Showing papers in "British Journal of Psychiatry in 2015"

Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis

Abstract: Background Cognitive bias modification (CBM) interventions are strongly advocated in research and clinical practice. Aims To examine the efficiency of CBM for clinically relevant outcomes, along with study quality, publication bias and potential moderators. Method We included randomised controlled trials (RCTs) of CBM interventions that reported clinically relevant outcomes assessed with standardised instruments. Results We identified 49 trials and grouped outcomes into anxiety and depression. Effect sizes were small considering all the samples, and mostly non-significant for patient samples. Effect sizes became non-significant when outliers were excluded and after adjustment for publication bias. The quality of the RCTs was suboptimal. Conclusions CBM may have small effects on mental health problems, but it is also very well possible that there are no significant clinically relevant effects. Research in this field is hampered by small and low-quality trials, and by risk of publication bias. Many positive outcomes are driven by extreme outliers.

Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis

Abstract: Background Pharmacological treatment is widely used for post-traumatic stress disorder (PTSD) despite questions over its efficacy. Aims To determine the efficacy of all types of pharmacotherapy, as monotherapy, in reducing symptoms of PTSD, and to assess acceptability. Method A systematic review and meta-analysis of randomised controlled trials was undertaken; 51 studies were included. Results Selective serotonin reuptake inhibitors were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference –0.23, 95% CI –0.33 to –0.12). For individual pharmacological agents compared with placebo in two or more trials, we found small statistically significant evidence of efficacy for fluoxetine, paroxetine and venlafaxine. Conclusions Some drugs have a small positive impact on PTSD symptoms and are acceptable. Fluoxetine, paroxetine and venlafaxine may be considered as potential treatments for the disorder. For most drugs there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more research in this area.

Technological innovations in mental healthcare: harnessing the digital revolution

Abstract: Digital technology has the potential to transform mental healthcare by connecting patients, services and health data in new ways. Digital online and mobile applications can offer patients greater access to information and services and enhance clinical management and early intervention through access to real-time patient data. However, substantial gaps exist in the evidence base underlying these technologies. Greater patient and clinician involvement is needed to evaluate digital technologies and ensure they target unmet needs, maintain public trust and improve clinical outcomes.

Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review

Abstract: Background Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings. Aims To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs). Method We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact. Results Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and −0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies. Conclusions There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

Disorder, not just state of risk: meta-analysis of functioning and quality of life in people at high risk of psychosis.

Abstract: Background The nosology of the psychosis high-risk state is controversial. Traditionally conceived as an ‘at risk’ state for the development of psychotic disorders, it is also conceptualised as a clinical syndrome associated with functional impairment. Aims To investigate meta-analytically the functional status of patients at high clinical risk for psychosis and its association with longitudinal outcomes. Method Three meta-analyses compared level of functioning ( n = 3012) and quality of life (QoL) ( n = 945) between a high-risk group, a healthy control group and group with psychosis, and baseline functioning in people in the high-risk group who did or did not have a transition to psychosis at follow-up ( n = 654). Results People at high risk had a large impairment in functioning ( P <0.001) and worse QoL ( P = 0.001) than the healthy control group, but only small to moderately better functioning ( P = 0.012) and similar QoL ( P = 0.958) compared with the psychosis group. Among the high-risk group, those who did not develop psychosis reported better functioning ( P = 0.001) than those who did. Conclusions Our results indicate that the high-risk state is characterised by consistent and large impairments of functioning and reduction in QoL similar to those in other coded psychiatric disorders.

Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis.

