Showing papers in "British Journal of Psychiatry in 2007"

Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder

Abstract: Background Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD). Aims To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative. Method An ADHD screen was administered to respondents aged 18-44 years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability. Results Estimates of ADHD prevalence averaged 3.4% (range 1.2-7.3%), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders. Conclusions Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case.

Mental ill-health in adults with intellectual disabilities: prevalence and associated factors.

Abstract: Background Reported prevalence of mental ill-health among adults with intellectual disabilities ranges from 7 to 97%, owing to methodological limitations. Little is known about associations. Aims To determine the prevalence of mental ill-health in adults with intellectual disabilities and to investigate factors independently associated with it. Method Population-based study ( n =1023) with comprehensive individual assessments modelled using regression analyses. Results Point prevalence of mental ill-health was 40.9% (clinical diagnoses), 35.2% (DC–LD), 16.6% (ICD–10–DCR) and 15.7% (DSM–IV–TR). The most prevalent type was problem behaviours. Mental ill-health was associated with more life events, female gender, type of support, lower ability, more consultations, smoking, incontinence, not having severe physical disabilities and not having immobility; it was not associated with deprived areas, no occupation, communication impairment, epilepsy, hearing impairment or previous institutional residence. Conclusions This investigation informs further longitudinal study, and development of appropriate interventions, public health strategy and policy. ICD–10–DCR and DSM–IV–TR undercount mental ill-health in this population compared with DC–LD.

Psychological treatments for chronic post-traumatic stress disorder : Systematic review and meta-analysis

Abstract: Background The relative efficacy of different psychological treatments for chronic post-traumatic stress disorder (PTSD) is unclear. Aims To determine the efficacy of specific psychological treatments for chronic PTSD. Method In a systematic review of randomised controlled trials, eligible studies were assessed against methodological quality criteria and data were extracted and analysed. Results Thirty-eight randomised controlled trials were included in the meta-analysis. Trauma-focused cognitive–behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group cognitive–behavioural therapy improved PTSD symptoms more than waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR but there was some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress management was superior to other therapies. Conclusions The first-line psychological treatment for PTSD should be trauma-focused (TFCBT or EMDR).

Theory of mind in schizophrenia: meta-analysis.

Abstract: Background Mentalising impairment (an impaired ability to think about people in terms of their mental states) has frequently been associated with schizophrenia. Aims To assess the magnitude of the deficit and analyse associated factors. Method Twenty-nine studies of mentalising in schizophrenia (combined n =1518), published between January 1993 and May 2006, were included to estimate overall effect size. Study descriptors predicted to influence effect size were analysed using weighted regression-analysis techniques. Separate analyses were performed for symptom subgroups and task types. Results The estimated overall effect size was large and statistically significant ( d =–1.255, P <0.0001) and was not significantly affected by sample characteristics. All symptom subgroups showed significant mentalising impairment, but participants with symptoms of disorganisation were significantly more impaired than the other subgroups ( P <0.01). Conclusions This meta-analysis showed significant and stable mentalising impairment in schizophrenia. The finding that patients in remission are also impaired favours the notion that mentalising impairment represents a possible trait marker of schizophrenia.

Stigma: ignorance, prejudice or discrimination?

Abstract: The term stigma refers to problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). Most research in this area has been based on attitude surveys, media representations of mental illness and violence, has only focused upon schizophrenia, has excluded direct participation by service users, and has included few intervention studies. However, there is evidence that interventions to improve public knowledge about mental illness can be effective. The main challenge in future is to identify which interventions will produce behaviour change to reduce discrimination against people with mental illness.

Cortisol and post-traumatic stress disorder in adults: systematic review and meta-analysis.

Abstract: Background Post-traumatic stress disorder (PTSD) has inconsistently been associated with lower levels of cortisol. Aims To compare basal cortisol levels in adults with current PTSD and in people without psychiatric disorder. Method Systematic review and meta-analysis. Standardised mean differences (SMD) in basal cortisol levels were calculated and random-effects models using inverse variance weighting were applied. Results Across 37 studies, 828 people with PTSD and 800 controls did not differ in cortisol levels (pooled SMD=–0.12, 95% CI=–0.32 to 0.080). Subgroup analyses revealed that studies assessing plasma or serum showed significantly lower levels in people with PTSD than in controls not exposed to trauma. Lower levels were also found in people with PTSD when females were included, in studies on physical or sexual abuse, and in afternoon samples. Conclusions Low cortisol levels in PTSD are only found under certain conditions. Future research should elucidate whether low cortisol is related to gender or abuse and depends on the measurement methods used.

