Along with all other branches of medicine, child and adolescent psychiatry is faced with the need to consider its evidence base and justify its activities accordingly.

To consider critically the use of the term ‘evidence’, to suggest limits to the value of conventionally defined evidence and to point to possible ways forward to bridge the gap between research findings and clinical practice.

A review of the literature relating to the use of evidence-based methods.

The term ‘evidence’ needs to be used more widely than is conventionally the case. Substantial evidence exists from controlled trials, but there are barriers to its use.

A move away from non-validated methods of intervention is both desirable and feasible. The use of qualitative methods of enquiry, both in situations where controlled trials are unlikely to be feasible and as adjuncts to quantitative methods, should be considered more seriously.

Previous meta-analyses of fluoxetine as an antidepressant have many methodological problems, including diagnosis of major depression, validity of outcome measures and lack of intention-to-treat analyses.

To provide an estimate of the effect of fluoxetine compared with placebo and tricyclic antidepressants (TCAs), and to investigate reasons for early discontinuation from acute treatment.

Randomised trials were analysed using both intention-to-treat, efficacy and end-point.

Fluoxetine was superior to placebo but effect size was low. In trials comparing fluoxetine v. TCA, the results for all trials and for the USA trials showed a trend in favour of fluoxetine. Those for the non-USA trials showed a trend in favour of TCA. When combined, the results showed that significantly fewer patients on fluoxetine discontinued treatment because of adverse events.

Fluoxetine is superior to placebo, irrespective of the analytical approach use, whereas the results obtained v. TCAs depend on the approach used. Hence, the results should be interpreted in this light.

Lithium treatment is claimed to reduce mortality in patients with affective disorder, but the evidence is conflicting.

To estimate mortality rates from a cohort of patients with affective disorder commenced on lithium with an observation period of two years and a follow-up after 16 years.

The mortality rates of patients were compared with those of the general Danish population, standardised for age, gender and calendar time with respect to death from all causes, suicide and death from cardiovascular disease.

Forty of the study's 133 patients died during the 16-year observation period (11 from suicide). Mortality among patients commenced on lithium was twice that of the general population. The statistically significantly elevated mortality was due largely to an excess of suicides; mortality from all other causes was similar to the background populations. Thirty-two patients died after the first two years of observation and were included in the analysis of the association between death and treatment compliance. Suicide occurred more frequently among those patients not complying with treatment.

Mortality, especially suicide, was significantly increased in unselected patients with affective disorder commenced on lithium relative to the general population.

Current concepts and measures of personality disorder are in many respects unsatisfactory.

To establish agreement between two contrasting measures of personality disorder, and to compare subject–informant agreement on each. To examine the extent to which trait abnormality can be separated from interpersonal and social role dysfunction.

Fifty-six subjects and their closest informants were interviewed and rated independently. Personality functioning was assessed using a modified Personality Assessment Schedule (M–PAS), and the Adult Personality Functioning Assessment (APFA).

Subject–informant agreement on the M–PAS was moderately good, and agreement between the M–PAS and the APFA, across and within subjects and informants, was comparable to that for the M–PAS. This was equally the case when M–PAS trait plus impairment scores and trait abnormality scores were used.

The M–PAS and the APFA are probably assessing similar constructs. Trait abnormalities occur predominantly in an interpersonal context and could be assessed within that context.

There are no published studies concerning the depiction of mental illness in children's television programmes.

To determine whether mental illness was depicted in children's television.

Sample of one complete week of children's television (57 hours, 50 minutes; 128 series episodes: 69 cartoon animations, 12 non-cartoon animations, 47 real life) provided for children under the age of 10 years. Disclosure analysis of portrayals of mental illness through repeated viewings identified patterns in the use of linguistic, semiotic and rhetorical resources.

Of the 128 episodes, 59 (46%) contained one or more references to mental illness, predominantly in cartoons (n=47, 80%) compared with other episode types (χ2=17.1, d.f.=2, P<0.05). Commonly occurring terms such as ‘crazy’ (n=28), ‘mad’ (n=19) and ‘losing your mind’ (n=13) were employed to denote loss of control. The six consistently mentally ill characters were almost entirely devoid of admirable attributes.

Young viewers are being socialised into stigmatising conceptions of mental illness.

There exists no instrument specifically designed to measure comprehensively the needs of older people with mental disorders.

To develop such an instrument which would take account of patients', staff and carers' views on needs.

Following an extensive development process, the assessment instrument was subjected to a test–retest and interrater reliability study, while aspects of validity were addressed both during development and with data provided by sites in the UK, Sweden and the USA.

The Camberwell Assessment of Need for the Elderly (CANE) comprises 24 items (plus two items for carer needs), and records staff, carer and patient views. It has good content, construct and consensual validity. It also demonstrates appropriate criterion validity. Reliability is generally very high: κ > 0.85 for all staff ratings of interrater reliability. Correlations of interrater and test–retest reliability of total numbers of needs identified by staff were 0.99 and 0.93, respectively.

The psychometric properties of the CANE seem to be highly acceptable. It was easily used by a wide range of professionals without formal training.

Depression is the most common mental disorder in the community-dwelling elderly.

To determine the three-year prognosis of depression in a cohort of 127 community-dwelling elderly subjects and identify factors relevant to outcome.

The subjects, diagnosed depressed at year 0 using the GMS–AGECAT package, were followed up three years later. A number of factors were investigated for an association with recovery from, or persistence of, depression.

At follow-up, 30.2% of the depressed subjects had died, 34.9% had persistent or relapsed case-level depression, 24.5% had other case- or subcase-level mental illness and 10.4% had recovered completely. Physical ill-health, bereavement and positive family history of depression were associated with poor outcome, whereas treatment with antidepressant medication significantly improved prognosis.

