Showing papers in "British Journal of Psychiatry in 2011"

Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis.

Abstract: Background No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. Aims To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework. Method Systematic review and modified narrative synthesis. Results Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery. Conclusions The conceptual framework is a theoretically defensible and robust synthesis of people’s experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.

Physical health disparities and mental illness: the scandal of premature mortality.

Abstract: A 20-year mortality gap for men, and 15 years for women, is still experienced by people with mental illness in high-income countries. The combination of lifestyle risk factors, higher rates of unnatural deaths and poorer physical healthcare contribute to this scandal of premature mortality that contravenes international conventions for the ‘right to health.’

Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders

Abstract: Background People with mental disorders evince excess mortality due to natural and unnatural deaths. The relative life expectancy of people with mental disorders is a proxy measure of effectiveness of social policy and health service provision. Aims To evaluate trends in health outcomes of people with serious mental disorders. Method We examined nationwide 5-year consecutive cohorts of people admitted to hospital for mental disorders in Denmark, Finland and Sweden in 1987–2006. In each country the risk population was identified from hospital discharge registers and mortality data were retrieved from cause-of-death registers. The main outcome measure was life expectancy at age 15 years. Results People admitted to hospital for a mental disorder had a two- to threefold higher mortality than the general population in all three countries studied. This gap in life expectancy was more pronounced for men than for women. The gap decreased between 1987 and 2006 in these countries, especially for women. The notable exception was Swedish men with mental disorders. In spite of the positive general trend, men with mental disorders still live 20 years less, and women 15 years less, than the general population. Conclusions During the era of deinstitutionalisation the life expectancy gap for people with mental disorders has somewhat diminished in the three Nordic countries. Our results support further development of the Nordic welfare state model, i.e. tax-funded community-based public services and social protection. Health promotion actions, improved access to healthcare and prevention of suicides and violence are needed to further reduce the life expectancy gap.

Neurodevelopmental hypothesis of schizophrenia

Abstract: The neurodevelopmental hypothesis of schizophrenia provided a valuable framework that allowed a condition that usually presents with frank disorder in adolescence or early adulthood to be understood at least in part as a consequence of events occurring early in development. However, the implications of the neurodevelopmental hypothesis for nosological conceptions of the disorder can only now be fully appreciated. Recent research indicates genetic overlap between schizophrenia and syndromes in which psychopathology is manifest in childhood and that are often grouped together as ‘ neurodevelopmental disorders’ such as autism-spectrum disorders, intellectual disability and attention-deficit hyperactivity disorder. These findings challenge the aetiological basis of current diagnostic categories and, together with evidence for frequent comorbidity, suggest that we should view the functional psychoses as members of a group of related and overlapping syndromes that result in part from a combination of genetic and environmental effects on brain development and that are associated with specific and general impairments of cognitive function. This has important implications for future research and for the configuration of psychiatric services.

Disease-modifying properties of long-term lithium treatment for amnestic mild cognitive impairment: randomised controlled trial

Abstract: Background Two recent clinical studies support the feasibility of trials to evaluate the disease-modifying properties of lithium in Alzheimer’s disease, although no benefits were obtained from short-term treatment. Aims To evaluate the effect of long-term lithium treatment on cognitive and biological outcomes in people with amnestic mild cognitive impairment (aMCI). Method Forty-five participants with aMCI were randomised to receive lithium (0.25–0.5 mmol/l) (n = 24) or placebo (n = 21) in a 12-month, double-blind trial. Primary outcome measures were the modification of cognitive and functional test scores, and concentrations of cerebrospinal fluid (CSF) biomarkers (amyloid-beta peptide (Aβ42), total tau (T-tau), phosphorylated-tau) (P-tau). Trial registration: [NCT01055392][1]. Results Lithium treatment was associated with a significant decrease in CSF concentrations of P-tau (P = 0.03) and better perform-ance on the cognitive subscale of the Alzheimer’s Disease Assessment Scale and in attention tasks. Overall tolerability of lithium was good and the adherence rate was 91%. Conclusions The present data support the notion that lithium has disease-modifying properties with potential clinical implications in the prevention of Alzheimer’s disease. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01055392&atom=%2Fbjprcpsych%2F198%2F5%2F351.atom

