This article aims to inform clinicians of current thinking in the area of victims and perpetrators of child sexual abuse. It covers prevalence data as well as identification, effects and interventions with victims, and also characteristics, assessment and treatment of perpetrators.

The review is based on manual searches and the authors' own clinical experience.

All clinicians should be aware of signs and symptoms that raise the possibility that someone has been or is being sexually abused and also of the possibilities of abuse of boys and of women as abusers. Methods of intervening are discussed, both in relation to victims and perpetrators. The importance of thoroughness when assessing perpetrators is emphasised because of their tendency to deny and/or minimise their offending. The demands of this work are underlined in a section on the necessary qualifications and characteristics of therapists working in this area.

Despite the lack of agreement in definitions and outcome measures used in research there are some positive findings in relation to clinical efficacy. In particular, the need for long-term treatment with those offenders who are more seriously deviant has been supported by recent research. There is a need for continuing attempts to standardise definitions and measures to aid realistic comparison of research results.

This study examines relations between regional cerebral blood flow (rCBF) and neuropsychological test results, age at onset and duration of disease in patients with frontotemporal-type dementia (FTD).

Sixteen patients with a diagnosis of probable FTD were examined using single photon emission computerised tomography (SPECT) with 99mTc-HMPAO as the tracer. The rCBF of 14 regions of interest relative to cerebellar blood flow was calculated. Psychological tests assessing language, verbal fluency, memory and visuospatial constructive ability were given.

Correlations were demonstrated between a global impairment score and relative blood flow in lateral frontal, medial frontal and left orbital frontal areas. Verbal fluency scores correlated with left lateral frontal medial frontal and left anterior inferior temporal blood flow. No relationships between decrease in CBF and age at onset or duration of disease, or between impaired cognitive function and age at onset or duration of disease, were found.

The present study demonstrates a close coupling between reduced rCBF and specific neuropsychological deficits in FTD.

The longer term prognosis of depressed patients treated with ECT is relatively unknown. We describe seven-year mortality and readmission risks for the Nottingham ECT series.

Cases were defined and subtyped using the Present State Examination (PSE). Follow-up was naturalistic. Death and readmission were ascertained using the Nottingham case register.

The risk of death was doubled (SMR=1.99, 95% CI = 1.34–2.84, P < 0.001). The seven-year cumulative probability of remaining without readmission was 0.27 (95% CI 0.19–0.35), being 0.79 (0.71–0.87) at 16 weeks (relapse) and 0.34 (0.24–0.44) thereafter (recurrence readmissions). Multiple regression analysis showed that delusions predicted relapse, while endogenous subtype, absence of psychomotor retardation, and previous history predicted recurrence readmissions.

Index ECT treatment predicted high longer-term mortality and readmission risks. PSE/CATEGO-based subtyping identified patients most vulnerable to relapse and recurrence.

The impact of major trauma on individuals with pre-existing and enduring mental health difficulties is poorly understood.

Twenty individuals with pre-existing and enduring mental health difficulties were assessed with the Clinician Administered Post Traumatic Stress Disorder Scale, the 28-item version of the GHQ, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale between four and eight weeks after their involvement in a major coach accident.

Ten (50%) individuals satisfied the full DSM–IV criteria for a diagnosis of PTSD. The questionnaire scores indicated a high level of psychological suffering among the group. On dividing the sample into those individuals with previous diagnoses of anxiety or depressive disorders and those with a previous diagnosis of chronic schizophrenia, the schizophrenia group displayed less marked psychological sequelae on all measures.

There was a high incidence of early psychological sequelae among the group as a whole. Some diagnoses (e.g. depression and anxiety) may predispose to psychological sequelae while others (e.g. chronic schizophrenia) may not.

Four previous studies of homeless adults have yielded conflicting results regarding the presence of cognitive impairment.

A consecutive series of 80 roofless entrants to a hostel for homeless men were sampled and 62 (76%) completed a range of assessments, including measures of mental state, cognitive functions and substance use.

Estimated premorbid IQ (mean=96), current IQ (mean=84) and cognitive speed were significantly lower than the norm. There was a significant IQ drop in all diagnostic groups. IQ drop, but not current IQ, correlated with duration of rooflessness. Those with schizophrenia or alcohol problems were roofless for longest. Alcohol misuse did not correlate with IQ drop, excepting alcohol withdrawal symptoms in those with schizophrenia.