Abstract: Background Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met. Aims To determine whether interventions provided to people caring for those with severe mental illness improve the experience of caring and reduce caregiver burden. Method We conducted a systematic review and meta-analyses of randomised controlled trials (RCTs) of interventions delivered by health and social care services to informal carers (i.e. family or friends who provide support to someone with severe mental illness). Results Twenty-one RCTs with 1589 carers were included in the review. There was evidence suggesting that the carers’ experience of care was improved at the end of the intervention by psychoeducation (standardised mean difference –1.03, 95% CI –1.69 to –0.36) and support groups (SMD = –1.16, 95% CI –1.96 to –0.36). Psychoeducation had a benefit on psychological distress more than 6 months later (SMD = –1.79, 95% CI –3.01 to –0.56) but not immediately post-intervention. Support interventions had a beneficial effect on psychological distress at the end of the intervention (SMD = –0.99, 95% CI –1.48 to –0.49) as did problem-solving bibliotherapy (SMD = –1.57, 95% CI –1.79 to –1.35); these effects were maintained at follow-up. The quality of the evidence was mainly low and very low. Evidence for combining these interventions and for self-help and self-management was inconclusive. Conclusions Carer-focused interventions appear to improve the experience of caring and quality of life and reduce psychological distress of those caring for people with severe mental illness, and these benefits may be gained in first-episode psychosis. Interventions for carers should be considered as part of integrated services for people with severe mental health problems.

Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction

Abstract: BACKGROUND Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation. AIMS To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings. METHOD Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration. RESULTS Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT). CONCLUSIONS SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

Abstract: BACKGROUND: There is growing interest in brief contact interventions for self-harm and suicide attempt. AIMS: To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide. METHOD: A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects. RESULTS: We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38). CONCLUSIONS: A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations.

A general psychopathology factor in early adolescence.

Abstract: Background Recently, a general psychopathology dimension reflecting common aspects among disorders has been identified in adults. This has not yet been considered in children and adolescents, where the focus has been on externalising and internalising dimensions. Aims To examine the existence, correlates and predictive value of a general psychopathology dimension in young people. Method Alternative factor models were estimated using self-reports of symptoms in a large community-based sample aged 11–13.5 years ( N = 23 477), and resulting dimensions were assessed in terms of associations with external correlates and future functioning. Results Both a traditional two-factor model and a bi-factor model with a general psychopathology bi-factor fitted the data well. The general psychopathology bi-factor best predicted future psychopathology and academic attainment. Associations with correlates and factor loadings are discussed. Conclusions A general psychopathology factor, which is equal across genders, can be identified in young people. Its associations with correlates and future functioning indicate that investigating this factor can increase our understanding of the aetiology, risk and correlates of psychopathology.

Maternal depression during pregnancy and offspring depression in adulthood: role of child maltreatment

Abstract: BackgroundStudies have shown that maternal depression during pregnancy predicts offspring depression in adolescence. Child maltreatment is also a risk factor for depression.AimsTo investigate (a) whether there is an association between offspring exposure to maternal depression in pregnancy and depression in early adulthood, and (b) whether offspring child maltreatment mediates this association.METHODProspectively collected data on maternal clinical depression in pregnancy, offspring child maltreatment and offspring adulthood (18-25 years) DSM-IV depression were analysed in 103 mother-offspring dyads of the South London Child Development Study.RESULTSAdult offspring exposed to maternal depression in pregnancy were 3.4 times more likely to have a DSM-IV depressive disorder, and 2.4 times more likely to have experienced child maltreatment, compared with non-exposed offspring. Path analysis revealed that offspring experience of child maltreatment mediated the association between exposure to maternal depression in pregnancy and depression in adulthood.CONCLUSIONSMaternal depression in pregnancy is a key vulnerability factor for offspring depression in early adulthood. Language: en

Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up

Abstract: Background Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment. Aims To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling. Method Randomly selected injury patients ( n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and functioning were assessed. Results Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit. Conclusions These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: randomised controlled trial.

Abstract: Background: As the population ages, older people account for a greater proportion of the health and social care budget. While some research has been conducted on the use of music therapy for specific clinical populations, little rigorous research has been conducted looking at the value of community singing on the mental health-related quality of life of older people. Aims: To evaluate the effectiveness and cost-effectiveness of community group singing for a population of older people in England. Method: A pilot pragmatic individual randomized controlled trial comparing group singing versus usual activities in those aged 60 years or more. Results: 258 participants were recruited across 5 centres in East Kent. At 6 months post-randomisation significant differences were observed in terms of mental health related quality of life measured using the SF12, mean difference 2.35 (95% CI 0.06 to 4.76) in favour of group singing. In addition the intervention was found to be marginally more cost-effective than usual activities. At 3 months significant differences were observed in terms of mental health components of quality of life (4.77; 2.53 to 7.01) anxiety (-1.78; -2.5; -1.06) and depression (-1.52; -2.13 to -0.92). Conclusions: Community group singing appears to have a significant effect on mental health related quality of life, anxiety and depression and may be a useful intervention to maintain and enhance the mental health of the older population.

