Showing papers in "British Journal of Psychiatry in 2013"

Late-life depression and risk of vascular dementia and Alzheimer’s disease: systematic review and meta-analysis of community-based cohort studies

Abstract: Background Late-life depression may increase the risk of incident dementia, in particular of Alzheimer’s disease and vascular dementia. Aims To conduct a systematic review and meta-analysis to evaluate the risk of incident all-cause dementia, Alzheimer’s disease and vascular dementia in individuals with late-life depression in population-based prospective studies. Method A total of 23 studies were included in the meta-analysis. We used the generic inverse variance method with a random-effects model to calculate the pooled risk of dementia, Alzheimer’s disease and vascular dementia in older adults with late-life depression. Results Late-life depression was associated with a significant risk of all-cause dementia (1.85, 95% CI 1.67-2.04, P <0.001), Alzheimer’s disease (1.65, 95% CI 1.42-1.92, P <0.001) and vascular dementia (2.52, 95% CI 1.77-3.59, P <0.001). Subgroup analysis, based on five studies, showed that the risk of vascular dementia was significantly higher than for Alzheimer’s disease ( P = 0.03). Conclusions Late-life depression is associated with an increased risk for all-cause dementia, vascular dementia and Alzheimer’s disease. The present results suggest that it will be valuable to design clinical trials to investigate the effect of late-life depression prevention on risk of dementia, in particular vascular dementia and Alzheimer’s disease.

Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis

Abstract: Background Depression after stroke is a distressing problem that may be associated with other negative health outcomes. Aims To estimate the natural history, predictors and outcomes of depression after stroke. Method Studies published up to 31 August 2011 were searched and reviewed according to accepted criteria. Results Out of 13 558 references initially found, 50 studies were included. Prevalence of depression was 29% (95% CI 25–32), and remains stable up to 10 years after stroke, with a cumulative incidence of 39–52% within 5 years of stroke. The rate of recovery from depression among patients depressed a few months after stroke ranged from 15 to 57% 1 year after stroke. Major predictors of depression are disability, depression pre-stroke, cognitive impairment, stroke severity and anxiety. Lower quality of life, mortality and disability are independent outcomes of depression after stroke. Conclusion Interventions for depression and its potential outcomes are required.

Vitamin D deficiency and depression in adults: systematic review and meta-analysis

Abstract: Background There is conflicting evidence about the relationship between vitamin D deficiency and depression, and a systematic assessment of the literature has not been available. Aims To determine the relationship, if any, between vitamin D deficiency and depression. Method A systematic review and meta-analysis of observational studies and randomised controlled trials was conducted. Results One case–control study, ten cross-sectional studies and three cohort studies with a total of 31 424 participants were analysed. Lower vitamin D levels were found in people with depression compared with controls (SMD = 0.60, 95% CI 0.23–0.97) and there was an increased odds ratio of depression for the lowest v . highest vitamin D categories in the cross-sectional studies (OR = 1.31, 95% CI 1.0–1.71). The cohort studies showed a significantly increased hazard ratio of depression for the lowest v . highest vitamin D categories (HR = 2.21, 95% CI 1.40–3.49). Conclusions Our analyses are consistent with the hypothesis that low vitamin D concentration is associated with depression, and highlight the need for randomised controlled trials of vitamin D for the prevention and treatment of depression to determine whether this association is causal.

Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK.

Abstract: Despite the evidence showing that young people aged 12-25 years have the highest incidence and prevalence of mental illness across the lifespan, and bear a disproportionate share of the burden of disease associated with mental disorder, their access to mental health services is the poorest of all age groups. A major factor contributing to this poor access is the current design of our mental healthcare system, which is manifestly inadequate for the unique developmental and cultural needs of our young people. If we are to reduce the impact of mental disorder on this most vulnerable population group, transformational change and service redesign is necessary. Here, we present three recent and rapidly evolving service structures from Australia, Ireland and the UK that have each worked within their respective healthcare contexts to reorient existing services to provide youth-specific, evidence-based mental healthcare that is both accessible and acceptable to young people.

Effectiveness of the Mindfulness in Schools Programme: non-randomised controlled feasibility study.

