with schizophrenia had smaller hippocampal volumes than the controls. The volume reduction was larger in older patients than in young, compared with age-matched controls. In the early illness group atypical antipsychotics rather than haloperidol were associated with larger hippocampal volumes even after controlling for differences in illness severity Conclusions The greater reduction of hippocampal volume in people with chronic v. early illness, after controlling for illness severity and age, supports the hypothesis of progressive hippocampal reduction in males with schizophrenia. Atypical antipsychotics early in illness may protect against this.

The view that most military personnel evacuated from war zones are suffering from combat stress reactions, or are otherwise traumatised by the horrors of war, has an impact on all aspects of military psychiatry.

To delineate the reasons for psychiatric aeromedical evacuation from Iraq from the start of build-up of UK forces in January 2003 until the end of October that year, 6 months after the end of formal hostilities.

A retrospective study was conducted of field and in-patient psychiatric assessments of 116 military personnel evacuated to the UK military psychiatric in-patient facility in Catterick Garrison.

Evacuees were mainly non-combatants (69%). A significant proportion were in reserve service (21%) and had a history of contact with mental health services (37%). Only 3% had a combat stress reaction. In over 85% of cases evacuation was for low mood attributed to separation from friends or family, or difficulties adjusting to the environment.

These findings have implications especially for screening for suitability for deployment, and for understanding any longer-term mental health problems arising in veterans from Iraq.

First-episode psychosis intervention may improve the course and outcome of schizophrenic disorders.

To describe the Danish National Schizophrenia Project and to measure the outcome of two different forms of intervention after 1 year, compared with standard treatment.

A prospective, longitudinal, multicentre investigation included 562 patients, consecutively referred over a 2-year period, with a first episode of psychosis. Patients were allocated to supportive psychodynamic psychotherapy as a supplement to treatment as usual, an integrated, assertive, psychosocial and educational treatment programme or treatment as usual.

There was a non-significant tendency towards greater improvement in social functioning in the integrated treatment group and the supportive psychodynamic psychotherapy group compared with the treatment as usual group. Significance was reached for some measures when the confounding effect of drug and alcohol misuse was included.

Integrated treatment and supportive psychodynamic psychotherapy in addition to treatment as usual may improve outcome after 1 year of treatment for people with first-episode psychosis, compared with treatment as usual alone.

Few investigations have examined the impact of childhood trauma, and domains of childhood abuse, on outcome in bipolar disorder.

To evaluate the prevalence and subtypes of childhood abuse reported by adult patients with bipolar disorder and relationshipto clinical outcome.

Prevalence rates of childhood abuse were retrospectively assessed and examined relative to illness complexity in a sample of 100 patients at an academic specialty centre for the treatment of bipolar disorder.

Histories of severe childhood abuse were identified in about half of the sample and were associated with early age at illness onset. Abuse subcategories were strongly inter-related. Severe emotional abuse was significantly associated with lifetime substance misuse comorbidity and past-year rapid cycling. Logistic regression indicated a significant association between lifetime suicide attempts and severe childhood sexual abuse. Multiple forms of abuse showed a graded increase in risk for both suicide attempts and rapid cycling.

Severe childhood trauma appears to have occurred in about half of patients with bipolar disorder, and may lead to more complex psychopathological manifestations.

Persistent impairments in neurocognitive function have been described in patients with bipolar disorder whose disease is in remission. However, methodological issues such as the effect of residual mood symptoms and hypercortisolaemia may confound such studies.

To assess neurocognitive functioning in prospectively verified euthymic patients with bipolar disorder.

Sixty-three patients with bipolar disorder and a matched control group completed a comprehensive neurocognitive test battery. Euthymia was confirmed in the patient group by prospective clinical ratings over 1 month prior to testing. Saliva samples were collected to profile basal cortisol secretion.

Patients were significantly impaired across a broad range of cognitive domains. Across the domains tested, clinically significant impairment was observed in 3% to 42% of patients. Deficits were not causally associated with residual mood symptoms or hypercortisolaemia.

Neurocognitive impairment persists in patients whose bipolar disorder is in remission. This may represent a trait abnormality and be a marker of underlying neurobiological dysfunction.

Beck's cognitive theory of depression has received little empirical support.

To test whether those with negative self-schemas were at risk of onset of depression.

Data were collected by postal questionnaire from 12003 women recruited during early pregnancy; questionnaires included measures of depressive symptoms and negative self-schemas. Regular questionnaires were sent during pregnancy and following childbirth.

Of 8540 women not depressed when recruited, 8.6% (95% CI 8.0–9.2) became depressed 14 weeks later. Those in the highest tertile for negative self-schema score were more likely to become depressed than those in the lowest tertile (odds ratio 3.04, 95% CI 2.48–3.73). The association remained after adjustment for baseline depressive symptoms and previous depression (OR 1.6, 95% CI1.27–2.02) and was of similar magnitude for onset 3 years later.

Holding a negative self-schema is an independent risk factor for the onset of depression in women. This finding supports a key element of Beck's cognitive theory. Understanding more about how negative self-schemas arise should help inform preventive policies.

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.