Psychological treatments for depression and anxiety in dementia and mild cognitive impairment: systematic review and meta-analysis.

Abstract: Background: Anxiety and depression are common in people with dementia and mild cognitive impairment (MCI) but there is uncertainty about the effectiveness of both pharmacological and psychological therapies. / Aims: To evaluate the evidence of effectiveness of psychological treatments in treating depression and anxiety in people with dementia and MCI. / Method: Systematic review and meta-analysis of randomized controlled trials of psychological treatment versus usual care in people with dementia and MCI. Primary outcomes were symptoms of anxiety and depression. Secondary outcomes were quality of life, ability to perform daily activities, neuropsychiatric symptoms, cognition, and carers' self-rated depressive symptoms. / Results: Six RCTs were included involving 439 participants with dementia, which used cognitive behavioural therapy, interpersonal therapy, counselling, or multimodal interventions including a specific psychological therapy. Beneficial effects were found for both depression and anxiety. Overall the quality of the evidence is moderate for depression and low for anxiety, due to methodological limitations of the studies identified and the limited number of trials. / Conclusions: Evidence from six randomised controlled trials suggests that psychological treatments are effective in reducing symptoms of depression and anxiety for people with dementia. There is a need for high quality multicentre trials including standardised, well defined interventions.

Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study

Abstract: Background We still know little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries. Aims To compare auditory hallucinations across three different cultures, by means of an interview-based study. Method An anthropologist and several psychiatrists interviewed participants from the USA, India and Ghana, each sample comprising 20 persons who heard voices and met the inclusion criteria of schizophrenia, about their experience of voices. Results Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind. Conclusions These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.

Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: randomised controlled trial

Abstract: Background Depression is common and tends to be recurrent. Alternative treatments are needed that are non-stigmatising, accessible and can be prescribed by general medical practitioners. Aims To compare the effectiveness of three interventions for depression: physical exercise, internet-based cognitive–behavioural therapy (ICBT) and treatment as usual (TAU). A secondary aim was to assess changes in self-rated work capacity. Method A total of 946 patients diagnosed with mild to moderate depression were recruited through primary healthcare centres across Sweden and randomly assigned to one of three 12-week interventions (trail registry: KCTR study ID: KT20110063). Patients were reassessed at 3 months (response rate 78%). Results Patients in the exercise and ICBT groups reported larger improvements in depressive symptoms compared with TAU. Work capacity improved over time in all three groups (no significant differences). Conclusions Exercise and ICBT were more effective than TAU by a general medical practitioner, and both represent promising non-stigmatising treatment alternatives for patients with mild to moderate depression.

Excess mortality in severe mental illness: 10-year population-based cohort study in rural Ethiopia.

Abstract: Background Evidence on mortality in severe mental illness (SMI) comes primarily from clinical samples in high-income countries. Aims To describe mortality in people with SMI among a population cohort from a low-income country. Method We followed-up 919 adults (from 68 378 screened) with SMI over 10 years. Standardised mortality ratios (SMR) and years of life lost (YLL) as a result of premature mortality were calculated. Results In total 121 patients (13.2%) died. The overall SMR was twice that of the general population; higher for men and people with schizophrenia. Patients died about three decades prematurely, mainly from infectious causes (49.6%). Suicide, accidents and homicide were also common causes of death. Conclusions Mortality is an important adverse outcome of SMI irrespective of setting. Addressing common natural and unnatural causes of mortality are urgent priorities. Premature death and mortality related to self-harm should be considered in the estimation of the global burden of disease for SMI.