Mental health of children and adolescents with intellectual disabilities in Britain

Abstract: Background Few studies have employed formal diagnostic criteria to determine the prevalence of psychiatric disorders in contemporaneous samples of children with and without intellectual disabilities. Aims To establish the prevalence of psychiatric disorders against ICD–10 criteria among children with and without intellectual disabilities, the association with social/environmental risk factors, and risk attributable to intellectual disability. Method Secondary analysis of the 1999 and 2004 Office for National Statistics surveys of the mental health of British children and adolescents with ( n =641) and without ( n =17 774) intellectual disability. Results Prevalence of psychiatric disorders was 36% among children with intellectual disability and 8% among children without (OR=6.5). Children with intellectual disabilities accounted for 14% of all British children with a diagnosable psychiatric disorder. Increased prevalence was particularly marked for autistic-spectrum disorder (OR=33.4), hyperkinesis (OR=8.4) and conduct disorders (OR=5.7). Cumulative risk of exposure to social disadvantage was associated with increased prevalence. Conclusions A significant proportion of the elevated risk for psychopathology among children with intellectual disability may be due to their increased rate of exposure to psychosocial disadvantage.

Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households

Abstract: Background Children looked after by local authorities are at higher risk of poor psychosocial outcomes than children living in private households, but nationally representative and random samples of the two groups of children have not previously been compared. Aims To find explanations for the increased prevalence of psychiatric disorder in children looked after by local authorities. Method We examined socio-demographic characteristics and psychopathology by type of placement among children looked after in Britain by local authorities ( n =1453), and compared these children with deprived and non-deprived children living in private households ( n =10 428). Results Children looked after by local authorities had higher levels of psychopathology, educational difficulties and neurodevelopmental disorders, and ‘looked after’ status was independently associated with nearly all types of psychiatric disorder after adjusting for these educational and physical factors. The prevalence of psychiatric disorder was particularly high among those living in residential care and with many recent changes of placement. Conclusions Our findings indicate a need for greater support of this vulnerable group of children.

Depression and socio-economic risk factors: 7-year longitudinal population study.

Abstract: BACKGROUND: Low socio-economic status is associated with a higher prevalence of depression, but it is not yet known whether change in socio-economic status leads to a change in rates of depression. AIMS: To assess whether longitudinal change in socio-economic factors affects change of depression level. METHOD: In a prospective cohort study using the annual Belgian Household Panel Survey (1992-1999), depression was assessed using the Global Depression Scale. Socio-economic factors were assessed with regard to material standard of living, education, employment status and social relationships. RESULTS: A lowering in material standard of living between annual waves was associated with increases in depressive symptoms and caseness of major depression. Life circumstances also influenced depression. Ceasing to cohabit with a partner increased depressive symptoms and caseness, and improvement in circumstances reduced them; the negative effects were stronger than the positive ones. CONCLUSIONS: The study showed a clear relationship between worsening socio-economic circumstances and depression.

Impact of psychiatric disorders on health-related quality of life: general population survey

Abstract: Background Measurement of health-related quality of life (HRQoL) with generic preference-based instruments enables comparisons of severity across different conditions and treatments. This is necessary for rational public health policy. Aims To measure HRQoL decrement and loss of quality-adjusted life-years (QALYs) associated with pure and comorbid forms of depressive and anxiety disorders and alcohol dependence. Method A general population survey was conducted of Finns aged 30 years and over. Psychiatric disorders were diagnosed with the Composite International Diagnostic Interview and HRQoL was measured with the 15D and EQ–5D questionnaires. Results Dysthymia, generalised anxiety disorder and social phobia were associated with the largest loss of HRQoL on the individual level before and after adjusting for somatic and psychiatric comorbidity. On the population level, depressive disorders accounted for 55%, anxiety disorders 30%, and alcohol dependence for 15% of QALY loss identified in this study. Conclusions Chronic anxiety disorders and dysthymia are associated with poorer HRQoL than previously thought.