The hypothesis that low IQ is a risk factor for rooflessness is supported. However, length of rooflessness was more closely related to IQ drop than to current IQ, suggesting that some third factor may be affecting both rooflessness and intellectual functioning. Roofless men with schizophrenia or alcohol problems may be especially at risk of long-term rooflessness.

Depression has a reported mean prevalence of 24% in patients diagnosed with cancer. However, little systematic research on the efficacy of antidepressants in patients with cancer has been performed.

The efficacy and safety of mianserin were studied in 55 depressed women with breast cancer (stage I or II and without known metastases), in a randomised, double-blind, six-week, placebo-controlled study.

Statistically significant differences in the decrease in score from baseline on the Hamilton Rating Scale for Depression and the number of responders, favouring mianserin, were present after 28 and 42 days of treatment Significantly more placebo-treated patients prematurely terminated the study due to lack of efficacy while the safety profile of mianserin was similar to that of placebo.

Treatment with mianserin resulted in a significant improvement in depressive symptoms in cancer patients, and was well tolerated.

A possible neuropsychological basis for poor insight in psychosis has been proposed Consistent supporting evidence for this is lacking.

Seventy-four consecutive acutely psychotic in-patients who were recruited for a randomised controlled trial of compliance therapy were given a battery of neuropsychological tests, along with a comprehensive clinical assessment before and after the intervention.

Performance on neuropsychological tests improved during the patients' admission and treatment in hospital as did symptoms and levels of insight Cognitive function showed no relationship to insight and compliance initially, and very little after the intervention. Factors related to insight and compliance prior to discharge included: diagnosis, attitudes to medication, side-effects, being a detained patient and whether or not compliance therapy was given.

Clinical variables and attitudes to treatment appear to be more relevant to compliance and the development of insight in acute psychosis than neuropsychological impairment.

Studies showing high rates of alcohol and drug misuse and deliberate self-harm in bulimia nervosa have led some authors to call for a distinct diagnostic subgroup, sometimes termed “multi-impulsive bulimia”. However, these studies have been uncontrolled and of clinic samples and may be subject to sampling bias.

One hundred and two women with DSM–III–R bulimia nervosa were compared with 204 normal controls and 102 controls with other psychiatric disorders, all recruited from the same community sample. Interview measures were used for diagnosis and for the assessment of alcohol and drug misuse and deliberate self-harm.

Bulimia nervosa cases did not differ from either of the control groups in terms of current alcohol consumption. Bulimia nervosa cases used more illicit drugs than either control group, but loss of control over drug use was very uncommon. Bulimia nervosa cases had a higher rate of deliberate self-harm than the controls. Only six (6%) bulimia nervosa cases had two or more of these behaviours concurrently.

Sampling bias is present in clinic-based studies of comorbidity in bulimia nervosa. Those with comorbid substance misuse and deliberate self-harm are probably heterogeneous in character, and their classification as a subgroup would therefore be premature.

Hypnagogic and hypnopompic hallucinations are common in narcolepsy. However, the prevalence of these phenomena in the general population is uncertain.

A representative community sample of 4972 people in the UK, aged 15–100, was interviewed by telephone (79.6% of those contacted). Interviews were performed by lay interviewers using a computerised system that guided the interviewer through the interview process.

Thirty-seven per cent of the sample reported experiencing hypnagogic hallucinations and 12.5% reported hypnopompic hallucinations. Both types of hallucinations were significantly more common among subjects with symptoms of insomnia, excessive daytime sleepiness or mental disorders. According to this study, the prevalence of narcolepsy in the UK is 0.04%.

Hypnagogic and hypnopompic hallucinations were much more common than expected, with a prevalence that far exceeds that which can be explained by the association with narcolepsy. Hypnopompic hallucinations may be a better indicator of narcolepsy than hypnagogic hallucinations in subjects reporting excessive daytime sleepiness.

The aim was to assess the effect of a flexible dose of paroxetine, compared with clomipramine and placebo, in obsessive-compulsive disorder (OCD).

