Showing papers in "British Journal of Psychiatry in 2004"

Global burden of depressive disorders in the year 2000

Abstract: Background The initial Global Burden of Disease study found that depression was the fourth leading cause of disease burden, accounting for 3.7% of total disability adjusted life years (DALYs) in the world in 1990. Aims To presentthe new estimates of depression burden for the year 2000. Method DALYs for depressive disorders in each world region were calculated, based on new estimates of mortality, prevalence, incidence, average age at onset, duration and disability severity. Results Depression is the fourth leading cause of disease burden, accounting for 4.4% of total DALYs in the year 2000, and it causes the largest amount of non-fatal burden, accounting for almost 12% of all total years lived with disability worldwide. Conclusions These data on the burden of depression worldwide represent a major public health problem that affects patients and society.

Causal association between cannabis and psychosis: examination of the evidence

Abstract: Background Controversy remains as to whether cannabis acts as a causal risk factor for schizophrenia or other functional psychotic illnesses. Aims To examine critically the evidence that cannabis causes psychosis using established criteria of causality. Method We identified five studies that included a well-defined sample drawn from population-based registers or cohorts and used prospective measures of cannabis use and adult psychosis. Results On an individual level, cannabis use confers an overall twofold increase in the relative risk for later schizophrenia. At the population level, elimination of cannabis use would reduce the incidence of schizophrenia by approximately 8%, assuming a causal relationship. Cannabis use appears to be neither a sufficient nor a necessary cause for psychosis. It is a component cause, part of a complex constellation of factors leading to psychosis. Conclusions Cases of psychotic disorder could be prevented by discouraging cannabis use among vulnerable youths. Research is needed to understand the mechanisms by which cannabis causes psychosis.

Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial.

Abstract: Background Advances in the ability to identify people at high risk of developing psychosis have generated interest in the possibility of preventing psychosis. Aims To evaluate the efficacy of cognitive therapy for the prevention of transition to psychosis. Method A randomised controlled trial compared cognitive therapy with treatment as usual in 58 patients at ultra-high riskof developing a first episode of psychosis. Therapy was provided over 6 months, and all patients were monitored on a monthly basis for 12 months. Results Logistic regression demonstrated that cognitive therapy significantly reduced the likelihood of making progression to psychosis as defined on the Positive and Negative Syndrome Scale over 12 months. In addition, it significantly reduced the likelihood of being prescribed antipsychotic medication and of meeting criteria for a DSM–IV diagnosis of a psychotic disorder. Analysis of covariance showed that the intervention also significantly improved positive symptoms of psychosis in this population over the 12-month period Conclusions Cognitive therapy appears to be an acceptable and efficacious intervention for people at high risk of developing psychosis.

Effect of web-based depression literacy and cognitive-behavioural therapy interventions on stigmatising attitudes to depression: randomised controlled trial.

Abstract: Background Little is known about the efficacy of educational interventions for reducing the stigma associated with depression. Aims To investigate the effects on stigma of two internet depression sites. Method A sample of 525 individuals with elevated scores on a depression assessment scale were randomly allocated to a depression information website (BluePages), a cognitive–behavioural skills training website (MoodGYM) or an attention control condition. Personal stigma (personal stigmatising attitudes to depression) and perceived stigma (perception of what most other people believe) were assessed before and after the intervention. Results Relative to the control, the internet sites significantly reduced personal stigma, although the effects were small. BluePages had no effect on perceived stigma and MoodGYM was associated with an increase in perceived stigma relative to the control. Changes in stigma were not mediated by changes in depression, depression literacy or cognitive–behavioural therapy literacy. Conclusions The internet warrants further investigation as a means of delivering stigma reduction programmes for depression.

Psychosis, victimisation and childhood disadvantage: evidence from the second British National Survey of Psychiatric Morbidity.