Rates and correlates of employment in people with schizophrenia in the UK, France and Germany

Abstract: Background Little is known about international variations in employment rates among people with schizophrenia or about the factors associated with employment in this disorder.Aims To describe employment patterns and the variables associated with working in an international sample of people with schizophrenia.Method An analysis was made of baseline data from the European Schizophrenia Cohort study, a 2-year investigation of people with schizophrenia in contact with secondary services and living in France, Germany and the UK (n=1208).Results Participants were working in all sections of the job market. People who had a degree, were living with their families or had experienced only a single episode of illness were more likely to be working. A continuous illness course, more severe non-psychotic symptoms and drug misuse reduced the odds of employment. There were large variations between centres in employment rates, which were highest in the three German study sites. These differences persisted after adjustment for individual characteristics.Conclusions Local social contexts may be as important as individual or illness-related factors in explaining employment status.

The Stigma Scale: Development of a standardised measure of the stigma of mental illness.

Abstract: Background There is concern about the stigma of mental illness, but it is difficult to measure stigma consistently. Aims To develop a standardised instrument to measure the stigma of mental illness. Method We used qualitative data from interviews with mental health service users to develop a pilot scale with 42 items. We recruited 193 service users in order to standardise the scale. Of these, 93 were asked to complete the questionnaire twice, 2 weeks apart, of whom 60 (65%) did so. Items with a test–retest reliability kappa coefficient of 0.4 or greater were retained and subjected to common factor analysis. Results The final 28-item stigma scale has a three-factor structure: the first concerns discrimination, the second disclosure and the third potential positive aspects of mental illness. Stigma scale scores were negatively correlated with global self-esteem. Conclusions This self-report questionnaire, which can be completed in 5–10 min, may help us understand more about the role of stigma of psychiatric illness in research and clinical settings.

Schizophrenia: a common disease caused by multiple rare alleles

Abstract: Schizophrenia is widely held to stem from the combined effects of multiple common polymorphisms, each with a small impact on disease risk. We suggest an alternative view: that schizophrenia is highly heterogeneous genetically and that many predisposing mutations are highly penetrant and individually rare, even specific to single cases or families. This "common disease--rare alleles" hypothesis is supported by recent findings in human genomics and by allelic and locus heterogeneity for other complex traits. We review the implications of this model for gene discovery research in schizophrenia.

Effects of antidepressant treatment following myocardial infarction

Abstract: Background Depression following myocardial infarction is associated with poor cardiac prognosis. It is unclear whether antidepressant treatment improves long-term depression status and cardiac prognosis. Aims To evaluate the effects of antidepressant treatment compared with usual care in an effectiveness study. Method In a multicentre randomised controlled trial, 2177 myocardial infarction patients were evaluated for ICD-10 depression and randomised to intervention (n=209) or care as usual (n=122). Both arms were evaluated at 18 months post-myocardial infarction for long-term depression status and new cardiac events. Results No differences were observed between intervention and control groups in mean scores on the Beck Depression Inventory (11.0, s.d.=7.5 v. 10.2, s.d.=5.1, P=0.45) or presence of ICD- 10 depression (30.5 v 32.1%, P=0.68). The cardiac event rate was 14% among the intervention group and 13% among controls (OR=1.07,95% CI 0.57-2.00). Conclusions Antidepressant treatment did not alter long-term depression post-myocardial infarction status or improve cardiac prognosis. Declaration of interest None. Funding detailed in Acknowledgements.

Precision of actuarial risk assessment instruments: evaluating the 'margins of error' of group v. individual predictions of violence.

Abstract: Background Actuarial risk assessment instruments (ARAIs) estimate the probability that individuals will engage in future violence. Aims To evaluate the `margins of error' at the group and individual level for risk estimates made using ARAIs. Method An established statistical method was used to construct 95% CI for group and individual risk estimates made using two popular ARAIs. Results The 95% CI were large for risk estimates at the group level; at the individual level, they were so high as to render risk estimates virtually meaningless. Conclusions The ARAIs cannot be used to estimate an individual's risk for future violence with any reasonable degree of certainty and should be used with great caution or not at all. In theory, reasonably precise group estimates could be made using ARAIs if developers used very large construction samples and if the tests included few score categories with extreme risk estimates.