Biogenetic explanations and public acceptance of mental illness: systematic review of population studies

Abstract: Background Biological or genetic models of mental illness are commonly expected to increase tolerance towards people with mental illness, by reducing notions of responsibility and blame. Aims To investigate whether biogenetic causal attributions of mental illness among the general public are associated with more tolerant attitudes, whether such attributions are related to lower perceptions of guilt and responsibility, to what extent notions of responsibility are associated with rejection of people who are mentally ill, and how prevalent notions of responsibility are among the general public with regard to different mental disorders. Method A systematic review was conducted of representative population studies examining attitudes towards people with mental illness and beliefs about such disorders. Results We identified 33 studies relevant to this review. Generally, biogenetic causal attributions were not associated with more tolerant attitudes; they were related to stronger rejection in most studies examining schizophrenia. No published study reported on associations of biogenetic causal attributions and perceived responsibility. The stereotype of self-responsibility was unrelated to rejection in most studies. Public images of mental disorder are generally dominated by the stereotypes of unpredictability and dangerousness, whereas responsibility is less relevant. Conclusions Biogenetic causal models are an inappropriate means of reducing rejection of people with mental illness.

Individual music therapy for depression: randomised controlled trial

Abstract: Background Music therapy has previously been found to be effective in the treatment of depression but the studies have been methodologically insufficient and lacking in clarity about the clinical model employed. Aims To determine the efficacy of music therapy added to standard care compared with standard care only in the treatment of depression among working-age people. Method Participants (n = 79) with an ICD–10 diagnosis of depression were randomised to receive individual music therapy plus standard care (20 bi-weekly sessions) or standard care only, and followed up at baseline, at 3 months (after intervention) and at 6 months. Clinical measures included depression, anxiety, general functioning, quality of life and alexithymia. Trial registration: [ISRCTN84185937][1]. Results Participants receiving music therapy plus standard care showed greater improvement than those receiving standard care only in depression symptoms (mean difference 4.65, 95% CI 0.59 to 8.70), anxiety symptoms (1.82, 95% CI 0.09 to 3.55) and general functioning (–4.58, 95% CI –8.93 to –0.24) at 3-month follow-up. The response rate was significantly higher for the music therapy plus standard care group than for the standard care only group (odds ratio 2.96, 95% CI 1.01 to 9.02). Conclusions Individual music therapy combined with standard care is effective for depression among working-age people with depression. The results of this study along with the previous research indicate that music therapy with its specific qualities is a valuable enhancement to established treatment practices. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN84185937

Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial

Abstract: Background About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive-behavioural therapy (CBT). Aims To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression. Method Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered ([ISRCTN22782150][1]). Results Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination. Conclusions This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v . non-specific therapy effects. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN22782150

Treatment of suicidal people around the world

Abstract: Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment. Conclusions Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking. Declaration of interest

Creativity and mental disorder: family study of 300 000 people with severe mental disorder

Abstract: Background There is a long-standing belief that creativity is coupled with psychopathology. Aims To test this alleged association and to investigate whether any such association is the result of environmental or genetic factors. Method We performed a nested case–control study based on Swedish registries. The likelihood of holding a creative occupation in individuals who had received in-patient treatment for schizophrenia, bipolar disorder or unipolar depression between 1973 and 2003 and their relatives without such a diagnosis was compared with that of controls. Results Individuals with bipolar disorder and healthy siblings of people with schizophrenia or bipolar disorder were overrepresented in creative professions. People with schizophrenia had no increased rate of overall creative professions compared with controls, but an increased rate in the subgroup of artistic occupations. Neither individuals with unipolar depression nor their siblings differed from controls regarding creative professions. Conclusions A familial cosegregation of both schizophrenia and bipolar disorder with creativity is suggested.

Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England

Abstract: Background A number of studies in a range of samples attest a link between childhood sexual abuse and psychosis. Aims To use data from a large representative general population sample (Adult Psychiatric Morbidity Survey 2007) to test hypotheses that childhood sexual abuse is linked to psychosis, and that the relationship is consistent with mediation by revictimisation experiences, heavy cannabis use, anxiety and depression. Method The prevalence of psychosis was established operationally in a representative cross-sectional survey of the adult household population of England ( n = 7353). Using computer-assisted self-interview, a history of various forms of sexual abuse was established, along with the date of first abuse. Results Sexual abuse before the age of 16 was strongly associated with psychosis, particularly if it involved non-consensual sexual intercourse (odds ratio (OR) = 10.14, 95% CI 4.8–21.3, population attributable risk fraction 14%). There was evidence of partial mediation by anxiety and depression, but not by heavy cannabis use nor revictimisation in adulthood. Conclusions The association between childhood sexual abuse and psychosis was large, and may be causal. These results have important implications for the nature and aetiology of psychosis, for its treatment and for primary prevention.

Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis

Abstract: Background Dose–effect relationship data suggest that short-term psychotherapy is insufficient for many patients with chronic distress or personality disorders (complex mental disorders). Aims To examine the comparative efficacy of long-term psychodynamic psychotherapy (LTPP) in complex mental disorders. Method We conducted a meta-analysis of controlled trials of LTPP fulfilling the following inclusion criteria: therapy lasting for at least a year or 50 sessions; active comparison conditions; prospective design; reliable and valid outcome measures; treatments terminated. Ten studies with 971 patients were included. Results Between-group effect sizes in favour of LTPP compared with less intensive (lower dose) forms of psychotherapy ranged between 0.44 and 0.68. Conclusions Results suggest that LTPP is superior to less intensive forms of psychotherapy in complex mental disorders. Further research on long-term psychotherapy is needed, not only for psychodynamic psychotherapy, but also for other therapies.

The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors.

Abstract: Here we revisit and reinterpret the original study in which the so-called ‘Maudsley (London) model’ of family therapy was compared with individual therapy for anorexia nervosa. Family therapy was more effective in adolescents with a short duration of illness. However, this is only part of the story. A later study describing the 5-year outcome contains important information. Those adolescents randomised to family therapy achieved a better outcome 5 years later. Moreover, the group with an onset in adolescence but who had been ill for over 3 years had a poor response to both family and individual therapy, suggesting that unless effective treatment is given within the first 3 years of illness onset, the outcome is poor. We examine other evidence supporting this conclusion and consider the developmental and neurobiological factors that can account for this.

Childhood eating disorders: British national surveillance study*

Abstract: Background The incidence of eating disorders appears stable overall, but may be increasing in younger age groups. Data on incidence, clinical features and outcome of early-onset eating disorders are sparse. Aims To identify new cases of early-onset eating disorders ( 8 months. A total of 50% were admitted to hospital, typically soon after diagnosis. Outcome data were available for 76% of individuals. At 1 year, 73% were reported improved, 6% worse and 10% unchanged (11% unknown). Most were still in treatment, and seven were hospital in-patients for most of the year. Conclusions Childhood eating disorders represent a significant clinical burden to paediatric and mental health services. Efforts to improve early detection are needed. These data provide a baseline to monitor changing trends in incidence.

Cannabis use before age 15 and subsequent executive functioning.

Abstract: Background Many studies have suggested that adolescence is a period of particular vulnerability to neurocognitive effects associated with substance misuse. However, few large studies have measured differences in cognitive performance between chronic cannabis users who started in early adolescence (before age 15) with those who started later. Aims To examine the executive functioning of individuals who started chronic cannabis use before age 15 compared with those who started chronic cannabis use after 15 and

Mental health of the non-heterosexual population of England.

