Showing papers in "Psychological Medicine in 2007"

Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis

Abstract: Background. We studied to what extent internet-based cognitive behaviour therapy (CBT) programs for symptoms of depression and anxiety are effective. Method. A meta-analysis of 12 randomized controlled trials. Results. The effects of internet-based CBT were compared to control conditions in 13 contrast groups with a total number of 2334 participants. A meta-analysis on treatment contrasts resulted in a moderate to large mean effect size (fixed effects analysis (FEA) d=0 . 40, mixed effects analysis (MEA) d=0 . 60) and significant heterogeneity. Therefore, two sets of post hoc subgroup analyses were carried out. Analyses on the type of symptoms revealed that interventions for symptoms of depression had a small mean effect size (FEA d=0 . 27, MEA d=0 . 32) and significant heterogeneity. Further analyses showed that one study could be regarded as an outlier. Analyses without this study showed a small mean effect size and moderate, non-significant heterogeneity. Interventions for anxiety had a large mean effect size (FEA and MEA d=0 . 96) and very low heterogeneity. When examining the second set of subgroups, based on therapist assistance, no significant heterogeneity was found. Interventions with therapist support (n=5) had a large mean effect size, while inter- ventions without therapist support (n=6) had a small mean effect size (FEA d=0 . 24, MEA d=0 . 26). Conclusions. In general, effect sizes of internet-based interventions for symptoms of anxiety were larger than effect sizes for depressive symptoms ; however, this might be explained by differences in the amount of therapist support.

Characteristics and functions of non-suicidal self-injury in a community sample of adolescents

Abstract: Background. Few studies have investigated non-suicidal self-injury (NSSI), or the deliberate, direct destruction of body tissue without conscious suicidal intent, and the motivations for engaging in NSSI among adolescents. This study assessed the prevalence, associated clinical characteristics, and functions of NSSI in a community sample of adolescents.Method. A total of 633 adolescents completed anonymous surveys. NSSI was assessed with the Functional Assessment of Self-Mutilation (FASM).Results. Some form of NSSI was endorsed by 46.5% (n=293) of the adolescents within the past year, most frequently biting self, cutting/carving skin, hitting self on purpose, and burning skin. Sixty per cent of these, or 28% of the overall sample, endorsed moderate/severe forms of NSSI. Self-injurers reported an average of 12.9 (S.D.=29.4) incidents in the past 12 months, with an average of 2.4 (S.D.=1.7) types of NSSI used. Moderate/severe self-injurers were more likely than minor self-injurers, who in turn were more likely than non-injurers, to have a history of psychiatric treatment, hospitalization and suicide attempt, as well as current suicide ideation. A four-factor model of NSSI functions was indicated, with self-injurers likely to endorse both reasons of automatic reinforcement and social reinforcement. The most common reasons for NSSI were 'to try to get a reaction from someone', 'to get control of a situation', and 'to stop bad feelings'.Conclusions. Community adolescents reported high rates of NSSI, engaged in to influence behaviors of others and to manage internal emotions. Intervention efforts should be tailored to reducing individual issues that contribute to NSSI and building alternative skills for positive coping, communication, stress management, and strong social support. Language: en

Genetic influences on measures of the environment: a systematic review.

Abstract: Background. Traditional models of psychiatric epidemiology often assume that the relationship between individuals and their environment is unidirectional, from environment to person. Accumulating evidence from developmental and genetic studies has made this perspective increasingly untenable. Method. Literature search using Medline, PsycINFO, article references and contact with experts to identify all papers examining the heritability of measures of environments of relevance to psychiatry/psychology. Results. We identified 55 independent studies organized into seven categories : general and specific stressful life events (SLEs), parenting as reported by child, parenting reported by parent, family environment, social support, peer interactions, and marital quality. Thirty-five environmental measures in these categories were examined by at least two studies and produced weighted heritability estimates ranging from 7 % to 39 %, with most falling between 15 % and 35%. The weighted heritability for all environmental measures in all studies was 27%. The weighted heritability for environmental measures by rating method was : self-report 29 %, informant report 26 %, and direct rater or videotape observation (typically examining 10 min of behavior) 14 %. Conclusion. Genetic influences on measures of the environment are pervasive in extent and modest to moderate in impact. These findings largely reflect ‘actual behavior ’ rather than ‘ only perceptions ’. Etiologic models for psychiatric illness need to account for the non-trivial influences of genetic factors on environmental experiences.

