The management of sexual delinquents, especially those with compulsive putting into action of aggressive sexual impulses, poses great problems for the medical profession from the therapeutic as well as the moral standpoint. In the past thirty years or so numerous different approaches have been tried with varying degrees of success. A much abridged list of more recent treatment procedures includes: surgical castration (Stürup, 1968), sedative and/or tranquillizer drugs (Litkey and Feniczy, 1967; Bartholomew, 1968), female sex hormones (Allen, 1970); psychological measures such as psychotherapy (Ellis, 1956; Mayerson and Lief, 1965; Allen, 1970) and/or behaviour (‘aversion’) therapy (MacCulloch and Feldman, 1967) and ‘right up-to-date’ hypothalamotomy (B.M. J., 1969). Unfortunately surgery, which is the most reliably effective of these treatments, may have unpleasant sequelae; its use, which (in Britain at least) is beset with ethical problems, is therefore justified in only the most recalcitrant and/or dangerous types of offender, and only then when other methods have failed.

Depression is a common illness which affects some 3% of the population per year. At least 25% of those with marked depression do not consult their general practitioner and in half of those who do the illness is not detected. Depression is easy to recognize when four or five of the core symptoms have been present for 2 weeks which often coincides with some occupational and social impairment. The core symptoms are depressed mood, loss of interest or pleasure, loss of energy or fatigue, concentration difficulties, appetite disturbance, sleep disturbance, agitation or retardation, worthlessness or self blame and suicidal thoughts. A diagnosis of depression is made when five of these core symptoms, one of which should be depressed mood or loss of interest or pleasure, have been present for 2 weeks. Four core symptoms are probably sufficient. Response to antidepressants is good in those with more than mild symptoms. When there are only few or very mild depressive symptoms evidence of response to antidepressants is more uncertain. Antidepressants are effective, they are not addictive and do not lose efficacy with prolonged use. The newer antidepressants have fewer side effects than the older tricyclics, they are better tolerated and lead to less withdrawals from treatment. They are less cardiotoxic and are safer in overdose. Antidepressants should be used at full therapeutic doses. Treatment failure is often due to too low a dose being used in general practice. It may be difficult to reach the right dose with the older tricyclics because of side effects. To consolidate response, treatment should be continued for at least 4 months after the patient is apparently well. Stopping the treatment before this is ill-advised as the partially treated depression frequently returns. Most depression is recurrent. Long-term antidepressant treatment is effective in reducing the risk of new episodes of depression and should be continued to keep the patient well.

This is a multicentre double-blind study of fluvoxamine versus mianserin in the treatment of major depressive episode in patients over 65 years of age. Fifty-seven patients received either fluvoxamine (100-200 mg daily) or mianserin (40-80 mg daily). There was no statistically significant difference in improvement between the 2 treatment groups as measured by the Montgomery-Asberg Depression Rating Scale. Eleven patients (7 in the fluvoxamine group and 4 in the mianserin group) discontinued treatment because of intolerance. No statistically significant differences were seen in biological parameters with either drug. Both drugs improved the symptoms of depression though the overall response rate was not outstanding. The side effects profile for the fluvoxamine was contrary to previous studies in that frequent nausea and vomiting were not seen.

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting. Biological changesMasters and Johnson described the physiology of coitus as having four components. Excitement, plateau, orgasm and resolution, all of which show age related changes. As ageing increases, desire may not always result in sexual excitement. The triggers for sexual excitement become more specifically sexual and may require intimate body contact and manual stimulation. The intensity of sexual fantasies decreases and it may take a man longer to achieve an erection and following ejaculation more time before an erection is possible. The physiological changes are listed in Box 1. In addition, older men experience anatomical changes, including thinning of the pubic hair, laxity of scrotal tissue, atrophy of the perineal muscles, loss of collagen tissue and occasionally weight gain. The phase of ejaculation undergoes changes which result in a decline in the intensity of orgasm and in the propulsive force of ejaculation. The volume of the ejaculate may be reduced by 50%. Sex drive and performance vary widely between individuals of the same group and the maintenance of sexual activity depends on factors such as regular sexual activity, the presence of a willing sexual partner, the absence of a major physical illness and the integrity of the relationship.Age-related changes in women (see Box 2) include thinning of the pubic hair, shrinkage of the labia, thinning of the vaginal mucosa and laxity of the perineal muscle. The thinning of the vaginal mucosa and the reduced lubrication may lead to dyspareunia and bleeding during intercourse. Orgasmic contractions may become painful.The ageing male experiences a reduction in the activity of the cells of Leydig with an associated drop in testosterone of 0.4-0.8% per year after the age of 50. Interested readers are referred to a Box 1. Physiological changes in ageing men Sexual organ atrophy Diminished testosterone level Delay in attaining erectionErection of poor quality Longer delay in achieving and maintaining a full penile erection Decline in intensity of orgasm Decreased hormone levels are associated with reduced desire

Cohen (1960) defined risk-taking as ‘embarking on a task without being certain of success', and he agreed with Stengel (1958) that it is possible to gain a better understanding of attempted suicide if we regard it as conveying a degree of uncertainty that the attempt will succeed or fail. Investigation after a suicide attempt usually reveals that the patient was at the time uncertain about the toxic effects and lethality of the overdose, and uncertain of whether others would intervene before the poison could take effect. Taking the widely held view that in most cases of so-called attempted suicide the prevailing motives are directed towards survival with all the advantages of having risked self-destruction, it might be argued that the attempt succeeds by avoiding rather than causing death. The alternative term ‘parasuicide’ suggested by Kreitman et al. (1969) is less paradoxical.