Abstract: Background Adverse early circumstances may be more common in people who later develop psychotic disorders. Aims To use data from the second British National Survey of Psychiatric Morbidity to examine associations between psychotic disorders and a number of early victimisation experiences. Method Psychiatric disorders were identified through structured assessment of adults resident in private households in Britain ( n =8580). Respondents were asked whether they had experienced selected events displayed on cards. Results Compared with respondents with other psychiatric disorders or with none, the prevalence of every experience bar one was significantly elevated in those with definite or probable psychosis. The largest odds ratio was for sexual abuse. Controlling for depressed mood somewhat reduced the odds ratios for the individual experiences. Conclusions In people with psychosis, there is a marked excess of victimising experiences, many of which will have occurred during childhood. This is suggestive of a social contribution to aetiology.

Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders.

Abstract: De huisarts ziet veel patienten met onverklaarde lichamelijke klachten, vaak in combinatie met angst- en depressieve klachten. Dit proefschrift beschrijft de resultaten van een prevalentie studie met een prospectieve follow-up en een daarop volgende behandelstudie. De prevalentie van somatoforme stoornissen (DSM-IV) was 16,1%: een op de zes patienten die de huisarts bezoekt had tenminste zes maanden last van onverklaarde lichamelijk klachten met aanzienlijke beperkingen. De overlap met angst en depressie was substantieel en vergrootte de ernst van de ziektelast. Deze bevindingen onderstrepen het belang van een brede diagnostiek in de huisartspraktijk die zowel angst en depressie als somatoforme stoornissen omvat. Het aantal symptomen, zowel lichamelijk als psychisch, kan een nuttig instrument zijn bij het identificeren van de ernstigste patienten. Het gegeven dat bijna driekwart van alle patienten met een somatoforme stoornis langdurig klachten houdt impliceert een grote behoefte aan behandeling. In een gecontroleerde behandelstudie konden we echter niet aantonen dat een cognitief-gedragsmatige interventie volgens het gevolgenmodel door getrainde huisartsen effectiever was dan gebruikelijke zorg. Aangezien de behandelde patienten vaak ernstige klachten hadden stellen de auteurs voor om een stapsgewijze behandelmethode te ontwikkelen zodat zowel kortdurende als chronische klachten goed aangepakt kunnen worden.

Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital

Abstract: Background The sudden emergence of severe acute respiratory syndrome (SARS) caused international anxiety owing to its highly contagious and pandemic transmission. Health workers are vulnerable and are at high risk of infection. Aims To assess SARS-related stress and its immediate psychological impact and responses among health workers. Method Health workers in a tertiary hospital affected by SARS were invited to complete a questionnaire designed to evaluate exposure experience, psychological impact and psychiatric morbidity. The risk and rates of psychiatric morbidity were estimated for exposure experience. Results Altogether, 1257 health workers successfully completed the survey. In the initial phase of the outbreak, when the infection was spreading rapidly, feelings of extreme vulnerability, uncertainty and threat to life were perceived, dominated by somatic and cognitive symptoms of anxiety. During the ‘repair’ phase, when the infection was being brought under control, depression and avoidance were evident. The estimated prevalence of psychiatric morbidity measured by the Chinese Health Questionnaire was about 75%. Conclusions The outbreak of SARS could be regarded as an acute episode of a bio-disaster, leading to a significantly high rate of psychiatric morbidity.

Prevalence and correlates of self-reported psychotic symptoms in the British population

Abstract: Background The psychosis phenotype is generally thought of as a categorical entity. However, there is increasing evidence that psychosis exists in the population as a continuum of severity rather than an all-or-none phenomenon. Aims To investigate the prevalence and correlates of self-reported psychotic symptoms using data from the 2000 British National Survey of Psychiatric Morbidity. Method A total of 8580 respondents aged 16–74 years were interviewed. Questions covered mental health, physical health, substance use, life events and socio-demographic variables. The Psychosis Screening Questionnaire (PSQ) was used to identify psychotic symptoms. Results Of the respondents, 5.5% endorsed one or more items on the PSQ. Factors independently associated with psychotic symptoms were cannabis dependence, alcohol dependence, victimisation, recent stressful life events, lower intellectual ability and neurotic symptoms. Male gender was associated with paranoid thoughts, whereas female gender predicted hallucinatory experiences. Conclusions Self-reported psychotic symptoms are less common in this study than reported elsewhere, because of the measure used. These symptoms have demographic and clinical correlates similar to clinical psychosis.

