Mental health review tribunals are required to apply legal criteria within a clinical context. This can create tensions within both law and psychiatry.

To examine the role of the medical member of the tribunal as a possible mediator between the two disciplines.

Observation of tribunal hearings and panel deliberations and interviews with tribunal members were used to describe the role of the medical member.

The dual roles imposed on the medical member as witness and decisionmaker and as doctor and legal actor create formal demands and ethical conflicts that are hard, in practice, either to meet or to resolve.

The structure for providing tribunals with access to expert psychiatric input and advice requires reconsideration.

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.

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.

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.

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.

Owing to the lack of controlled trials of treatment setting in adolescent anorexia nervosa, the benefits and costs of in-patient treatment are not established.

To clarify the relationship between a range of presenting features, treatment received and medium- to long-term outcome in adolescent anorexia nervosa.

A range of presenting variables were rated for 75 cases of DSM – III – R anorexia nervosa at presentation to an adolescent service, including the Morgan–Russell Global Assessment Score. Cases were followed up at 2–7 years and outcome rated according to reliable methods. Setting of treatment received was also recorded.

Two out of 75 cases had died by the time of follow-up. Adequate data for 72 enabled an outcome category to be assigned. The 21 who had received in-patient treatment had a significantly worse outcome than the 51 never admitted to hospital. Multivariate analysis suggests admission to be the major predictor of poor outcome.

The benefits and costs of admission to hospital require further investigation, ideally in a randomised-controlled trial. The negative consequences of in-patient treatment are neglected in research.

There is little information on whether patterns of steroids precede and are associated with depressive onset.

To establish whether there is an association between salivary cortisol and/or dihydroepiandrosterone (DHEA) levels and depression independent of psychosocial risk.

Two subgroups of adolescents in the community at high (n=181) and low (n=65) risk for psychopathology were interviewed for recent psychiatric disorder at entry and again at 12 months. Salivary samples (08.00 and 20.00 h) for hormone estimations and self-reports on current mood and cognitive style were obtained at both assessments.

Neither hormone was associated with risk status, current mood or cognitive style at entry. Of 31 onsets of major depression that occurred over the next 12 months, 30 came from the high-risk group but were not associated with any particular pattern of risk. Increased negative mood and feelings and DHEA (08.00 h) hypersecretion at entry were associated with subsequent major depression.

Both negative mood and feelings and alterations in adrenal steroid function precede the onset of first-episode major depression in adolescents. Variation in levels of hormones may arise from more distal origins than recent life events and current ongoing difficulties.

An excess of both depression and undesirable life events in first-degree relatives of probands with depression as compared with controls has been reported. This association may have reflected a familial factor in common.

To examine the familiality of life events and depression and whether there may be a common familial factor influencing vulnerability to depression and the experiencing of life events.

In a sib-pairdesign, 108 probands with depression and their siblings were compared with 105 healthy controls and their siblings for psychopathology and life events.

The lifetime relative risk of depressive disorder in the siblings of depressed subjects as compared with siblings of controls was 9.74, although these groups did not differ in the life events measures. Several categories of events showed significant sibling correlations, but this was due to the same event affecting both members of the pair.

Although depressive disorder was strongly familial, the familial effects on life events were largely explained by shared experiences. There was no evidence for a common factor influencing both depression and life events.

Alzheimer's disease manifests considerable heterogeneity, the cause of which is unknown.

To determine the familial (genotypic) influence on phenomenology (phenotype) in Alzheimer's disease.

Affected sibling pairs with Alzheimer's disease were assessed for a range of cognitive and non-cognitive symptoms. Resemblance for phenotypic characteristics was estimated using intraclass correlations for continuous traits and by pairwise concordance for dichotomous traits. The relationship between age of onset and APOE genotype was examined using linear regression analysis.

Significant familial effects on age of onset (intraclass correlation 0.41) and mood state (intraclass correlation 0.26), and a relatively high pairwise concordance for agitation (excess concordance 0.1) were found. The APOE locus was found to account for 4% of the variance in age of onset.

Substantial familial influence on age of onset, depression and agitation suggests that genotype does influence phenotype in Alzheimer's disease. Establishing the molecular basis for this phenotypic variation may prove relevant to other neuropsychiatric disorders.

Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health.

To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders.

Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained.

Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended.

Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.

Recent concern about drug use has focused attention on the illegal income generated by users.

To investigate factors associated with drugs expenditure and to estimate the cost of illegal acquisitions used to pay for drugs.