Abstract: BACKGROUND: There has been little research into the prevalence of mental health problems in lesbian, gay and bisexual (LGB) people in the UK with most work conducted in the USA. AIMS: To relate the prevalence of mental disorder, self-harm and suicide attempts to sexual orientation in England, and to test whether psychiatric problems were associated with discrimination on grounds of sexuality. METHOD: The Adult Psychiatric Morbidity Survey 2007 (n = 7403) was representative of the population living in private UK households. Standardised questions provided demographic information. Neurotic symptoms, common mental disorders, probable psychosis, suicidality, alcohol and drug dependence and service utilisation were assessed. In addition, detailed information was obtained about aspects of sexual identity and perceived discrimination on these grounds. RESULTS: Self-reported identification as non-heterosexual (determined by both orientation and sexual partnership, separately) was associated with unhappiness, neurotic disorders overall, depressive episodes, generalised anxiety disorder, obsessive-compulsive disorder, phobic disorder, probable psychosis, suicidal thoughts and acts, self-harm and alcohol and drug dependence. Mental health-related general practitioner consultations and community care service use over the previous year were also elevated. In the non-heterosexual group, discrimination on the grounds of sexual orientation predicted certain neurotic disorder outcomes, even after adjustment for potentially confounding demographic variables. CONCLUSIONS: This study corroborates international findings that people of non-heterosexual orientation report elevated levels of mental health problems and service usage, and it lends further support to the suggestion that perceived discrimination may act as a social stressor in the genesis of mental health problems in this population. Language: en

Epilepsy in autism: features and correlates

Abstract: Background Epilepsy occurs in a significant minority of individuals with autism, but few long-term follow-up studies have been reported, so the prevalence, features (type of seizures, age at onset and severity, etc.) and correlates (IQ history of regression, family history) have only partially been identified. Aims To undertake a long-term follow-up study of individuals with autism in order to better characterise the features and correlates of epilepsy in individuals with autism. Method One hundred and fifty individuals diagnosed with autism in childhood were followed up when they were 21+ years of age. All individuals were screened for a history of possible seizures by parental/informant questionnaire. An epilepsy interview was undertaken and medical notes reviewed for individuals with a history of possible seizures. The features and correlates of epilepsy were examined using survival and regression analysis. Results Epilepsy developed in 22% of participants. In the majority, seizures began after 10 years of age. Generalised tonic–clonic seizures predominated (88%). In over a half (19/33), seizures occurred weekly or less frequently and in the majority of individuals (28/31) they were controlled with the prescription of one to two anticonvulsants. Epilepsy was associated with gender (female), intellectual disability and poorer verbal abilities. Although the presence of epilepsy in the probands was not associated with an increased risk of epilepsy in their relatives, it was associated with the presence of the broader autism phenotype in relatives. This indicates that the familial liability to autism was associated with the risk for epilepsy in the proband. Conclusions Epilepsy is an important medical complication that develops in individuals with autism. Seizures may first begin in adolescence or adulthood. Putative risk factors for epilepsy in autism were identified and these will require further investigation in future studies.

Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months

Abstract: This paper has been corrected post-publication in deviation from print and in accordance with a correction printed in the February 2012 issue of the Journal. Background Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare. Aims To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders. Method Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with [clinicaltrials.gov][1] ([NCT00446407][2]). Results A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities. Conclusions Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities. [1]: http://clinicaltrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00446407&atom=%2Fbjprcpsych%2F199%2F6%2F459.atom

Previous prenatal loss as a predictor of perinatal depression and anxiety

Abstract: Background Prenatal loss, the death of a fetus/child through miscarriage or stillbirth, is associated with significant depression and anxiety, particularly in a subsequent pregnancy. Aims This study examined the degree to which symptoms of depression and anxiety associated with a previous loss persisted following a subsequent successful pregnancy. Method Data were derived from the Avon Longitudinal Study of Parents and Children cohort, a longitudinal cohort study in the west of England that has followed mothers from pregnancy into the postnatal period. A total of 13 133 mothers reported on the number and conditions of previous perinatal losses and provided self-report measures of depression and anxiety at 18 and 32 weeks’ gestation and at 8 weeks and 8, 21 and 33 months postnatally. Controls for pregnancy outcome and obstetric and psychosocial factors were included. Results Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (β = 0.18, s.e. = 0.07, P <0.01) and anxiety (β = 0.14, s.e. = 0.05, P <0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child. Conclusions Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study