Stigma: the feelings and experiences of 46 people with mental illness. Qualitative study.

Abstract: Background Stigma defines people in terms of some distinguishing characteristic and devalues them as a consequence. Aims To describe the relationship of stigma with mental illness, psychiatric diagnosis, treatment and its consequences of stigma for the individual. Method Narrative interviews were conducted by trained users of the local mental health services; 46 patients were recruited from community and day mental health services in North London. Results Stigma was a pervasive concern to almost all participants. People with psychosis or drug dependence were most likely to report feelings and experiences of stigma and were most affected by them. Those with depression, anxiety and personality disorders were more affected by patronising attitudes and feelings of stigma even if they had not experienced any overt discrimination. However, experiences were not universally negative. Conclusions Stigma may influence how a psychiatric diagnosisis accepted, whether treatment will be adhered to and how people with mental illness function in the world. However, perceptions of mental illness and diagnoses can be helpful and non-stigmatising for some patients.

Mental health survey of the adult population in Iran

Abstract: Background No national data on the prevalence of mental disorders are available in Iran. Such information may be a prerequisite for efficient national mental health intervention. Aims To determine the mental health status of a population sample aged 15 years and over. Method Through random cluster sampling, 35 014 individuals were selected and evaluated using the 28-item version of the General Health Questionnaire. A complementary semi-structured clinical interview was also undertaken to detect learning disability (‘mental retardation’), epilepsy and psychosis. Results About a fifth of the people in the study (25.9% of the women and 14.9% of the men) were detected as likely cases. The prevalence of mental disorders was 21.3% in rural areas and 20.9% in urban areas. Depression and anxiety symptoms were more prevalent than somatisation and social dysfunction. The interview of families by general practitioners revealed that the rates of learning disability, epilepsy and psychosis were 1.4%, 1.2% and 0.6%, respectively. Prevalence increased with age and was higher in the married, widowed, divorced, unemployed and retired people. Conclusions Prevalence rates are comparable with international studies. There is a wide regional difference in the country, and women are at greater risk.

Clinical efficacy of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial.

Abstract: Background Preliminary results have demonstrated the clinical efficacy of computerised cognitive – behavioural therapy (CBT) in the treatment of anxiety and depression in primary care. Aims To determine, in an expanded sample, the dependence of the efficacy of this therapy upon clinical and demographic variables. Method A sample of 274 patients with anxiety and/or depression were randomly allocated to receive, with or without medication, computerised CBT or treatment as usual, with follow-up assessment at 6 months. Results The computerised therapy improved depression, negative attributional style, work and social adjustment, without interaction with drug treatment, duration of preexisting illness or severity of existing illness. For anxiety and positive attributional style, treatment interacted with severity such that computerised therapy did better than usual treatment for more disturbed patients. Computerised therapy also led to greater satisfaction with treatment. Conclusions Computer-delivered CBT is a widely applicable treatment for anxiety and/or depression in general practice.

Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders

Abstract: Background Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced. Aims To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each. Method Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared interms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs). Results Summing across all disorders, current treatment averted 13% of the burden, at an average cost of AUS$30 000 per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of AUS$18 000 per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at AUS$16 000 per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable. Conclusions The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders.

Impact of child sexual abuse on mental health: prospective study in males and females.

Abstract: Background The lack of prospective studies and data on male victims leaves major questions regarding associations between child sexual abuse and subsequent psychopathology. Aims To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design. Method Children ( n =1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period. Results Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v . 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v .10.2%). Conclusions This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.

Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence.