Late-life depression in community-dwelling subjects is a chronic condition. However, the positive response to antidepressant medication suggests that it should be vigorously treated.

The emergence of new skills in the setting of dementia suggests that loss of function in one brain area can release new functions elsewhere.

To characterise 12 patients with frontotemporal dementia (FTD) who acquired, or sustained, new musical or visual abilities despite progression of their dementia.

Twelve patients with FTD who acquired or maintained musical or artistic ability were compared with 46 patients with FTD in whom new or sustained ability was absent.

The group with musical or visual ability performed better on visual, but worse on verbal tasks than did the other patients with FTD. Nine had asymmetrical left anterior dysfunction. Nine showed the temporal lobe variant of FTD.

Loss of function in the left anterior temporal lobe may lead to facilitation of artistic or musical skills. Patients with the left-sided temporal lobe variant of FTD offer an unexpected window into the neurological mediation of visual and musical talents.

The relationship between depression and low blood pressure is unclear.

To examine the temporal relation between low blood pressure and depression in a two-year follow-up.

The study group consisted of 1389 subjects aged 59–71 years; 1272 (92%) were examined after two years. Subjects completed the Center for Epidemiological Studies–Depression (CES–D) and the Spielberger inventory scales to assess depressive and anxiety symptoms respectively. Data were collected on socio-demographic characteristics, smoking and drinking habits, medical history, drug use and blood pressure measures.

Among 1112 subjects who were considered as non-depressed at baseline, logistic regression models showed that low diastolic blood pressure (DBP) and decrease of blood pressure were predictors of high depressive symptomatology at follow-up. Baseline high CES–D scores did not predict low blood pressure two years after.

In our study, low blood pressure was a risk factor for, but not a consequence of, high depressive symptomatology.

Recent studies of the relationship between the apolipoprotein E (APOE) gene and Alzheimer's disease in adults with Down's syndrome have revealed inconsistent results.

To assess the role of the APOE gene in the manifestation of Alzheimer's disease in adults with Down's syndrome.

We studied the APOE genotypes of 24 adults with dementia and 33 non-demented adults with Down's syndrome over 35 years of age, and an additional group of 164 non-learning disabled adults. We also carried out a meta-analysis of all previously published studies of association between APOE and Down's syndrome, incorporating the current data.

We observed a non-significant excess of APOE ε4 and a reduction of ε2 in adults with dementia compared with non-demented adults with Down's syndrome in our sample. However, meta-analysis showed a significantly higher frequency of ε4 in adults with dementia compared with non-demented adults with Down's syndrome (odds ratio=2.02, 95% CI 1.33–3.07, P=0.001), but no significant reduction in the frequency of ε2.

The APOE ε4 allele acts as a risk factor for the age-specific manifestation of Alzheimer's disease in people with Down's syndrome.

People with learning disabilities and mental health problems have complex needs. Care should be provided according to need.

To develop a standardised needs-assessment instrument for adults with learning disabilities and mental health problems.

The Camberwell Assessment of Need for Adults with Developmental and Intellectual Disabilities (CANDID) was developed by modifying the Camberwell Assessment of Need (CAN). Concurrent validity was tested using the Global Assessment of Functioning (GAF) and the Disability Assessment Schedule (DAS). Test–retest and interrater reliability were investigated using 40 adults with learning disabilities and mental health problems.

CANDID scores were significantly correlated with both DAS (P<0.05) and GAF scores (P<0.01). Correlation coefficients for interrater reliability were 0.93 (user), 0.90 (carer), and 0.97 (staff ratings); for test–retest reliability they were 0.71, 0.69 and 0.86 respectively. Mean interview duration was less than 30 minutes.

The CANDID is a brief, valid and reliable needs assessment instrument for adults with learning disabilities and mental health problems.

The Mental Health Act 1983 (MHA) is due to be revised by Parliament in the near future.

To explore changes in the use of the Act since its introduction.

The Department of Health and the Home Office routinely collect data on the numbers of patients admitted to psychiatric hospitals under the MHA. We present absolute figures, by year, for the total numbers admitted under each section of the Act. We used the total psychiatric hospital admissions and total prison populations as denominator data.

Formal admissions rose from 16 044 in 1984 to 26 308 in 1996, a 63% increase. Admissions under the MHA have increased as a proportion of all admissions. The increase is mainly accounted for by changes in the use of Part II of the Act, in particular sections 2 and 3. The use of forensic sections (Part III) has also increased, with a marked increase of sections 47 and 48. Use of Part X of the Act (sections 135 and 136) declined in the late 1980s but rose again in the 1990s.

Formal admissions are more common than they were in 1984, despite there being fewer psychiatric beds. This is probably due to changes in the provision of psychiatric services, and changing societal pressures on psychiatrists away from libertarianism and towards coercion.

The effectiveness of hospital-based treatment models for personality disorder is still uncertain.

To compare effectiveness of two models of psychosocial intervention for personality disorder.

Two samples of people with personality disorder allocated to a one-stage treatment model (in-patient treatment with no after care) and to a two-stage model (shorter in-patient admission followed by outreach therapy) are prospectively compared.

Subjects in the two-stage sample did significantly better on global assessment of mental health (according to the Global Assessment Score (GAS)) at 6 and 12 months and on social adjustment (according to the Social Adjustment Scale (SAS)) at 12 months. Significant differences in rates of reliable improvement on the GAS (43% v. 17%) and SAS (39% v. 15%) in favour of the two-stage condition were found at 12 months. Subjects with borderline personality disorder (BPD) allocated to the two-stage model improved significantly more than such patients in the one-stage model.

A long-term phased model which combines hospital-based and community-based strategies has advantages over a purely in-patient model for the treatment of BPD.