Abstract: Background Mental health service users are at high risk of domestic violence but this is often not detected by mental health services. Aims To explore the facilitators and barriers to disclosure of domestic violence from a service user and professional perspective. Method A qualitative study in a socioeconomically deprived south London borough, UK, with 18 mental health service users and 20 mental health professionals. Purposive sampling of community mental health service users and mental healthcare professionals was used to recruit participants for individual interviews. Thematic analysis was used to determine dominant and subthemes. These were transformed into conceptual maps with accompanying illustrative quotations. Results Service users described barriers to disclosure of domestic violence to professionals including: fear of the consequences, including fear of Social Services involvement and consequent child protection proceedings, fear that disclosure would not be believed, and fear that disclosure would lead to further violence; the hidden nature of the violence; actions of the perpetrator; and feelings of shame. The main themes for professionals concerned role boundaries, competency and confidence. Service users and professionals reported that the medical diagnostic and treatment model with its emphasis on symptoms could act as a barrier to enquiry and disclosure. Both groups reported that enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional. Conclusions Mental health services are not currently conducive to the disclosure of domestic violence. Training of professionals in how to address domestic violence to increase their confidence and expertise is recommended.

Guidelines for screening and monitoring of cardiometabolic risk in schizophrenia: systematic evaluation

Abstract: Background Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia. Aims To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia. Method Systematic review and quality assessment of guidelines/recommendations for cardiovascular risk in people with schizophrenia published between 2000 and 2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE). Results The AGREE domain scores varied between the 18 identified guidelines. Most guidelines scored best on the domains ‘scope and purpose’ and ‘clarity of presentation’. The domain ‘rigour of development’ was problematic in most guidelines, and the domains ‘stakeholder involvement’ and ‘editorial independence’ scored the lowest. The following measurements were recommended (in order of frequency): fasting glucose, body mass index, fasting triglycerides, fasting cholesterol, waist, high-density lipoprotein/low-density lipoprotein, blood pressure and symptoms of diabetes. In terms of interventions, most guidelines recommended advice on physical activity, diet, psychoeducation of the patient, treatment of lipid abnormalities, treatment of diabetes, referral for advice and treatment, psychoeducation of the family and smoking cessation advice. Compared across all domains and content, four European guidelines could be recommended. Conclusions Four of the evaluated guidelines are of good quality and should guide clinicians' screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement.

Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis.

Abstract: Most patients with depressive symptoms do not reach the minimum diagnostic criteria for major depression, and are described as having minor or subsyndromal or subthreshold depression.1 For subthreshold depression, different definitions based on the number of depressive symptoms, duration of symptoms, exclusion criteria and associated functional impairment have been proposed.2 Judd and colleagues defined the category subsyndromal symptomatic depression as ‘any two or more simultaneous symptoms of depression, present for most or all of the time, at least two weeks in duration, associated with evidence of social dysfunction, occurring in individuals who do not meet criteria for diagnoses of major depression and/or dysthymia’.3,4 The public health importance of minor depression has been highlighted, with reported rates varying according to the definition used: 2.5–9.9% in community samples or 5–16% in primary care patients.3,5,6 Minor depression is associated with psychological suffering, significant decrements in health, significant impairment in daily living activities and with a considerable impact on quality of life.7–10 Minor depression is also a strong risk factor for major depression, which develops in 10–25% of patients with subthreshold depression within 1–3 years.11 Additionally, minor depression might increase the risk of death in older individuals.12 Under ordinary circumstances, patients with depressive symptoms, but not major depression or dysthymia, have been frequently treated with antidepressants and benzodiazepines.13–18 In the province of Alberta, Canada, for example, more than 67% of a community sample of individuals receiving antidepressants did not have any psychiatric diagnosis, but reported, as the main reasons for taking these medicines, depressive symptoms, stress, sleep problems, anxiety or headache.13 In Europe, a cross-sectional population-based study conducted in Belgium, France, Germany, Italy, The Netherlands and Spain found that nearly 10% of individuals without any episode of major depression currently used either or both antidepressants and benzodiazepines. In this study, seeking help for emotional problems appeared to be a more important predictor for the use of antidepressants or benzodiazepines than a formal diagnosis of major depression.14 The use of antidepressants and benzodiazepines in minor depression has been explored by narrative reviews that concluded that antidepressants may have a small to moderate benefit in patients with this condition,19,20 and that benzodiazepines seem to have some effect on anxiety rather than depressive symptoms.21 The literature searches of these reviews, however, were last updated in 2001, and therefore did not include studies published thereafter. In the present systematic review we sought to determine the efficacy and acceptability of pharmacological treatments for patients with minor depression.