Abstract: Background Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness among young people. Aims To assess the acceptability and efficacy of a schools-based universal mindfulness intervention to enhance mental health and well-being. Method A total of 522 young people aged 12-16 in 12 secondary schools either participated in the Mindfulness in Schools Programme (intervention) or took part in the usual school curriculum (control). Results Rates of acceptability were high. Relative to the controls, and after adjusting for baseline imbalances, children who participated in the intervention reported fewer depressive symptoms post-treatment ( P = 0.004) and at follow-up ( P = 0.005) and lower stress ( P = 0.05) and greater well-being ( P = 0.05) at follow-up. The degree to which students in the intervention group practised the mindfulness skills was associated with better well-being ( P <0.001) and less stress ( P = 0.03) at 3-month follow-up. Conclusions The findings provide promising evidence of the programme’s acceptability and efficacy.

Non-suicidal self-injury v. attempted suicide: new diagnosis or false dichotomy?

Abstract: Non-suicidal self-injury (NSSI) is a term that is becoming popular especially in North America and it has been proposed as a new diagnosis in DSM-5. In this paper we consider what self-harm research can tell us about the concept of NSSI and examine the potential pitfalls of introducing NSSI into clinical practice.

The past and future of delusions research: from the inexplicable to the treatable.

Abstract: Background Problems with the diagnosis and treatment of schizophrenia have led for a call to change strategy and focus on individual psychotic experiences. In recent years, research on delusions has led the way. Aims To update our 1999 review of almost 40 studies on delusions. Method A systematic literature search was conducted of reasoning and affective processes related to delusions. Results Over 200 studies were identified. The presence of ‘jumping to conclusions’ in individuals with delusions has been substantiated, the theory of mind account has not stood up to subsequent testing, and there is a promising new focus on the ways that affective processes contribute to delusional experience. Conclusions Theoretical work rendering delusions understandable can be translated into treatment; future clinical trials should focus on individual psychotic experiences as outcomes.

Suicide by occupation: systematic review and meta-analysis

Abstract: Background Previous research has shown that those employed in certain occupations, such as doctors and farmers, have an elevated risk of suicide, yet little research has sought to synthesise these findings across working-age populations. Aims To summarise published research in this area through systematic review and meta-analysis. Method Random effects meta-analyses were used to calculate a pooled risk of suicide across occupational skill-level groups. Results Thirty-four studies were included in the meta-analysis. Elementary professions (e.g. labourers and cleaners) were at elevated risk compared with the working-age population (rate ratio (RR) = 1.84, 95% CI 1.46-2.33), followed by machine operators and deck crew (RR = 1.78, 95% CI 1.22-2.60) and agricultural workers (RR = 1.64, 95% CI 1.19-2.28). Results suggested a stepwise gradient in risk, with the lowest skilled occupations being at greater risk of suicide than the highest skill-level group. Conclusions This is the first comprehensive meta-analytical review of suicide and occupation. There is a need for future studies to investigate explanations for the observed skill-level differences, particularly in people employed in lower skill-level groups.

Affective disorders and risk of developing dementia: systematic review

Abstract: Background Affective disorders are associated with cognitive disturbances but their role as risk factors for dementia is still not fully investigated. Aims To evaluate the risk of developing dementia in individuals with a history of affective disorder. Method We conducted a systematic review of case–control and cohort studies addressing the risk of developing dementia in people with affective disorders. To the best of our knowledge, this is the first systematic review that has included studies evaluating this risk specifically in people with bipolar disorder. Results Fifty-one studies were included. Most of the studies found an increased risk for developing dementia in individuals with depression. Greater frequency and severity of depressive episodes seem to increase this risk. The evidence is contradictory regarding whether there is a difference in risk in people with early- or late-onset depression. The few available risk estimates for dementia in people with bipolar disorder suggest an even higher risk than for those with depression. Conclusions Affective disorders appear to be associated with an increased risk of developing dementia, and one that is dependent on clinical and demographic variables. Depression may be both a prodrome and a risk factor for dementia. Future research should aim to elucidate the mechanisms that mediate these links.

Attitudes towards psychiatric treatment and people with mental illness: changes over two decades

Abstract: Background Over the past decades, psychiatry, as a science and a clinical discipline, has witnessed profound changes. Aims To examine whether these changes are reflected in changes in the public’s conceptualisation of mental disorders, the acceptance of mental health treatment and attitudes towards people with mental illness. Method In 1990 and 2011, population surveys were conducted in Germany on public attitudes about schizophrenia, depression and alcohol dependence. Results Although the public has become more inclined to endorse a biological causation of schizophrenia, the opposite trend was observed with the other two disorders. The public’s readiness to recommend help-seeking from mental health professionals and using psychotherapy and psychotropic medication has increased considerably. Attitudes towards people with schizophrenia worsened, whereas for depression and alcohol dependence no or inconsistent changes were found. Conclusions The growing divide between attitudes towards schizophrenia and other mental disorders should be of particular concern to future anti-stigma campaigns.