Insulin resistance and outcome in bipolar disorder

Abstract: Background Little is known about the impact of insulin resistance on bipolar disorder. Aims To examine the relationships between insulin resistance, type 2 diabetes and clinical course and treatment outcomes in bipolar disorder. Method We measured fasting glucose and insulin in 121 adults with bipolar disorder. We diagnosed type 2 diabetes and determined insulin resistance. The National Institute of Mental Health Life Chart was used to record the course of bipolar disorder and the Alda scale to establish response to prophylactic lithium treatment. Results Patients with bipolar disorder and type 2 diabetes or insulin resistance had three times higher odds of a chronic course of bipolar disorder compared with euglycaemic patients (50% and 48.7% respectively v. 27.3%, odds ratio (OR) = 3.07, P = 0.007), three times higher odds of rapid cycling (38.5% and 39.5% respectively v. 18.2%, OR = 3.13, P = 0.012) and were more likely to be refractory to lithium treatment (36.8% and 36.7% respectively v. 3.2%, OR = 8.40, P <0.0001). All associations remained significant after controlling for antipsychotic exposure and body mass index in sensitivity analyses. Conclusions Comorbid insulin resistance may be an important factor in resistance to treatment in bipolar disorder.

Antidepressant use in 27 European countries: associations with sociodemographic, cultural and economic factors

Abstract: Background Prescribing of antidepressants varies widely between European countries despite no evidence of difference in the prevalence of affective disorders. Aims To investigate associations between the use of antidepressants, country-level spending on healthcare and country-level attitudes towards mental health problems. Method We used Eurobarometer 2010, a large general population survey from 27 European countries, to measure antidepressant use and regularity of use. We then analysed the associations with country-level spending on healthcare and country-level attitudes towards mental health problems. Results Higher country spending on healthcare was strongly associated with regular use of antidepressants. Beliefs that mentally ill people are ‘dangerous’ were associated with higher use, and beliefs that they ‘never recover’ or ‘have themselves to blame’ were associated with lower and less regular use of antidepressants. Conclusions Contextual factors, such as healthcare spending and public attitudes towards mental illness, may partly explain variations in antidepressant use and regular use of these medications.

The role of social media in reducing stigma and discrimination

Abstract: This editorial explores the implications of social media practices whereby people with mental health problems share their experiences in online public spaces and challenge mental health stigma. Social media enable individuals to bring personal experience into the public domain with the potential to affect public attitudes and mainstream media. We draw tentative conclusions regarding the use of social media by campaigning organisations.

Common and disorder-specific neural responses to emotional faces in generalised anxiety, social anxiety and panic disorders.

Abstract: Background Although evidence exists for abnormal brain function across various anxiety disorders, direct comparison of neural function across diagnoses is needed to elicit abnormalities common across disorders and those distinct to a particular diagnosis. Aims To delineate common and distinct abnormalities within generalised anxiety (GAD), panic and social anxiety disorder (SAD) during affective processing. Method Fifty-nine adults (15 with GAD, 15 with panic disorder, 14 with SAD, and 15 healthy controls) underwent functional magnetic resonance imaging while completing a facial emotion matching task with fearful, angry and happy faces. Results Greater differential right amygdala activation to matching fearful v. happy facial expressions related to greater negative affectivity (i.e. trait anxiety) and was heightened across all anxiety disorder groups compared with controls. Collapsing across emotional face types, participants with panic disorder uniquely displayed greater posterior insula activation. Conclusions These preliminary results highlight a common neural basis for clinical anxiety in these diagnoses and also suggest the presence of disorder-specific dysfunction.

Incision and stress regulation in borderline personality disorder: neurobiological mechanisms of self-injurious behaviour

Abstract: Background Patients with borderline personality disorder frequently show non-suicidal self-injury (NSSI). In these patients, NSSI often serves to reduce high levels of stress. Aims Investigation of neurobiological mechanisms of NSSI in borderline personality disorder Method In total, 21 women with borderline personality disorder and 17 healthy controls underwent a stress induction, followed by either an incision into the forearm or a sham treatment. Afterwards participants underwent resting-state functional magnetic resonance imaging while aversive tension, heart rate and heart rate variability were assessed. Results We found a significant influence of incision on subjective and objective stress levels with a stronger decrease of aversive tension in the borderline personality disorder group following incision than sham. Amygdala activity decreased more and functional connectivity with superior frontal gyrus normalised after incision in the borderline personality disorder group. Conclusions Decreased stress levels and amygdala activity after incision support the assumption of an influence of NSSI on emotion regulation in individuals with borderline personality disorder and aids in understanding why these patients use self-inflicted pain to reduce inner tension.