Behavioural activation delivered by the non-specialist: phase II randomised controlled trial

Abstract: Background Behavioural activation appears as effective as cognitive–behaviour therapy (CBT) in the treatment of depression. If equally effective, then behavioural activation may be the preferred treatment option because it may be suitable for delivery by therapists with less training. This is the first randomised controlled trial to look at this possibility. Aims To examine whether generic mental health workers can deliver effective behavioural activation as a step-three high-intensity intervention. Method A randomised controlled trial ([ISRCTN27045243][1]) comparing behavioural activation ( n = 24) with treatment as usual ( n = 23) in primary care. Results Intention-to-treat analyses indicated a difference in favour of behavioural activation of –15.79 (95% CI –24.55 to –7.02) on the Beck Depression Inventory–II and Work and Social Adjustment Scale (mean difference –11.12, 95% CI –17.53 to –4.70). Conclusions Effective behavioural activation appears suitable for delivery by generic mental health professionals without previous experience as therapists. Large-scale trial comparisons with an active comparator (CBT) are needed. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN27045243

Abortion and mental health: quantitative synthesis and analysis of research published 1995–2009

Abstract: Background Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians. Aims To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome. Method After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios. Results Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour. Conclusions This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

Sleep-wake cycles and cognitive functioning in schizophrenia

Abstract: Background Irregular sleep–wake cycles and cognitive impairment are frequently observed in schizophrenia, however, how they interact remains unclear. Aims To investigate the repercussions of circadian rhythm characteristics on cognitive performance and psychopathology in individuals with schizophrenia. Method Fourteen middle-aged individuals diagnosed with schizophrenia underwent continuous wrist actimetry monitoring in real-life settings for 3 weeks, and collected saliva samples to determine the onset of endogenous melatonin secretion as a circadian phase marker. Moreover, participants underwent multiple neuropsychological testing and clinical assessments throughout the study period. Results Sleep–wake cycles in individuals with schizophrenia ranged from well entrained to highly disturbed rhythms with fragmented sleep epochs, together with delayed melatonin onsets and higher levels of daytime sleepiness. Participants with a normal rest–activity cycle (objectively determined by high relative amplitude of day/night activity) performed significantly better in frontal lobe function tasks. Stepwise regression analysis revealed that relative amplitude and age represented the best predictors for cognitive performance (Stroop colour–word interference task, Trail Making Test A and B, semantic verbal fluency task), whereas psychopathology (Positive and Negative Syndrome Scale) did not significantly correlate with either cognitive performance levels or the quality of sleep–wake cycles. Conclusions Consolidated circadian rhythms and sleep may be a prerequisite for adequate cognitive functioning in individuals with schizophrenia.

Internet-based cognitive–behavioural therapy for severe health anxiety: randomised controlled trial

Abstract: Background Hypochondriasis, characterised by severe health anxiety, is a common condition associated with functional disability. Cognitive–behavioural therapy (CBT) is an effective but not widely disseminated treatment for hypochondriasis. Internetbased CBT, including guidance in the form of minimal therapist contact via email, could be a more accessible treatment, but no study has investigated internet-based CBT for hypochondriasis. Aims To investigate the efficacy of internet-based CBT for hypochondriasis. Method A randomised controlled superiority trial with masked assessment comparing internet-based CBT (n = 40) over 12 weeks with an attention control condition (n = 41) for people with hypochondriasis. The primary outcome measure was the Health Anxiety Inventory. This trial is registrated with ClinicalTrials.gov (NCT00828152). Results Participants receiving internet-based CBT made large and superior improvements compared with the control group on measures of health anxiety (between-group Cohen’s d range

Advanced dental disease in people with severe mental illness: systematic review and meta-analysis