Differential mortality rates in major and subthreshold depression: meta-analysis of studies that measured both

Abstract: Background Although the association between depression and excess mortality has been well established, it is not clear whether this is greater in major depression than in subthreshold depression. Aims To compare excess mortality in major depression with that in subthreshold depression. Method We searched bibliographic databases and included prospective studies in which both major and subthreshold depression were examined at baseline and mortality was measured at follow-up. Results A total of 22 studies were included. People with major depression had a somewhat increased chance of dying earlier than people with subthreshold depression but this difference was not significant, although there was a trend (relative risk 1.13, 95% CI 0.98-1.30, P=0.1). The population attributable fraction was 7% for major depression and an additional 7% for subthreshold depression. Conclusions Although excess mortality may be somewhat higher in major than in subthreshold depression, the difference is small and the overall impact on excess mortality is comparable.

Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009-2012

Abstract: Background Public stigma against people with mental health problems is damaging to individuals with mental illness and is associated with substantial societal burden. Aims To investigate whether public knowledge, attitudes and behaviour in relation to people with mental health problems have improved among the English population since the inception of the Time To Change programme in 2009. Method We analysed longitudinal trends in public knowledge, attitudes and behaviour between 2009 and 2012 among a nationally representative sample of English adults. Results There were improvements in intended behaviour (0.07 standard deviation units, 95% CI 0.01-0.14) and a non-significant trend for improvement in attitudes ( P = 0.08) among the English population. There was, however, no significant improvement in knowledge or reported behaviour. Conclusions The findings provide support for effectiveness of the national Time to Change programme against stigma and discrimination in improving attitudes and intended behaviour, but not knowledge, among the public in England.

Prevention and early intervention for borderline personality disorder: current status and recent evidence.

Abstract: Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.

Clinical staging in psychiatry: a cross-cutting model of diagnosis with heuristic and practical value

Abstract: Staging models are used routinely in general medicine for potentially serious or chronic physical disorders such as diabetes, arthritis and cancers, describing the links between biomarkers, clinical phenotypes and disease extension, and promoting a personalised or stratified medicine approach to treatment planning. Clinical staging involves a detailed description of where an individual exists on a continuum of disorder progression from stage 0 (an at-risk or latency stage) through to stage IV (late or end-stage disease). The approach is popular owing to its clinical utility and is increasingly being applied in psychiatry. The concept offers an informed approach to research and the active promotion of indicated prevention and early intervention strategies. We suggest that for young persons with emerging bipolar disorder, such transdiagnostic staging models could provide a framework that better reflects the developmental psychopathology and matches the complex longitudinal inter-relationships between subsyndromal and syndromal mood, psychotic and other disorders.

Impact of patient involvement in mental health research: longitudinal study

Abstract: Background It is deemed good practice to involve patients routinely in research but no study has investigated the practical benefits, particularly to successful recruitment. Aims To identify whether patient involvement is associated with study success. Method All studies listed on the Mental Health Research Network (MHRN) portfolio database ( n = 374) were interrogated using logistic regression, ANOVA and Pearson’s correlation to identify associations with study characteristics, funding bodies and recruitment success. Results Patient involvement increased over time although in some areas of research it was limited. Some funders, especially the National Institute for Health Research (NIHR), had more associated patient involvement than others. Studies that involved patients to a greater extent were more likely to have achieved recruitment targets (χ2 = 4.58, P <0.05), defined as reaching at least 90% of the target. Conclusions This is the first time associations with study success have been identified for patient involvement. Researchers might now consider ways to involve patients more comprehensively as this is associated with study success. Further research is needed to explore this finding.

Transitional interventions to reduce early psychiatric readmissions in adults: systematic review

Abstract: Background Up to 13% of psychiatric patients are readmitted shortly after discharge. Interventions that ensure successful transitions to community care may play a key role in preventing early readmission. Aims To describe and evaluate interventions applied during the transition from in-patient to out-patient care in preventing early psychiatric readmission. Method Systematic review of transitional interventions among adults admitted to hospital with mental illness where the study outcome was psychiatric readmission. Results The review included 15 studies with 15 non-overlapping intervention components. Absolute risk reductions of 13.6 to 37.0% were observed in statistically significant studies. Effective intervention components were: pre- and post-discharge patient psychoeducation, structured needs assessments, medication reconciliation/education, transition managers and in-patient/out-patient provider communication. Key limitations were small sample size and risk of bias. Conclusions Many effective transitional intervention components are feasible and likely to be cost-effective. Future research can provide direction about the specific components necessary and/or sufficient for preventing early psychiatric readmission.