Abstract: Background There is controversy about whether mental health services should be provided in community or hospital settings.There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas. Aims To provide an evidence base for this debate, and present a stepped care model. Method Cochrane systematic reviews and other reviews were summarised. Results The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation. Conclusions Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.

Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11 583 patients

Abstract: Background Repetition of deliberate self-harm (DSH) is a risk factor for suicide. Little information is available on the risk for specific groups of people who deliberately harm themselves repeatedly. Aims To investigate the long-term risk of suicide associated with repetition of DSH by gender, age and frequency of repetition. Method A mortality follow-up study to the year 2000 was conducted on 11 583 people who presented to the general hospital in Oxford between 1978 and 1997. Repetition of DSH was determined from reported episodes prior to the index episode and episodes presenting to the same hospital during the follow-up period. Deaths were identified through national registers. Results Thirty-nine per cent of patients repeated the DSH. They were at greater relative risk of suicide than the single-episode DSH group (2.24; 95% CI 1.77–2.84). The relative risk of suicide in the repeated DSH group compared with the single-episode DSH group was greater in females (3.5; 95% CI 1.3–2.4) than males (1.8; 95% CI 2.3–5.3) and was inversely related to age (up to 54 years). Suicide risk increased further with multiple repeat episodes of DSH in females. Conclusions Repetition of DSH is associated with an increased risk of suicide in males and females. Repetition may be a better indicator of risk in females, especially young females.

Urbanisation and incidence of psychosis and depression: follow-up study of 4.4 million women and men in Sweden.

Abstract: Background Previous studies of differences in mental health between urban and rural populations are inconsistent. Aims To examine whether a high level of urbanisation is associated with increased incidence rates of psychosis and depression, after adjustment for age, marital status, education and immigrant status. Method Follow-up study of the total Swedish population aged 25–64 years with respect to first hospital admission for psychosis or depression. Level of urbanisation was defined by population density and divided into quintiles. Results With increasing levels of urbanisation the incidence rates of psychosis and depression rose. In the full models, those living in the most densely populated areas (quintile 5) had 68–77% more risk of developing psychosis and12–20% more risk of developing depression than the reference group (quintile 1). Conclusions A high level of urbanisation is associated with increased risk of psychosis and depression for both women and men.

Genotype-environment interaction in schizophrenia-spectrum disorder. Long-term follow-up study of Finnish adoptees.

Abstract: Background Earlier adoption studies have convincingly confirmed the importance of a genetic contribution to schizophrenia. The designs, however, did not incorporate observations of the rearing-family environment. Aims To test the hypothesis that genetic factors moderate susceptibility to environmentally mediated risks associated with rearing-family functioning. Method A Finnish national sample of adopted-away offspring of mothers with schizophrenia-spectrum disorders was compared blindly with adoptees without this genetic risk. Adoptive rearing was assessed using family rating scales based upon extended family observations at initial assessment. Adoptees were independently re-diagnosed after a median interval of12 years, with register follow-up after 21 years. Results In adoptees at high genetic risk of schizophrenia, but not in those at low genetic risk, adoptive-family ratings were a significant predictor of schizophrenia-spectrum disorders in adoptees at long-term follow-up. Conclusions Adoptees at high genetic risk are significantly more sensitive to adverse v. ‘healthy’ rearing patterns in adoptive families than are adoptees at low genetic risk.

Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial

Abstract: Background Cognitive–behavioural therapy (CBT) is effective for treating anxiety and depression in primary care, but there is a shortage of therapists. Computer-delivered treatment may be a viable alternative. Aims To assess the cost-effectiveness of computer-delivered CBT. Method A sample of people with depression or anxiety were randomised to usual care ( n =128) or computer-delivered CBT ( n =146). Costs were available for 123 and 138 participants, respectively. Costs and depression scores were combined using the net benefit approach. Results Service costs were £40 (90% CI – £28 to £ 148) higher over 8 months for computer-delivered CBT. Lost-employment costs were £407 (90% CI £196 to £586) less for this group. Valuing a 1-unit improvement on the Beck Depression Inventory at £40, there is an 81% chance that computer-delivered CBT is cost-effective, and it revealed a highly competitive cost per quality-adjusted life year. Conclusions Computer-delivered CBT has a high probability of being cost-effective, even if a modest value is placed on unit improvements in depression.