Abstract: Background Psychiatric patients have increased comorbid physical illness. There is less information concerning dental disease in this population in spite of risk factors including diet and psychotropic side-effects (such as xerostomia). Aims To compare the oral health of people with severe mental illness with that of the general population. Method A systematic search for studies from the past 20 years was conducted using Medline, PsycINFO, Embase and article bibliographies. Papers were independently assessed. The primary outcome was total tooth loss (edentulousness), the end-stage of both untreated caries and periodontal disease. We also assessed dental decay through standardised measures: the mean number of decayed, missing and filled teeth (DMFT) or surfaces (DMFS). For studies lacking a control group we used controls of similar ages from a community survey within 10 years of the study. Results We identified 21 papers of which 14 had sufficient data (n = 2784 psychiatric patients) and suitable controls (n = 31 084) for a random effects meta-analysis. People with severe mental illness had 3.4 times the odds of having lost all their teeth than the general community (95% CI 1.6-7.2). They also had significantly higher scores for DMFT (mean difference 6.2, 95% CI 0.6-11.8) and DMFS (mean difference 14.6, 95% CI 4.1-25.1). Fluoridated water reduced the gap in oral health between psychiatric patients and the general population. Conclusions Psychiatric patients have not shared in the improving oral health of the general population. Management should include oral health assessment using standard checklists that can be completed by non-dental personnel. Interventions include oral hygiene and management of xerostomia.

Neuropathological correlates of late-life depression in older people

Abstract: Background Depression is common in old age and is associated with risk of dementia, but its neuropathological correlates in the community are unknown. Aims To investigate for the first time in a population-representative sample of people with no dementia the association between depression observed during life and neurofibrillary tangles, diffuse and neuritic plaques, Lewy bodies, brain atrophy and cerebrovascular disease found in the brain at post-mortem. Method Out of 456 donations to a population-based study, 153 brains were selected where donors had no dementia measured in life. Alzheimer and vascular pathology measures, Lewy bodies and neuronal loss were compared between those with ( n = 36) and without ( n = 117) depression ascertained using a fully structured diagnostic interview during life. Brain areas examined included frontal, parietal, temporal and occipital cortical areas as well as the entorhinal cortex, hippocampus and brain-stem monoaminergic nuclei. Results Depression was significantly associated with the presence of subcortical Lewy bodies. No association was found between depression and cerebrovascular or Alzheimer pathology in cortical or subcortical areas, although depression was associated with neuronal loss in the hippocampus as well as in some of the subcortical structures investigated (nucleus basalis, substantia nigra, raphe nucleus). Conclusions Late-life depression was associated with subcortical and hippocampal neuronal loss but not with cerebrovascular or Alzheimer pathology.

Eating disorders, DSM–5 and clinical reality

Abstract: The DSM–IV scheme for classifying eating disorders is a poor reflection of clinical reality. In adults it recognises two conditions, anorexia nervosa and bulimia nervosa, yet these states are merely two presentations among many. As a consequence, at least half the cases seen in clinical practice are relegated to the residual diagnosis ‘eating disorder not otherwise specified’. The changes proposed for DSM–5 will only partially succeed in correcting this shortcoming. With DSM–6 in mind, it is clear that comprehensive transdiagnostic samples need to be studied with data collected on their current state, course and response to treatment. Only with such data will it be possible to derive an empirically based classificatory scheme that is both rooted in clinical reality and of value to clinicians.

Longitudinal neuroimaging correlates of subjective memory impairment: 4-year prospective community study.

Abstract: Background Complaints about memory are common in older people but their relationship with underlying brain changes is controversial. Aims To investigate the relationship between subjective memory impairment and previous or subsequent changes in white matter lesions and brain volumes. Method In a community cohort study of 1336 people without dementia, 4-year changes in brain magnetic resonance imaging measures were investigated as correlates of subjective memory impairment at baseline and follow-up. Results Subjective memory impairment at baseline was associated with subsequent change in hippocampal volume and at follow-up impairment was associated with previous change in hippocampal, cerebrospinal fluid and grey matter volume and with subcortical white matter lesion increases. All associations with volume changes were U-shaped with significant quadratic terms – associations between least decline and subjective memory impairment were potentially explained by lower baseline hippocampal volumes in the groups with least volume change. Associations between hippocampal volume change and subjective memory impairment at follow-up were independent of cognitive decline and depressive symptoms, they were stronger in participants with the apolipoprotein E (APOE) ϵ4 allele and in those without baseline subjective memory impairment. Conclusions Complaints of poor memory by older people, particularly when new, may be a realistic subjective appraisal of recent brain changes independent of observed cognitive decline.