Health Anxiety in Australia: Prevalence, Comorbidity, Disability and Service Use

Abstract: Background Health anxiety is associated with high distress, disability and increased health service utilisation. However, there are relatively few epidemiological studies examining the extent of health anxiety or the associated sociodemographic and health risk factors in the general population. Aims To provide epidemiological data on health anxiety in the Australian population. Method Lifetime and current prevalence estimates, associations between comorbid disorders, psychological distress, impairment, disability and mental health service utilisation were generated using the Australian 2007 National Survey of Mental Health and Wellbeing. Results Health anxiety affects approximately 5.7% of the Australian population across the lifespan and 3.4% met criteria for health anxiety at the time of the interview. Age, employment status, smoking status and comorbid physical conditions were significantly related to health anxiety symptoms. Health anxiety was associated with significantly more distress, impairment, disability and health service utilisation than that found in respondents without health anxiety. Conclusions Health anxiety is non-trivial; it affects a significant proportion of the population and further research and clinical investigation of health anxiety is required.

Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial

Abstract: Background Little is known about whether treatment in a specialised out-patient mood disorder clinic improves long-term prognosis for patients discharged from initial psychiatric hospital admissions for bipolar disorder. Aims To assess the effect of treatment in a specialised out-patient mood disorder clinic v. standard decentralised psychiatric treatment among patients discharged from one of their first three psychiatric hospital admissions for bipolar disorder. Method Patients discharged from their first, second or third hospital admission with a single manic episode or bipolar disorder were randomised to treatment in a specialised out-patient mood disorder clinic or standard care ([ClinicalTrials.gov][1]: [NCT00253071][2]). The primary outcome measure was readmission to hospital, which was obtained from the Danish Psychiatric Central Register. Results A total of 158 patients with mania/bipolar disorder were included. The rate of readmission to hospital was significantly decreased for patients treated in the mood disorder clinic compared with standard treatment (unadjusted hazard ratio 0.60, 95% CI 0.37–0.97, P = 0.034). Patients treated in the mood disorder clinic more often used a mood stabiliser or an antipsychotic and satisfaction with treatment was more prevalent than among patients who received standard care. Conclusions Treatment in a specialised mood disorder clinic early in the course of bipolar disorder substantially reduces readmission to a psychiatric hospital and increases satisfaction with care. [1]: http://ClinicalTrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00253071&atom=%2Fbjprcpsych%2F202%2F3%2F212.atom

Country- and individual-level socioeconomic determinants of depression: multilevel cross national comparison

Abstract: Background The prevalence and correlates of depression vary across countries. Contextual factors such as country-level income or income inequalities have been hypothesised to contribute to these differences. Aims To investigate associations of depression with socioeconomic factors at the country level (income inequality, gross national income) and individual (education, employment, assets and spending) level, and to investigate their relative contribution in explaining the cross-national variation in the prevalence of depression. Method Multilevel study using interview data of 187 496 individuals from 53 countries participating in the World Health Organization World Health Surveys. Results Depression prevalence varied between 0.4 and 15.7% across countries. Individual-level factors were responsible for 86.5% of this variance but there was also reasonable variation at the country level (13.5%), which appeared to increase with decreasing economic development of countries. Gross national income or country-level income inequality had no association with depression. At the individual level, fewer material assets, lower education, female gender, economic inactivity and being divorced or widowed were associated with increased odds of depression. Greater household spending, unlike material assets, was associated with increasing odds of depression (adjusted analysis). Conclusions The variance of depression prevalence attributable to country-level factors seemed to increase with decreasing economic development of countries. However, country-level income inequality or gross national income explained little of this variation, and individual-level factors appeared more important than contextual factors as determinants of depression. The divergent relationship of assets and spending with depression emphasise that different socioeconomic measures are not interchangeable in their associations with depression.