Lithium and risk for Alzheimer's disease in elderly patients with bipolar disorder.

Abstract: Bipolar disorder is associated with increased risk for dementia. We compared the prevalence of Alzheimer's disease between 66 elderly euthymic patients with bipolar disorder who were on chronic lithium therapy and 48 similar patients without recent lithium therapy. The prevalence of dementia in the whole sample was 19% v. 7% in an age-comparable population. Alzheimer's disease was diagnosed in 3 patients (5%) on lithium and in 16 patients (33%) who were not on lithium (P<0.001). Our case-control data suggest that lithium treatment reduced the prevalence of Alzheimer's disease in patients with bipolar disorder to levels in the general elderly population. This is in accordance with reports that lithium inhibits crucial processes in the pathogenesis of Alzheimer's disease.

Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support.

Abstract: Background Although effective therapies for social phobia exist, many individuals refrain from seeking treatment owing to the embarrassment associated with help-seeking. Internet-based cognitive–behavioural self-help can be an alternative, but adherence is a problem. Aims To evaluate a 9-week programme of internet-based therapy designed to increase treatment adherence by the addition of short weekly telephone calls, nine in all, with a total duration of 95 min. Method In a randomised controlled trial the effects of internet-based cognitive–behavioural therapy in the treatment group ( n =29) were compared with a waiting-list control group ( n =28). Results Compared with the control group the treated participants experienced greater reductions on measures of general and social anxiety, avoidance and depression. Adherence to treatment was high, with 93% finishing the complete treatment package. One year later all improvements were maintained. Conclusions This study provides evidence to support the use of internet-based treatment supplemented by short, weekly telephone calls.

Social exclusion and mental health: conceptual and methodological review.

Abstract: Background The concept of social exclusion is now widely used in discussions about the nature of disadvantage, and there are ongoing initiatives to promote social inclusion among those with mental health problems. Aims To conduct a conceptual and methodological review of social exclusion, focusing initially on the origins and definitions of the concept and then on approaches to its measurement, both in general and in relation to mental health. Method We used two main strategies. First, we utilised expertise within the study team to identify major texts and reviews on social exclusion and related topics. Second, we searched major bibliographic databases for literature on social exclusion and mental health. We adopted a non-quantitative approach to synthesising the findings. Results There is no single accepted definition of social exclusion. However, most emphasise lack of participation in social activities as the core characteristic. There are a number of approaches to measuring social exclusion, including use of indicator lists and dimensions. In the mental health literature, social exclusion is poorly defined and measured. Conclusions If social exclusion is a useful concept for understanding the social experiences of those with mental health problems, there is an urgent need for more conceptual and methodological work.

Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes.

Abstract: Background It is unclear how the recurrence of major depression in adolescence affects later life outcomes. Aims To examine the associations between the frequency of major depression at ages 16–21 and later outcomes, both before and after controlling for potentially confounding factors. Method Data were gathered from a 25-year longitudinal study of a birth cohort of New Zealand children ( n =982). Outcome measures included DSM–IV symptom criteria for major depression and anxiety disorders, suicidal ideation and attempted suicide, achieving university degree or other tertiary education qualification, welfare dependence and unemployment, and income at ages 21–25 years. Results There were significant ( P <0.05) associations between the frequency of depression at ages 16–21 years and all outcome measures. After adjustment for confounding factors, the association between frequency of depression and all mental health outcomes, and welfare dependence and unemployment, remained significant ( P <0.05). Conclusions The frequency of depression in adolescence and young adulthood is associated with adverse mental health and economic outcomes in early adulthood.

Substance use in a population-based clinic sample of people with first-episode psychosis

Abstract: Background Substance use is implicated in the cause and course of psychosis. Aims To characterise substance and alcohol use in an epidemiologically representative treatment sample of people experiencing a first psychotic episode in south Cambridgeshire. Method Current and lifetime substance use was recorded for 123 consecutive referrals to a specialist early intervention service. Substance use was compared with general population prevalence estimates from the British Crime Survey. Results Substance use among people with first-episode psychosis was twice that of the general population and was more common in men than women. Cannabis abuse was reported in 51% of patients ( n =62) and alcohol abuse in 43% ( n =53). More than half ( n =68, 55%) had used Class A drugs, and 38% ( n =43) reported polysubstance abuse. Age at first use of cannabis, cocaine, ecstasy and amphetamine was significantly associated with age at first psychotic symptom. Conclusions Substance misuse is present in the majority of people with first-episode psychosis and has major implications for management. The association between age at first substance use and first psychotic symptoms has public health implications.