A systematic review and meta-analysis of set-shifting ability in eating disorders.

Abstract: Background. The aim was to critically appraise and synthesize the literature relating to set-shifting ability in eating disorders. PsycINFO, Medline, and Web of Science databases were searched to December 2005. Hand searching of eating-disorder journals and relevant reference sections was also undertaken. Method. The 15 selected studies contained both eating disorder and healthy control groups, and employed at least one of the following six neuropsychological measures of set-shifting ability ; Trail Making Test (TMT), Wisconsin Card Sort Test (WCST), Brixton task, Haptic Illusion, CatBat task, or the set-shifting subset of the Cambridge Neuropsychological Test Automated Battery (CANTAB). The outcome variable was performance on the set-shifting aspect of the task. Pooled standardized mean differences (effect sizes) were calculated. Results. TMT, WCST, CatBat and Haptic tasks had sufficient sample sizes for meta-analysis. These four tasks yielded acceptable pooled standardized effect sizes (0 . 36 ; TMT x1 . 05; Haptic) with moderate variation within studies (as measured by confidence intervals). The Brixton task showed a small pooled mean difference, and displayed more variation between sample results. The effect size for CANTAB set shifting was 0 . 17. Conclusion. Problems in set shifting as measured by a variety of neuropsychological tasks are present in people with eating disorders.

Work stress precipitates depression and anxiety in young, working women and men.

Abstract: In the United States and the European Union, 30–40% of workers are exposed to work stress, and these rates appear to have increased since the 1990s (National Institute of Occupational Health and Safety, 1999; European Foundation for the Improvement of Living and Working Conditions, 2005). Stressful work conditions predict poor mental health and there is growing concern that such conditions contribute to the population burden of psychiatric morbidity (Parkes, 1990; Phelan et al. 1991; Bromet et al. 1992; Stansfeld et al. 1997; Niedhammer et al. 1998; Stansfeld et al. 1999; Mausner-Dorsch and Eaton, 2000; Tennant, 2001; Paterniti et al. 2002). Yet, inference from past research is limited by several methodological shortcomings, which we aimed to address using data from a birth cohort followed from childhood to adulthood. With notable exceptions (Bromet et al. 1988; Mausner-Dorsch and Eaton, 2000; Cropley et al. 1999; Shields, 1999; Wang et al. 2004), past research has focused on symptoms of psychological distress (Phelan et al. 1991; Bromet et al. 1992; Niedhammer et al. 1998; Tennant, 2001; Paterniti et al. 2002; Stansfeld et al. 1997; Stansfeld et al. 1999), showing elevated rates in workers who report high job demands, low job control or insufficient work social support. However, the relationship between these work conditions and clinically-significant psychiatric disorders associated with healthcare and lost productivity costs is not known. Here, we study the risk of psychiatric disorder assessed using standardized diagnostic instruments. Additionally, past research has primarily focused on depressive symptomatology (Phelan et al. 1991; Bromet et al. 1992; Niedhammer et al. 1998; Tennant, 2001; Paterniti et al. 2002; Wang et al. 2004), while there is evidence of strong comorbidity and shared risk factors between major depression and generalized anxiety disorder (Mineka et al. 1998; Moffitt et al. 2007). Thus, workers exposed to stressful work conditions could be at increased risk of depression or anxiety and in this study we examine both major depressive disorder and generalized anxiety disorder. We address three additional methodological problems. First, the effects of work stress on mental health need to be separated from the effects of low occupational status (Stansfeld et al. 1999; Paterniti et al. 2002) and our analyses are adjusted for participants’ socio-economic position. Second, the association between work stress and mental health may be due to reporting bias wherein depressed or anxious workers describe their job characteristics in a negative light (Stansfeld et al. 1997; Paterniti et al. 2002), and our analyses control for participants’ negative affective style. Third, individuals who experience depression and anxiety disorders in childhood are at increased risk of psychiatric disorder in adulthood (Kim-Cohen et al. 2003) and could be selected into stressful jobs. Thus, the association between work stress and mental health problems in adulthood could be spurious, reflecting past psychiatric disorder. To our knowledge this hypothesis has not yet been tested and we examine it 1) by controlling for participants’ prospective psychiatric diagnoses prior to their labor-market entry (ages 11–18) and 2) by testing the association between work stress and new cases of depression and anxiety at age 32.