The structure of paranoia in the general population

Abstract: Background Psychotic phenomena appear to form a continuum with normal experience and beliefs, and may build on common emotional interpersonal concerns. Aims We tested predictions that paranoid ideation is exponentially distributed and hierarchically arranged in the general population, and that persecutory ideas build on more common cognitions of mistrust, interpersonal sensitivity and ideas of reference. Method Items were chosen from the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) questionnaire and the Psychosis Screening Questionnaire in the second British National Survey of Psychiatric Morbidity ( n = 8580), to test a putative hierarchy of paranoid development using confirmatory factor analysis, latent class analysis and factor mixture modelling analysis. Results Different types of paranoid ideation ranged in frequency from less than 2% to nearly 30%. Total scores on these items followed an almost perfect exponential distribution ( r = 0.99). Our four a priori first-order factors were corroborated (interpersonal sensitivity; mistrust; ideas of reference; ideas of persecution). These mapped onto four classes of individual respondents: a rare, severe, persecutory class with high endorsement of all item factors, including persecutory ideation; a quasi-normal class with infrequent endorsement of interpersonal sensitivity, mistrust and ideas of reference, and no ideas of persecution; and two intermediate classes, characterised respectively by relatively high endorsement of items relating to mistrust and to ideas of reference. Conclusions The paranoia continuum has implications for the aetiology, mechanisms and treatment of psychotic disorders, while confirming the lack of a clear distinction from normal experiences and processes.

Amygdala activation in maltreated children during pre-attentive emotional processing

Abstract: Background: Childhood adversity is associated with significantly increased risk of psychiatric disorder. To date, functional magnetic resonance imaging (fMRI) studies of children have mainly focused on institutionalisation and investigated conscious processing of affect. Aims: To investigate neural response to pre-attentively presented affect cues in a community sample of children with documented experiences of maltreatment in the home. Method: A masked dot-probe paradigm involving pre-attentive presentation of angry, happy and neutral facial expressions was employed. Eighteen maltreated children were compared with 23 carefully matched non-maltreated peers. Results: Increased neural response was observed in the right amygdala for pre-attentively presented angry and happy faces in maltreated v. non-maltreated children. Level of amygdala activation was negatively associated with age at onset for several abuse subtypes. Conclusions: Maltreatment is associated with heightened neural response to positive and negative facial affect, even to stimuli outside awareness. This may represent a latent neural risk factor for future psychiatric disorder.

Treatment for mild cognitive impairment: systematic review

Abstract: Background More people are presenting with mild cognitive impairment (MCI), frequently a precursor to dementia, but we do not know how to reduce deterioration. Aims To systematically review randomised controlled trials (RCTs) evaluating the effects of any intervention for MCI on cognitive, neuropsychiatric, functional, global outcomes, life quality or incident dementia. Method We reviewed 41 studies fitting predetermined criteria, assessed validity using a checklist, calculated standardised outcomes and prioritised primary outcome findings in placebo-controlled studies. Results The strongest evidence was that cholinesterase inhibitors did not reduce incident dementia. Cognition improved in single trials of: a heterogeneous psychological group intervention over 6 months; piribedil, a dopamine agonist over 3 months; and donepezil over 48 weeks. Nicotine improved attention over 6 months. There was equivocal evidence that Huannao Yicong improved cognition and social functioning. Conclusions There was no replicated evidence that any intervention was effective. Cholinesterase inhibitors and rofecoxib are ineffective in preventing dementia. Further good-quality RCTs are needed and preliminary evidence suggests these should include trials of psychological group interventions and piribedil.

Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder

Abstract: Background Attention-deficit hyperactivity disorder (ADHD) is associated with bipolar disorder and schizophrenia, and it has been suggested that combined bipolar disorder and ADHD is aetiologically distinct from the pure disorders. Aims To clarify whether ADHD shares genetic and environmental factors with bipolar disorder and schizophrenia. Method By linking longitudinal Swedish national registers, we identified 61 187 persons with ADHD (the proband group) and their first- and second-degree relatives, and matched them with a control group of people without ADHD and their corresponding relatives. Conditional logistic regression was used to determine the risks of bipolar disorder and schizophrenia in the relatives of the two groups. Results First-degree relatives of the ADHD proband group were at increased risk of both bipolar disorder (odds ratio (OR) = 1.84-2.54 for parents, offspring and full siblings) and schizophrenia (OR = 1.71-2.22 for parents, offspring and full siblings). The risks of bipolar disorder and schizophrenia among second-degree relatives were substantially lower than among full siblings. Conclusions These findings suggest that the co-occurrence of ADHD and bipolar disorder as well as ADHD and schizophrenia is due to shared genetic factors, rather than representing completely aetiologically distinct subsyndromes.

Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis.