Systematic synthesis of barriers and facilitators to service user-led care planning.

Abstract: Background Service user (patient) involvement in care planning is a principle enshrined by mental health policy yet often attracts criticism from patients and carers in practice. Aims To examine how user-involved care planning is operationalised within mental health services and to establish where, how and why challenges to service user involvement occur. Method Systematic evidence synthesis. Results Synthesis of data from 117 studies suggests that service user involvement fails because the patients' frame of reference diverges from that of providers. Service users and carers attributed highest value to the relational aspects of care planning. Health professionals inconsistently acknowledged the quality of the care planning process, tending instead to define service user involvement in terms of quantifiable service-led outcomes. Conclusions Service user-involved care planning is typically operationalised as a series of practice-based activities compliant with auditor standards. Meaningful involvement demands new patient-centred definitions of care planning quality. New organisational initiatives should validate time spent with service users and display more tangible and flexible commitments to meeting their needs.

Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial

Abstract: Background Individual-based cognitive–behavioural therapy (CBT) is in short supply and expensive. Aims The aim of this randomised controlled trial (RCT) was to compare mindfulness-based group therapy with treatment as usual (primarily individual-based CBT) in primary care patients with depressive, anxiety or stress and adjustment disorders. Method This 8-week RCT ([ClinicalTrials.gov][1] ID: [NCT01476371][2]) was conducted during spring 2012 at 16 general practices in Southern Sweden. Eligible patients (aged 20–64 years) scored ⩾10 on the Patient Health Questionnaire-9, ⩾7 on the Hospital Anxiety and Depression Scale or 13–34 on the Montgomery–Asberg Depression Rating Scale (self-rated version). The power calculations were based on non-inferiority. In total, 215 patients were randomised. Ordinal mixed models were used for the analysis. Results For all scales and in both groups, the scores decreased significantly. There were no significant differences between the mindfulness and control groups. Conclusions Mindfulness-based group therapy was non-inferior to treatment as usual for patients with depressive, anxiety or stress and adjustment disorders. [1]: http://ClinicalTrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01476371&atom=%2Fbjprcpsych%2Fearly%2F2014%2F11%2F11%2Fbjp.bp.114.150243.atom

Socioeconomic gradients and mental health: implications for public health

Abstract: Background Research on mental well-being is relatively new and studies of its determinants are rare. Aims To investigate whether the socioeconomic correlates of mental well-being mirror those for mental illness. Method Using logistic regression analyses, the independent odds ratios of high and low mental well-being, compared with middle-range mental well-being, were estimated for a number of sociodemographic variables known to be associated with mental illness from 13 983 participants in the 2010 and 2011 Health Surveys for England. Results Independent odds ratios for low mental well-being were as expected from studies of mental illness with increased odds for the unemployed (OR = 1.46, 95% CI 1.01–2.10) and those aged 35–54 years (OR = 1.58, 95% CI 1.35–1.84) and reduced odds for the married (OR = 0.78, 95% CI 0.62–0.97). A linear trend was observed with education and equivalised income. Odds ratios for high mental well-being differed from those for low mental well-being with regard to age (55+ years: OR = 1.48, 95% CI 1.23–1.79); employment status where there was an association only with retirement (OR = 1.35, 95% CI 1.09–1.69); education where there was no association; and equivalised income for which the association was non-linear. Conclusions Odds ratios for low mental well-being mirrored those for mental illness, but not those for high mental well-being, suggesting that the socioeconomic factors associated with positive mental health are different from those associated with mental illness.

Risk of stroke among patients with post-traumatic stress disorder: nationwide longitudinal study