The endophenotype concept in psychiatric genetics

Abstract: The idea that some phenotypes bear a closer relationship to the biological processes that give rise to psychiatric illness than diagnostic categories has attracted considerable interest. Much effort has been devoted to finding such endophenotypes, partly because it is believed that the genetic basis of endophenotypes will be easier to analyse than that of psychiatric disease. This belief depends in part on the assumption that the effect sizes of genetic loci contributing to endophenotypes are larger than those contributing to disease susceptibility, hence increasing the chance that genetic linkage and association tests will detect them. We examine this assumption by applying meta-analytical techniques to genetic association studies of endophenotypes. We find that the genetic effect sizes of the loci examined to date are no larger than those reported for other phenotypes. A review of the genetic architecture of traits in model organisms also provides no support for the view that the effect sizes of loci contributing to phenotypes closer to the biological basis of disease is any larger than those contributing to disease itself. While endophenotype measures may afford greater reliability, it should not be assumed that they will also demonstrate simpler genetic architecture.

Work stress precipitates depression and anxiety in young, working women and men. Commentary

Abstract: Background. Rates of depression have been rising, as have rates of work stress. We tested the influence of work stress on diagnosed depression and anxiety in young working adults. Method. Participants were enrolled in the Dunedin study, a 1972-1973 longitudinal birth cohort assessed most recently in 2004-2005, at age 32 (n=972, 96% of 1015 cohort members still alive). Work stress (psychological job demands, work decision latitude, low work social support, physical work demands) was ascertained by interview. Major depressive disorder (MDD) and generalized anxiety disorder (GAD) were ascertained using the Diagnostic Interview Schedule (DIS) and diagnosed according to DSM-IV criteria. Results. Participants exposed to high psychological job demands (excessive workload, extreme time pressures) had a twofold risk of MDD or GAD compared to those with low job demands. Relative risks (RRs) adjusting for all work characteristics were: 1·90 [95% confidence interval (CI) 1·22-2·98] in women, and 2·00 (95 % CI 1·13-3·56) in men. Analyses ruled out the possibility that the association between work stress and disorder resulted from study members' socio-economic position, a personality tendency to report negatively, or a history of psychiatric disorder prior to labour-market entry. Prospective longitudinal analyses showed that high-demand jobs were associated with the onset of new depression and anxiety disorder in individuals without any pre-job history of diagnosis or treatment for either disorder. Conclusions. Work stress appears to precipitate diagnosable depression and anxiety in previously healthy young workers. Helping workers cope with work stress or reducing work stress levels could prevent the occurrence of clinically significant depression and anxiety.

What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression.

Abstract: BackgroundAlthough self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators.MethodRandomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression.ResultsThirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those ‘at risk’), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0·36, 95% confidence interval (CI) 0·05–0·68, p=0·03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background.ConclusionsThe results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help.

Early childhood factors associated with the development of post-traumatic stress disorder : results from a longitudinal birth cohort

Abstract: Background Childhood factors have been associated with increased risk of developing post-traumatic stress disorder (PTSD). Previous studies assessed only a limited number of childhood factors retrospectively. We examined the association between childhood neurodevelopmental, temperamental, behavioral and family environmental characteristics assessed before age 11 years and the development of PTSD up to age 32 years in a birth cohort.

Implications for neurobiological research of cognitive models of psychosis: a theoretical paper.

Abstract: BackgroundCognitive models of the positive symptoms of psychosis specify the cognitive, social and emotional processes hypothesized to contribute to their occurrence and persistence, and propose that vulnerable individuals make characteristic appraisals that result in specific positive symptoms.MethodWe describe cognitive models of positive psychotic symptoms and use this as the basis of discussing recent relevant empirical investigations and reviews that integrate cognitive approaches into neurobiological frameworks.ResultsEvidence increasingly supports a number of the hypotheses proposed by cognitive models. These are that: psychosis is on a continuum; specific cognitive processes are risk factors for the transition from subclinical experiences to clinical disorder; social adversity and trauma are associated with psychosis and with negative emotional processes; and these emotional processes contribute to the occurrence and persistence of psychotic symptoms. There is also evidence that reasoning biases contribute to the occurrence of delusions.ConclusionsThe benefits of incorporating cognitive processes into neurobiological research include more sophisticated, bidirectional and interactive causal models, the amplification of phenotypes in neurobiological investigations by including emotional processes, and the adoption of more specific clinical phenotypes. For example, there is potential value in studying gene×environment×cognition/emotion interactions. Cognitive models and their derived phenotypes constitute the missing link in the chain between genetic or acquired biological vulnerability, the social environment and the expression of individual positive symptoms.