Abstract: Background The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity. Aims To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity. Method An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses. Results Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P <0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P <0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively. Conclusions The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z -score.

Experiences of discrimination among people using mental health services in England 2008-2011

Abstract: Background Research suggests that levels of discrimination against people using mental health services are high; however, reports of these people’s experiences are rare. Aims To determine whether the Time to Change (TTC) programme target of 5% reduction in discrimination has been achieved. Method Separate samples of people using mental health services were interviewed annually from 2008 to 2011 using the Discrimination and Stigma Scale to record instances of discrimination. Results Ninety-one per cent of participants reported one or more experiences of discrimination in 2008 compared with 88% in 2011 ( z = –1.9, P = 0.05). The median negative discrimination score was 40% in 2008 and 28% in 2011 (Kruskal-Wallis χ2 = 83.4, P <0.001). Conclusions The proportion of participants experiencing no discrimination increased significantly over the course of TTC but by less than the initial target. The overall median discrimination score fell by 11.5%. Data from 2010 and 2011 suggest that these gains may be hard to maintain during economic austerity.

Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study

Abstract: Background One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control. Aims To develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the therapist is able to control so that the avatar progressively yields control to the patient. Method Avatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS). Results The control group showed no change over time in their scores on the three assessments, whereas the novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 ( P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 ( P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU with the period of avatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8. Conclusions Avatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.

Prevalence of experiences of domestic violence among psychiatric patients: systematic review.

Abstract: Background Domestic violence has been linked with many mental disorders, including anxiety, depression, post-traumatic stress disorder, eating disorders and psychosis. Aims To estimate the prevalence (adult lifetime and past year) of different types of domestic violence experienced by men and women receiving psychiatric treatment. Method In a systematic review, a search of 18 electronic databases was supplemented by hand searching, citation tracking and updating a recent systematic review of criminal victimisation in psychiatric populations. Two reviewers independently extracted data and appraised study quality. Results Forty-two studies were included. The median prevalence of lifetime partner violence reported in high-quality papers was 30% (interquartile range (IQR) 26–39) among female in-patients and 33% (IQR 21–53) among female out-patients. Among male patients, one high-quality study reported a lifetime prevalence of 32% across mixed psychiatric settings. No study included a control group. Conclusions Psychiatric patients experience a high prevalence of domestic violence but there is limited information on family (non-partner) domestic violence, the prevalence of emotional abuse and the extent of risk compared with non-psychiatric controls.

The future of academic psychiatry may be social

Abstract: The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

Religion, spirituality and mental health: results from a national study of English households

Abstract: Background Religious participation or belief may predict better mental health but most research is American and measures of spirituality are often conflated with well-being Aims To examine associations between a spiritual or religious understanding of life and psychiatric symptoms and diagnoses Method We analysed data collected from interviews with 7403 people who participated in the third National Psychiatric Morbidity Study in England Results Of the participants 35% had a religious understanding of life, 19% were spiritual but not religious and 46% were neither religious nor spiritual Religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former were less likely to have ever used drugs (odds ratio (OR) = 073, 95% CI 060–088) or be a hazardous drinker (OR = 081, 95% CI 069–096) Spiritual people were more likely than those who were neither religious nor spiritual to have ever used (OR = 124, 95% CI 102–149) or be dependent on drugs (OR = 177, 95% CI 120–261), and to have abnormal eating attitudes (OR = 146, 95% CI 110–194), generalised anxiety disorder (OR = 150, 95% CI 109–206), any phobia (OR = 172, 95% CI 107–277) or any neurotic disorder (OR = 137, 95% CI 112–168) They were also more likely to be taking psychotropic medication (OR = 140, 95% CI 105–186) Conclusions People who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder

Transfers and transitions between child and adult mental health services.

Abstract: Background Transfer of care from one healthcare provider to another is often understood as a suboptimal version of the process of transition. Aims To separate and evaluate concepts of transfer and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Method In a retrospective case-note survey of young people reaching the upper age boundary at six English CAMHS, optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer. Results Of 154 cases, 76 transferred to AMHS. Failure to transfer resulted mainly from non-referral by CAMHS ( n = 12) and refusal by service users ( n = 12) rather than refusal by AMHS ( n = 7). Four cases met all criteria for optimal transition, 13 met none; continuity of care ( n = 63) was met most often. Conclusions Transfer was common but good transition rare. Reasons for failure to transfer differ from barriers to transition. Transfer should be investigated alongside transition in research and service development.