The bipolar spectrum.

Abstract: The two-dimensional bipolar spectrum described here comprises a continuum of severity from normal to psychotic and a continuum from depression, via three bipolar subgroups to mania. This combination of dimensional and categorical principles for classifying mood disorders may help alleviate the problems of underdiagnosis and undertreatment of bipolar disorders.

Population level of unmet need for mental healthcare in Europe.

Abstract: Background The high prevalence of mental disorders has fuelled controversy about the need for mental health services. Aims To estimate unmet need for mental healthcare at the population level in Europe. Method As part of the European Study of Epidemiology of Mental Disorders (ESEMeD) project, a cross-sectional survey was conducted of representative samples of the adult general population of Belgium, France, Germany, Italy, The Netherlands and Spain ( n =8796). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0. Individuals with a 12-month mental disorder that was disabling or that had led to use of services in the previous 12 months were considered in need of care. Results About six per cent of the sample was defined as being in need of mental healthcare. Nearly half (48%) of these participants reported no formal healthcare use. In contrast, only 8% of the people with diabetes had reported no use of services for their physical condition. In total, 3.1% of the adult population had an unmet need for mental healthcare. About 13% of visits to formal health services were made by individuals without any mental morbidity. Conclusions There is a high unmet need for mental care in Europe, which may not be eliminated simply by reallocating existing healthcare resources.

Interventions for reducing the use of seclusion in psychiatric facilities : Review of the literature

Abstract: Background The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted. Aims To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities. Method We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion. Results Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare. Conclusions Reducing seclusion rates is challenging andgenerally requires staff to implement several interventions.

Prevalence of depressive symptoms and syndromes in later life in ten European countries: The SHARE study

Abstract: Background The EURO–D, a12-item self-report questionnaire for depression, was developed with the aim of facilitating cross-cultural research into late-life depression in Europe Aims To describe the national variation in depression symptoms and syndrome prevalence across ten European countries Method The EURO–D was administered to cross-sectional nationally representative samples of noninstitutionalised persons aged ≥50 years ( n =22 777) The effects of age, gender, education and cognitive functioning on individual symptoms and EURO–D factor scores were estimated Country-specific depression prevalence rates and mean factor scores were re-estimated, adjusted for these compositional effects Results The prevalence of all symptoms was higher in the Latin ethno-lingual group of countries, especially symptoms related to motivation Women scored higher on affective suffering; older people and those with impaired verbal fluency scored higher on motivation Conclusions The prevalence of individual EURO–D symptoms and of probable depression (cut-off score ≥4) varied consistently between countries Standardising for effects of age, gender, education and cognitive function suggested that these compositional factors did not account for the observed variation

Effects of treating postnatal depression on mother-infant interaction and child development: systematic review.

Abstract: Background Postnatal depression has detrimental effects on the child’s cognitive and emotional development. Aims To assess the benefits of treating postnatal depression for mother–infant interaction and child development. Method A systematic search was made of 12 electronic bibliographic databases for randomised controlled trials and controlled clinical trials on treatment of mothers with postnatal depression, where outcomes were assessed in children; findings were assessed. Results Only eight trials met the inclusion criteria. Of those included, interventions varied widely but all involved therapies directed at the mother–infant relationship. One study with intensive and prolonged therapy showed cognitive improvement, whereas two others with briefer interventions improved maternal–infant relationships but did not affect the child’s cognitive or behavioural development. All five studies assessing only mother–infant relationships showed improvements. Conclusions Cognitive development in children of depressed mothers, along with better mother–infant relationships, might be improved with sustained interventions. Trials assessing treatments for postnatal depression would benefit from looking more closely at benefits for children as well as mothers, using validated objective measures.

Efficacy of three screening instruments in the identification of autistic-spectrum disorders.