The sources of co-morbidity between major depression and generalized anxiety disorder in a Swedish national twin sample.

Abstract: Background. Prior studies report high levels of co-morbidity between major depression (MD) and generalized anxiety disorder (GAD) and suggest that these disorders are closely related genetically. The personality trait of neuroticism (N) is substantially correlated with risk for MD and GAD. Method. Bivariate twin models were applied to lifetime diagnoses of modified DSM-IV diagnosis of MD and GAD obtained at personal interview in 1998–2003 with 37 296 twins from the populationbased Swedish Twin Registry. A trivariate Cholesky model with N, MD and GAD was applied to a subset (23 280 members of same-sex twin pairs) who completed a self-report questionnaire assessing N in 1972–1973. Results. In the best-fit bivariate model, the genetic correlation between MD and GAD was estimated at +1 . 00 in females and +0 . 74 in males. Individual-specific environmental factors were also shared between the two disorders with an estimated correlation of +0 . 59 in males and +0 . 36 in females. In the best-fit trivariate Cholesky model, genetic factors indexed by N impacted equally on risk for MD and GAD in males and females. However, in both sexes, genetic risk factors indexed by N contributed only around 25% to the genetic correlation between MD and GAD. Conclusion. Genetic risk factors for lifetime MD and GAD are strongly correlated, with higher correlations in women than in men. Although genetic risk factors indexed by the personality trait of N contribute substantially to risk for both MD and GAD, the majority of genetic covariance between the two disorders results from factors not shared with N.

Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a randomized controlled clinical trial

Abstract: Background. Subthreshold depression is a highly prevalent condition and a risk factor for developing a major depressive episode. Internet-based cognitive behaviour therapy may be a promising approach for the treatment of subthreshold depression. The current study had two aims : (1) to determine whether an internet-based cognitive behaviour therapy intervention and a group cognitive behaviour therapy intervention are more effective than a waiting-list control group ; and (2) to determine whether the effect of the internet-based cognitive behaviour therapy differs from the group cognitive behaviour therapy intervention. Method. A total of 191 women and 110 men with subthreshold depression were randomized into internet-based treatment, group cognitive behaviour therapy (Lewinsohn's Coping With Depression course), or a waiting-list control condition. The main outcome measure was treatment response after 10 weeks, defined as the difference in pre- and post-treatment scores on the Beck Depression Inventory (BDI). Missing data, a major limitation of this study, were imputed using the Multiple Imputation (MI) procedure Data Augmentation. Results. In the waiting-list control group, we found a pre- to post-improvement effect size of 0 . 45, which was 0 . 65 in the group cognitive behaviour therapy condition and 1 . 00 within the internet- based treatment condition. Helmert contrasts showed a significant difference between the waiting- list condition and the two treatment conditions (p=0 . 04) and no significant difference between both treatment conditions (p=0 . 62). Conclusions. An internet-based intervention may be at least as effective as a commonly used group cognitive behaviour therapy intervention for subthreshold depression in people over 50 years of age.

Generalized anxiety disorder and depression : childhood risk factors in a birth cohort followed to age 32

Abstract: BACKGROUND: The close association between generalized anxiety disorder (GAD) and major depressive disorder (MDD) prompts questions about how to characterize them in future diagnostic systems. We tested whether risk factors for MDD and GAD are similar or different. METHOD: The representative 1972-73 Dunedin birth cohort of 1037 males and females was followed to age 32 with 96% retention. Adult GAD and MDD were diagnosed at ages 18, 21, 26, and 32 years, and juvenile anxiety/depression were also taken into account. Thirteen prospective risk measures indexed domains of family history, adverse family environment, childhood behavior, and adolescent self-esteem and personality traits. RESULTS: Co-morbid MDD+GAD was antedated by highly elevated risk factors broadly across all domains. MDD+GAD was further characterized by the earliest onset, most recurrence, and greatest use of mental health services and medication. Pure GAD had levels of risk factors similar to the elevated levels for co-morbid MDD+GAD; generally, pure MDD did not. Pure GAD had risks during childhood not shared by pure MDD, in domains of adverse family environment (low SES, somewhat more maltreatment) and childhood behavior (internalizing problems, conduct problems, somewhat more inhibited temperament). Pure MDD had risks not shared by pure GAD, in domains of family history (of depression) and personality (low positive emotionality). CONCLUSIONS: Specific antecedent risk factors for pure adult MDD versus GAD may suggest partly different etiological pathways. That GAD and co-morbid MDD+GAD share many risk markers suggests that the presence of GAD may signal a pathway toward relatively more severe internalizing disorder. Language: en

Does normal developmental expression of psychosis combine with environmental risk to cause persistence of psychosis? A psychosis proneness-persistence model.