Hypothalamic-pituitary-adrenal axis function in patients with bipolar disorder

Abstract: Background Hypothalamic-pituitary-adrenal (HPA) axis function, as variously measured by the responses to the combined dexamethasone/corticotrophin-releasing hormone (dex/CRH) test, the dexamethasone suppression test (DST) and basal cortisol levels, has been reported to be abnormal in bipolar disorder. Aims To test the hypothesis that HPA axis dysfunction persists in patients in remission from bipolar disorder. Method Salivary cortisol levels and the plasma cortisol response to the DST and dex/CRH test were examined in 53 patients with bipolar disorder, 27 of whom fulfilled stringent criteria for remission, and in 28 healthy controls. Serum dexamethasone levels were measured. Results Patients with bipolar disorder demonstrated an enhanced cortisol response to the dex/CRH test compared with controls ( P =0.001). This response did not differ significantly between remitted and non-remitted patients. These findings were present after the potentially confounding effects of dexamethasone levels were accounted for. Conclusions The dex/CRH test is abnormal in both remitted and non-remitted patients with bipolar disorder. This measure of HPA axis dysfunction is a potential trait marker in bipolar disorder and thus possibly indicative of the core pathophysiological process in this illness.

Epidemiology of involuntary placement of mentally ill people across the European Union

Abstract: Background Despite the tendency for harmonisation of strategies for mental health care delivery, rules and regulations for involuntary placement or treatment of mentally ill persons still differ remarkably internationally. Rapid European integration and other political developments require valid and reliable international overviews, sound studies and profound analyses of this controversial issue. Aims To give an overview of compulsory admission data from official sources across the European Union (EU). Method Data on the legal frameworks for involuntary placement or treatment of people with mental illness and their outcomes were provided and assessed by experts from all EU member states. Results Total frequencies of admission and compulsory admission rates vary remarkably across the EU. Variation hints at the influence of differences in legal frameworks or procedures. Time series suggest an overall tendency towards more or less stable quotas in most member states. Conclusions Further research is greatly needed in this field. Common international health reporting standards are essential to the compilation of basic data.

Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in 14 world regions.

Abstract: Background International evidence on the cost and effects of interventions for reducing the global burden of depression remain scarce. Aims To estimate the population-level cost-effectiveness of evidence-based depression interventions and their contribution towards reducing current burden. Method Primary-care-based depression interventions were modelled at the level of whole populations in 14 epidemiological subregions of the world. Total population-level costs (in international dollars or I$) and effectiveness (disability adjusted life years (DALYs) averted) were combined to form average and incremental cost-effectiveness ratios. Results Evaluated interventions have the potential to reduce the current burden of depression by 10–30%. Pharmacotherapy with older antidepressant drugs, with or without proactive collaborative care, are currently more cost-effective strategies than those using newer antidepressants, particularly in lower-income subregions. Conclusions Even in resource-poor regions, each DALYaverted by efficient depression treatments in primary care costs less than 1 year of average per capita income, making such interventions a cost-effective use of health resources. However, current levels of burden can only be reduced significantlyif there is a substantialincrease substantial increase intreatment coverage.