In a multinational randomised study, 406 subjects with OCD of at least six months duration received double-blind mediation for up to 12 weeks. Doses were adjusted according to therapeutic effect and side-effects. Primary efficacy measures were the Yale–Brown Obsessive–Compulsive Scale and the National Institute of Mental Health Obsessive–Compulsive Scale. Secondary efficacy measures were the Montgomery–åsberg Depression Rating Scale, Symptom Check-List (90), Clinical Global Impression, and Patients' Global Evaluation.

Paroxetine was significantly more effective than placebo, and of comparable efficacy to clomipramine. Paroxetine had significantly superior tolerability to clomipramine on three measures: CGI efficacy index, anticholinergic adverse events, and adverse events leading to withdrawal.

Paroxetine is as effective as clomipramine in the treatment of OCD. The comparable efficacy and better tolerability of paroxetine suggest that it would be an appropriate treatment for OCD.

This trial evaluated the feasibility, acceptability and effectiveness of a structured approach to the management of schizophrenia in general practice.

All patients with non-affective psychosis (mainly schizophrenia) in four inner-city general practices were recruited. A check-list and a set of outcome measures were used by the general practitioner and the practice nurses. Information on attendances at the general practice and psychiatric out-patient departments was also collected.

Two practices took part in the intervention and two served as control practices. Sixty-seven patients with non-affective psychosis were identified. Thirty-three (81%) of the 41 patients in the two intervention practices attended the initial assessment by the doctor and nurse, but only 13 (32%) attended the first review assessment. The attendance for the second review, after six months, was six out of 15 (40%) in one practice, but rose to 16 out of 18 (89%) in the other practice. Significant improvements were recorded in the intervention group on the Global Assessment Scale (GAS) and the Behaviour, Speech and Other Syndromes (BSO) subscore of the Present State Examination (PSE). The absolute risk reduction and relative risk reduction as a result of the intervention as measured by the GAS scores, was 29% (95% CI 4% to 54%) and 36% (95% CI 5% to 66%), respectively, and in the case of the BSO subscores of the PSE, this was 23% (95% CI – 1.8% to 47.2%) and 28% (95% CI – 2.2% to 57%), respectively. For one patient to show an improvement in GAS and BSO scores 3.5 patients (95% CI 1.85 to 25) and 4.3 patients (95% CI – 55 to 2.1), respectively, would need to receive the intervention. There was a significant increase in consultation rates for patients in the intervention practices.

Health surveillance of patients with non-affective psychosis is possible in general practice.

Clozapine can cause reversible agranulocytosis and neutropenia. This study documents the occurrence of blood dyscrasias and identifies predisposing risk factors.

An analysis was made of the haematological, demographic, and dosage data from a central database on 6316 patients receiving clozapine over four and a half years in the UK and Ireland.

During the study period 2.9% of the patients developed neutropenia and 0.8% developed agranulocytosis. The peak incidence of both disorders was in the first 6–18 weeks of treatment. Fatal agranulocytosis occurred in 0.03% of patients. After the first year of treatment the incidence of agranulocytosis significantly decreased to the order noted with some phenothiazines.

The use of a patient monitoring service kept the haematological risks associated with using clozapine within acceptable limits, particularly in view of the benefits of this medication in treatment-resistant schizophrenia.

Clinical and demographic information on patients seen as a result of deliberate self-harm (DSH) was collected in an attempt to identify factors in the index episode of DSH predictive of subsequent suicide.

Specific data were prospectively collected on all DSH patients who lived in Blacktown Municipality, Sydney, Australia, and seen from October 1975 to September 1976. Follow-up at 18 years was by evaluation of coroners' records and identification of ‘probable suicide’.

Two hundred and twenty-three patients harmed themselves on one or more occasions. Follow-up at 18 years showed that 15 of the 223 (6.7%) had completed suicide. The proportion at five and eight years was 4.0% and at 10 years was 4.5%. Identified predictors of suicide were: narcotic overdose; more than one episode of DSH in the year of the study; planned episode; and mental illness. Teenage narcotic-abusing males were at greatest risk, and in females a planned episode was the most powerful predictor.