We collected self-report data from 954 current injectors, interviewed at multiple street, needle/syringe exchange and drug treatment sites throughout Glasgow.

Injectors' mean weekly drug spending was £324. The mean annual illegal drugs spend was estimated to be £11 000 per injector. We provide a central estimate – £194 million per annum – of the retail value of goods acquired illegally by injectors in Glasgow in order to pay for drugs. Higher drug spends were associated with having been imprisoned more often and with those reporting acquisitive crime, drug dealing and prostitution. Treatment with methadone, among individuals who injected in the previous two months, was associated with a 20% reduction in atypical spend on drugs.

Treatment effectiveness needs to be measured both in terms of health benefit and in terms of reduction in drugs expenditure and recidivism.

Quality of life (QOL) has gained importance as a global measure of social and clinical outcome in schizophrenia.

To identify the clinical correlates of QOL at the time of first presentation with schizophrenia.

Over two years, consecutive first-episode psychosis patients presenting to a catchment area psychiatric service underwent validated clinical assessments of premorbid adjustment, illness duration, symptoms and QOL.

At presentation, subjects already had a diminished QOL. Although independent of gender and age at onset of psychosis, QOL was influenced by premorbid adjustment, duration of untreated psychosis and symptoms.

Reducing the duration of untreated psychosis may have a beneficial effect on the subsequent QOL of patients presenting with schizophrenia. First-episode patients with a protracted duration of untreated psychosis or impaired premorbid adjustment may warrant specific treatment interventions to prevent the development of secondary handicaps.

Over 390 000 people in the UK are disfigured. Facial disfigurement distresses sufferers markedly but has been studied little.

To compare fearful avoidance of people with a facial disfigurement with that of a group of patients with phobia.

Comparison of Fear Questionnaire agoraphobia, social phobia and anxiety depression sub-scale scores of 112 facially disfigured people (who scored high on Fear Questionnaire problem severity in three survey studies) with those of 66 out-patients with agoraphobia and 68 out-patients with social phobia.

Facially disfigured people and patients with social phobia had similar Fear Questionnaire scores. In contrast, facially disfigured people scored lower on the agoraphobia sub-score but higher on the social phobia sub-score than did patients with agoraphobia.

Facially disfigured people with psychological difficulties resembled people with social phobia on Fear Questionnaire social phobia, agoraphobia and anxiety/depression sub-scores but were less agoraphobic and more socially phobic than were people with agoraphobia. Facially disfigured people thus appeared to be socially phobic and to deserve the cognitive – behavioural therapy that is effective for such phobias.

Uncertainties remain about the role of serotonin in the aetiology and treatment of panic disorder.

To investigate the effect of reducing brain serotonin function on anxiety at rest, and following 5% CO2 provocation in normal controls and patients with panic disorder.

Twenty drug-free patients with DSM–III–R panic disorder and 19 controls received a tryptophan-free amino acid drink on one occasion and a control drink on the other in a double-blind, balanced protocol. 5% CO2 was given as a panic challenge after 270 minutes.

Plasma tryptophan fell by more than 80% both patients and controls after the tryptophan-free drink. Tryptophan depletion did not alter resting anxiety. In patients alone, tryptophan depletion caused a greater anxiogenic response and an increased rate of panic attacks (9 v. 2, P<0.05) after 5% CO2 challenge. No normal volunteers panicked.

Serotonin may directly modulate panic anxiety in patients with panic disorder. This may underlie the efficacy of serotonergic antidepressants in treating panic disorder.

Rapid eye movement (REM) sleep behaviour disorder is a relatively new diagnostic category. It has never before been associated with a treatable depressive condition.

To repot on a 74-year-old man with a history of depression and REM sleep behaviour disorder, associated with mild cognitive impairment.

Assessment using brain CT, MRI, PET, electroencephalography, neuropsychological testing and nocturnal polysomnography.

Depression was treated with sertraline. Sleep laboratory studies supported a diagnosis of REM sleep behaviour disorder, which was treated with clonazepam. Sleep apnoea, revealed later, was treated with nasal continuous positive airways pressure. Brain MRI showed mild atrophy, but neuropsychological testing indicated no progressive cognitive deterioration.

This case draws attention to REM sleep behaviour disorder and its potential interaction with depression and cognitive impairment, producing symptoms which can be mistaken for early dementia. The diagnosis of REM sleep behaviour disorder is easily missed, and it requires careful history-taking and sleep investigation in all suspected sufferers. Associated neurological, sleep and psychiatric conditions (including depression and cognitive impairment) may confound the diagnosis.