Prevalence of DSM—IV psychiatric disorder in the French elderly population

Abstract: Background France has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates. Aims To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder. Method A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM — IV criteria were re-examined by a clinical panel. Results Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis. Conclusions Results show veryhigh rates of lifetime but not current major depression. Rates of currentphobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

Stimulant psychosis: systematic review

Abstract: Background Psychosis associated with stimulant use is an increasing problem, but there is little research evidence about the nature of the problem and its management. Aims To critically review the literature on stimulant psychosis and sensitisation. Method Systematic review of studies that have investigated stimulant use and psychosis in humans. The main outcome measures were increases in psychosis with stimulant use, and differences between stimulant users and non-users. Results Fifty-four studies met the inclusion criteria. Experimental studies show that a single dose of a stimulant drug can produce a brief increase in psychosis ratings (a‘response’) in 50-70% of participants with schizophrenia and pre-existing acute psychotic symptoms, unaffected by the presence of antipsychotic medication. Those with schizophrenia who do not have acute psychotic symptoms respond, but less frequently (30%). There has been little research into the longer-term effects of use. Conclusions Compliance with antipsychotic medication by someone with schizophrenia will not prevent a relapse or worsening of psychotic symptoms if stimulants are used. Low-dose antipsychotic treatment may be beneficial in stimulant users, to prevent sensitisation.

Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabiliser v. mood stabiliser alone.

Abstract: Background Few controlled studies have examined the use of atypical antipsychotic drugs for prevention of relapse in patients with bipolar I disorder Aims To evaluate whether olanzapine plus either lithium or valproate reduces the rate of relapse, compared with lithium or valproate alone Method Patients achieving syndromic remission after 6 weeks’treatment with olanzapine plus either lithium (06–12 mmol/l) or valproate (50–125 μg/ml) received lithium or valproate plus either olanzapine 5–20 mg/day (combination therapy) or placebo (monotherapy), and were followed in a double-masked trial for 18 months Results The treatment difference in time to relapse into either mania or depression was not significant for syndromic relapse (median time to relapse: combination therapy 94 days, monotherapy 405 days; P =0742), but was significant for symptomatic relapse (combination therapy 163 days, monotherapy 42 days; P =0023) Conclusions Patients taking olanzapine added to lithium or valproate experienced sustained symptomatic remission, but not syndromic remission, for longer than those receiving lithium or valproate monotherapy

Cognitive therapy for command hallucinations: randomised controlled trial.

Abstract: Background Command hallucinations are a distressing and high-risk group of symptoms that have long been recognised but little understood, with few effective treatments. In line with our recent research, we propose that the development of an effective cognitive therapy for command hallucinations (CTCH) would be enhanced by applying insights from social rank theory. Aims We tested the efficacy of CTCH in reducing beliefs about the power of voices and thereby compliance, in a single-blind, randomised controlled trial. Method Atotal of 38 patients with command hallucinations, with which they had recently complied with serious consequences, were allocated randomly to CTCH or treatment as usual and followed up at 6 months and12 months. Results Large and significant reductions in compliance behaviour were obtained favouring the cognitive therapy group (effect size 1.1). Improvements were also observed in the CTCH but not the control group in degree of conviction in the power and superiority of the voices and the need to comply, and in levels of distress and depression. No change in voice topography (frequency, loudness, content) was observed. The differences were maintained at 12 months’ follow-up. Conclusions The results support the efficacy of cognitive therapy for CTCH.

Salivary cortisol response to awakening in chronic fatigue syndrome

Abstract: Background: There is accumulating evidence of hypothalamic-pituitary-adrenal (HPA) axis disturbances in chronic fatigue syndrome (CFS). The salivary cortisol response to awakening hasbeen described recentlyas a non-invasive test of the capacityof the HP Aaxis to respond to stress. The results of this test correlate closely with those of more invasive dynamic tests reported in the literature; furthermore, i tcan be undertaken in a naturalistic setting. Aims: To assess the HPA axis using the salivary cortisol response to awakening in CFS. Method: We measured salivary cortisol upon awakening and 10, 20, 30 and 60 min afterwards in 56 patients with CFS and 35 healthy volunteers. Results: Patients had a lower cortisol response to awakening, measured by the area under the curve. Conclusions: This naturalistic test of the HPA axis response to stress showed impaired HPA axis function in CFS.

Globalisation and mental disorders. Overview with relation to depression.