Suicides continued to occur over 18 years. One of the striking differences between this and other studies is the finding of teenage male DSH, associated with narcotic abuse, as a strong predictor of subsequent suicide. These findings are particularly relevant to the issue of young male suicide, which increased from the 1970s onwards in Australia and elsewhere.

Differences and similarities were examined of suicide in Hong Kong, Beijing and Taiwan, the populations of which are all ethnically Chinese and share some characteristics of culture but which have very different social and political environments.

The official death statistics were used for the periods 1981–94 (Hong Kong and Taiwan) and 1987–94 (Beijing).

Hong Kong has experienced a slight increase in suicide rate, whereas a significant decline was observed in Taiwan and Beijing. The suicide rates in all three increased with age, the rate among the elderly being four to five times the average. A relatively low male:female ratio (1.0–1.9) was also observed. Jumping and hanging were the most common methods of suicide in Hong Kong and Taiwan, respectively. Hong Kong had the most years of potential life lost.

Despite the remarkable economic growth in all three places during the study period, the differences in suicide trends suggest that the social and political environments may be more important than the economic environment in suicide. In Hong Kong the suicide rate is likely to remain high or even to increase.

Reports on erotomania frequently include schizophrenic patients with secondary erotomania, but there are no reports on the prevalence and characteristics of erotomanic symptoms in schizophrenic patients.

A structured item on erotomanic delusions was added to the Chinese version of the Scale for Assessment of Positive Symptoms and administered to 448 randomly selected schizophrenic patients on admission to four psychiatric hospitals in China.

Erotomanic symptoms were identified in 9.4% of the patients (42/448; 95% CI 6.9–12.4%); 4.5% (20/448; CI 2.8–6.8%) had erotomanic ideation and 4.9% (22/448; CI 3.1–7.4%) had fixed erotomanic delusions. Compared with patients without erotomanic symptoms, erotomanic patients were more likely to be male and unmarried, and they had a higher level of education, more severe grandiose delusions, more prominent hostility, and less severe negative symptoms.

The relatively common occurrence of erotomanic symptoms in Chinese schizophrenic patients may be related to the indirect manner of expressing sexual interest in Chinese culture and, thus, be an example of the cultural moulding of psychiatric symptoms.

Diagnostic classes (derived from catego) can be correlated with regional brain metabolism in patients with major psychiatric disorders.

Seventeen patients with schizophrenia, 15 with mania, 10 with depression and 10 healthy volunteers were examined with positron emission tomography (PET) and 18F-labelled fluorodeoxyglucose, as a marker for glucose metabolism. The number of possible comparisons of regions of interest was reduced by principal-components analysis, and differences in factor scores were determined between diagnostic groups.

Four independent factors, representing distributed brain systems, emerged: an anterior–posterior (1), a left–right temporal (2), a temporofrontal (3), and a mediofrontal (4) system, of which (1), (2) and (3) were abnormal in schizophrenia, (1) and (2) in mania, and (1) in depression.

Abnormal patterns of metabolism could be detected, in decreasing order, in schizophrenia, mania and depression. Some of these abnormalities are likely to be due to medication, but others will be associated with structural or functional abnormalities of the frontolimbic system in the diagnostic groups.

A comparison of the performance of the 5-item mental health dimension of SF–36 (MHI–5) with that of the 12-item General Health Questionnaire (GHQ–12) in a defined, non-patient population, using standard statistical tests.

A postal survey of 3000 patients aged 16–64 years was conducted. Patients were randomly selected from the practice lists of two general practices chosen to represent populations with different socio-economic characteristics.

Considerable evidence was found for the internal consistency of both instruments (Cronbach's α 0.91 and 0.84 for GHQ–12 and the MHI–5 respectively) and for their construct validity in terms of distinguishing between groups with measured health differences. Both instruments showed a significant difference in the mean scores for men and women. In contrast to the GHQ–12, no correlation was found between age and score for the MHI–5. Both instruments were equally sensitive to socio-economic characteristics and to levels of social support The scores on the two instruments were highly correlated (Spearman rank correlation – 0.73).

The MHI–5 has comparable psychometric performance to the GHQ–12, and can be used to measure and compare mental health in defined populations. Operational advantages of the MHI–5 over the GHQ–12 are that it is in the public domain, is part of a general health measure (SF–36) and is shorter.