Abstract: Background Screening instruments for autistic-spectrum disorders have not been compared in the same sample. Aims To compare the Social Communication Questionnaire (SCQ), the Social Responsiveness Scale (SRS) and the Children's Communication Checklist (CCC). Method Screen and diagnostic assessments on 119 children between 9 and 13 years of age with special educational needs with and without autistic-spectrum disorders were weighted to estimate screen characteristics for a realistic target population. Results The SCQ performed best (area under receiver operating characteristic curve (AUC)=0.90; sensitivity 0.86; specificity 0.78). The SRS had a lower AUC (0.77) with high sensitivity (0.78) and moderate specificity (0.67). The CCC had a high sensitivity but lower specificity (AUC=0.79; sensitivity 0.93; specificity 0.46). The AUC of the SRS and CCC was lower for children with IQ < 70. Behaviour problems reduced specificity for all three instruments. Conclusions The SCQ, SRS and CCC showed strong to moderate ability to identify autistic-spectrum disorder in this at-risk sample of school-age children with special educational needs.

Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial.

Abstract: Background Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa. Aims To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa. Method Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment. Results Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes. Conclusions First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

Phenomenology of delirium. Assessment of 100 adult cases using standardised measures.

Abstract: Background Delirium phenomenology is understudied. Aims To investigate the relationship between cognitive and non-cognitive delirium symptoms and test the primacy of inattention in delirium. Method People with delirium ( n =100) were assessed using the Delirium Rating Scale–Revised–98 (DRS–R98) and Cognitive Test for Delirium (CTD). Results Sleep–wake cycle abnormalities and inattention were most frequent, while disorientation was the least frequent cognitive deficit. Patients with psychosis had either perceptual disturbances or delusions but not both. Neither delusions nor hallucinations were associated with cognitive impairments. Inattention was associated with severity of other cognitive disturbances but not with non-cognitive items. CTD comprehension correlated most closely with non-cognitive features of delirium. Conclusions Delirium phenomenology is consistent with broad dysfunction of higher cortical centres, characterised in particular by inattention and sleep–wake cycle disturbance. Attention and comprehension together are the cognitive items that best account for the syndrome of delirium. Psychosis in delirium differs from that in functional psychoses.

Mental capacity in psychiatric patients: Systematic review.

Abstract: Background Mental capacity is central to legal and ethical debates on the use of compulsion in psychiatry. Aims To describe the clinical epidemiology of mental incapacity in patients with psychiatric disorders, including interrater reliability of assessments, frequency in the psychiatric population and associations of mental incapacity. Method Cross-sectional studies of capacity to consent to treatment for psychiatric patients were systematically reviewed from Medline, EMBASE and PsycInfo databases. Information on the reliability of assessments, frequency and associations of mental incapacity was extracted. Results Out of 37 papers reviewed, 29 different capacity assessment tools were identified. Studies were highly heterogeneous in their measurement and definitions of capacity. Interrater reliabilities between tools were high. Studies indicate incapacity is common (median 29%) but the majority of psychiatric in-patients are capable of making treatment decisions. Psychosis, severity of symptoms, involuntary admission and treatment refusal were the strongest risk factors for incapacity. Conclusions Mental capacity can be reliably assessed. The majority of psychiatric in-patients have capacity, and socio-demographic variables do not have a major impact but clinical ones do.

Heroin-assisted treatment for opioid dependence: randomised controlled trial.

Abstract: Background Heroin-assisted treatment has been found to be effective for people with severe opioid dependence who are not interested in or do poorly on methadone maintenance. Aims To study heroin-assisted treatment in people on methadone who continue intravenous heroin and in those who are heroin dependent but currently not in treatment. Method In an open-label multicentre randomised controlled trial, 1015 people with heroin dependence received a variable dose of injectable heroin (n=515) or oral methadone (n=500) for 12 months. Two response criteria, improvement of physical and/or mental health and decrease in illicit drug use, were evaluated in an intent-to-treat analysis. Results Retention was higher in the heroin (67.2%) than in the methadone group (40.0%) and the heroin group showed a significantly greater response on both primary outcome measures. More serious adverse events were found in the heroin group, and were mainly associated with intravenous use. Conclusions Heroin-assisted treatment is more effective for people with opioid dependence who continue intravenous heroin while on methadone maintenance or who are not enrolled in treatment. Despite a higher risk, it should be considered for treatment resistance under medical supervision.