Abstract: Background Globalisation is the process by which traditional boundaries of cultures are changing. Industrialisation, urbanisation and influence of the media are influencing idioms of distress across cultures. Aims To discuss the role of globalisation, using the epidemiology, diagnosis, clinical presentation and treatment of depression across various cultures as an example. Method Recent studies focusing on transcultural aspects of depression were reviewed and summarised. Results Cultural, social and religious mores account for variations in the presentation of depression across cultures. Somatic symptoms are common presenting features throughout the world and may serve as cultural idioms of distress, but psychological symptoms can usually be found when probed. Feelings of guilt and suicide rates vary across cultures and depression may be underdiagnosed. Conclusions Training packages could enhance clinicians’cultural competency in multicultural settings. However, globalisation is likely to influence idioms of distress and pathways to care in ways that are difficult to predict.

Cognitive-behavioural therapy in first-episode and early schizophrenia: 18-month follow-up of a randomised controlled trial

Abstract: Background The initial phase of a trial of cognitive-behavioural therapy (CBT) for acutely ill patients with schizophrenia of recent onset showed that it speeded recovery. Aims To testthe hypothesis that CBT in addition to treatment as usual (TAU) during the first or second acute episode of schizophrenia will confer clinical benefit over a follow-up period. Method This was an18-month follow-up of a multicentre prospective trial of CBT or supportive counselling administered as an adjunct to TAU, compared with TAU alone, for patients hospitalised for an acute episode of schizophrenia of recent onset. Primary outcomes were total and positive symptom scales, time to relapse and re-hospitalisation. Results There were significant advantages for CBT and supportive counselling over TAU alone on symptom measures at18 months but no group difference was seen for relapse or re-hospitalisation. There was a significant centre-treatment interaction, reflecting centre differences in the effect of introducing either treatment, but not in the comparison of CBTand supportive counselling. Medication dosage and compliance did not explain group differences. Conclusions Adjunctive psychological treatments can have a beneficial long-term effect on symptom reduction.

Relapse in schizophrenia: costs, clinical outcomes and quality of life

Abstract: Background Relapse is one of the most costly aspects of schizophrenia. Aims To compare costs, clinical outcomes and quality of life for patients who experienced relapse in schizophrenia with a control group who did not relapse. Method Patients were randomly selected from current psychiatric case-loads drawn from urban and suburban areas of Leicester. Differences in costs and outcomes by relapse status in the previous 6 months were examined using parametric and non-parametric tests, and multivariate analysis was used to examine factors associated with relapse and costs. Results Costs for the patients who relapsed were over four times higher than those for the non-relapse group. There were few statistically significant differences in clinical and quality of life measures by relapse status. Multivariate analyses suggested some significant correlates of relapse and costs. Conclusions The higher costs associated with relapse will be of interest to policy-makers who face difficultchoices concerning new but more expensive treatments for patients with schizophrenia.

Trauma exposure and post-traumatic stress symptoms in urban African schools. Survey in CapeTown and Nairobi.

Abstract: Background There is a lack of comparative data on the prevalence and effects of exposure to violence in African youth. Aims We assessed trauma exposure, post-traumatic stress symptoms and gender differences in adolescents from two African countries. Method A sample of 2041 boys and girls from 18 schools in CapeTown and Nairobi completed anonymous self-report questionnaires. Results More than 80% reported exposure to severe trauma, either as victims or witnesses. Kenyan adolescents, compared with South African, had significantly higher rates of exposure to witnessing violence (69% v . 58%), physical assault by a family member (27% v . 14%) and sexual assault (18% v . 14%). But rates of current full-symptom post-traumatic stress disorder (PTSD) (22.2% v . 5%) and current partial-symptom PTSD (12% v . 8%) were significantly higher in the South African sample. Boys were as likely as girls to meet PTSD symptom criteria. Conclusions Although the lifetime exposure to trauma was comparable across both settings, Kenyan adolescents had much lower rates of PTSD. This difference may be attributable to cultural and other trauma-related variables. High rates of sexual assault and PTSD, traditionally documented in girls, may also occur in boys and warrant further study.