Abstract: Background Previous evidence has shown positive associations between post-traumatic stress disorder (PTSD) and hypertension, dyslipidaemia and diabetes mellitus, which are all risk factors for stroke, but the role of PTSD in the subsequent development of stroke is still unknown. Aims To investigate the temporal association between PTSD and the development of stroke. Method Identified from the Taiwan National Health Insurance Research Database, 5217 individuals aged ≥18 years, with PTSD but with no history of stroke, and 20 868 age- and gender-matched controls were enrolled between 2002 and 2009, and followed up until the end of 2011 to identify the development of stroke. Results Individuals with PTSD had an increased risk of developing any stroke (hazard ratio (HR) 3.37, 95% CI 2.44–4.67) and ischaemic stroke (HR = 3.47, 95% CI 2.23–5.39) after adjusting for demographic data and medical comorbidities. Sensitivity tests showed consistent findings (any stroke HR = 3.02, 95% CI 2.13–4.28; ischaemic stroke HR = 2.89, 95% CI 1.79–4.66) after excluding the first year of observation. Conclusions Individuals with PTSD have an increased risk of developing any stroke and ischaemic stroke. Further studies are required to investigate the underlying mechanisms.

Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression.

Abstract: Background: De-escalation techniques are a recommended non-physical intervention for the management of violence and aggression in mental health. Although taught as part of mandatory training for all NHS mental health staff, there remains a lack of clarity around training effectiveness. Aim: To conduct a systematic review of the learning, performance and clinical safety outcomes of deescalation techniques training. Method: The review process involved a systematic literature search of 20 electronic databases, eligibility screening of results, data extraction, quality appraisal, and data synthesis. Results: 38 relevant studies were identified. The strongest impact of training appears to be on deescalation- related knowledge, confidence to manage aggression and de-escalation performance (although limited to artificial training scenarios). No strong conclusions could be drawn about the impact of training on assaults, injuries, containment and organisational outcomes owing to the low quality of evidence and conflicting results. Conclusions: It is assumed that de-escalation techniques training will improve staff’s ability to deescalate violent and aggressive behaviour and improve safety in practice. There is currently limited evidence that this training has these effects.

Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication

Abstract: Background Severe depression can be a life-threatening disorder, especially in elderly patients. A fast-acting treatment is crucial for this group. Electroconvulsive therapy (ECT) may work faster than medication. Aims To compare the speed of remission using ECT v. medication in elderly in-patients. Method The speed of remission in in-patients with a DSM-IV diagnosis of major depression (baseline MADRS score ≥20) was compared between 47 participants (mean age 74.0 years, s.d. = 7.4) from an ECT randomised controlled trial (RCT) and 81 participants (mean age 72.2 years, s.d. = 7.6) from a medication RCT (nortriptyline v. venlafaxine). Results Mean time to remission was 3.1 weeks (s.d. = 1.1) for the ECT group and 4.0 weeks (s.d. = 1.0) for the medication group; the adjusted hazard ratio for remission within 5 weeks (ECT v. medication) was 3.4 (95% CI 1.9–6.2). Conclusions Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.

Mood instability: significance, definition and measurement.

Abstract: Mood instability is common, and an important feature of several psychiatric disorders. We discuss the definition and measurement of mood instability, and review its prevalence, characteristics, neurobiological correlates and clinical implications. We suggest that mood instability has underappreciated transdiagnostic potential as an investigational and therapeutic target.

Adolescent eating disorder behaviours and cognitions: gender-specific effects of child, maternal and family risk factors

Abstract: Background Eating disorder behaviours begin in adolescence. Few longitudinal studies have investigated childhood risk and protective factors. Aims To investigate the prevalence of eating disorder behaviours and cognitions and associated childhood psychological, physical and parental risk factors among a cohort of 14-year-old children. Method Data were collected from 6140 boys and girls aged 14 years. Gender-stratified models were used to estimate prospective associations between childhood body dissatisfaction, body mass index (BMI), self-esteem, maternal eating disorder and family economic disadvantage on adolescent eating disorder behaviours and cognitions. Results Childhood body dissatisfaction strongly predicted eating disorder cognitions in girls, but only in interaction with BMI in boys. Higher self-esteem had a protective effect, particularly in boys. Maternal eating disorder predicted body dissatisfaction and weight/shape concern in adolescent girls and dieting in boys. Conclusions Risk factors for eating disorder behaviours and cognitions vary according to gender. Prevention strategies should be gender-specific and target modifiable predictors in childhood and early adolescence.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness

Abstract: Background A cognitive–behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. Aims To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: [NCT00494650][1]). Method In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. Results There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. Conclusions Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00494650&atom=%2Fbjprcpsych%2F206%2F6%2F501.atom