Abstract: Background. Research suggests that low-grade psychotic experiences in the general population are a common but transitory developmental phenomenon. Using two independent general population samples, the hypothesis was examined that common, non-clinical developmental expression of psychosis may become abnormally persistent when synergistically combined with developmental exposures that may impact on behavioural and neurotransmitter sensitization such as cannabis, trauma and urbanicity. Method. The amount of synergism was estimated from the additive statistical interaction between baseline cannabis use, childhood trauma and urbanicity on the one hand, and baseline psychotic experiences on the other, in predicting 3-year follow-up psychotic experiences, using data from two large. longitudinal, random population samples from the Netherlands [The Netherlands Mental Health Survey and Incidence Study (NEMESIS)] and Germany [The Early Developmental Stages of Psychopathology (EDSP) study]. Results. The 3-year persistence rates of psychotic experiences were low at 26% in NEMESIS and 31% in EDSP. However, persistence rates were progressively higher with greater baseline number of environmental exposures in predicting follow-up psychotic experiences (chi(2)=6.9, df=1, p=0009 in NEMESIS and chi(2)=4.2, df=1, p=0.04 in EDSP). Between 21% and 83% (NEMESIS) and 29% and 51% (EDSP) of the subjects exposed to both environmental exposures and psychotic experiences at baseline had persistence of psychotic experiences at follow-up because of the synergistic action of the two factors. Conclusion. The findings suggest that environmental risks for psychosis act additively, and that the level of environmental risk combines synergistically with non-clinical developmental expression of psychosis to cause abnormal persistence and, eventually, need for care.

The epidemiology of DSM-IV specific phobia in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

Abstract: Background There is a lack of current detailed national data on the prevalence, correlates, disability and co-morbidity of DSM-IV specific phobia (SP), the prevalence of specific objects and situations feared, and associations between impairment, treatment and co-morbidity and the number of specific situations and objects feared, among adults in the USAMethod The data were derived from a large (43093) representative sample of the adult population in the USAResults Prevalences of 12-month and lifetime DSM-IV SP were 7·1% and 9·4% respectively Being female, young, and low income increased risk, while being Asian or Hispanic decreased risk (p<0·05) The mean age at onset of SP was 9·7 years, the mean duration of episode was 20·1 years and only 8·0% reported treatment specifically for SP Most specific phobias involved multiple fears, and an increasing number of fears, regardless of content, was associated with greater disability and impairment, treatment seeking and co-morbidity with other Axis I and II disordersConclusions SP is a highly prevalent, disabling and co-morbid disorder in the US adult population The early onset of SP and the disorders most strongly associated with it highlights the need for longitudinal studies beginning in early childhood Results suggest the existence of a generalized subtype of SP much like social phobia, which, once revealed, may lead to a classification of SP that is more etiologically and therapeutically meaningful

Physical activity and prevalence and incidence of mental disorders in adolescents and young adults

Abstract: Background. Although positive effects of physical activity on mental health indicators have been reported, the relationship between physical activity and the development of specific mental disorders is unclear. Method. A cross-sectional (12-month) and prospective-longitudinal epidemiological study over 4 years in a community cohort of 2548 individuals, aged 14-24 years at outset of the study. Physical activity and mental disorders were assessed by the DSM-IV Composite International Diagnostic Interview (CIDI) with an embedded physical activity module. Multiple logistic regression analyses controlling for age, gender and educational status were used to determine the cross-sectional and prospective associations of mental disorders and physical activity. Results. Cross-sectionally, regular physical activity was associated with a decreased prevalence of any and co-morbid mental disorder, due to lower rates of substance use disorders, anxiety disorders and dysthymia. Prospectively, subjects with regular physical activity had a substantially lower overall incidence of any and co-morbid mental disorder, and also a lower incidence of anxiety, somatoform and dysthymic disorder. By contrast, the incidence of bipolar disorder was increased among those with regular physical activity at baseline. In terms of the population attributable fraction (PAF), the potential for preventive effects of physical activity was considerably higher for men than for women. Conclusions. Regular physical activity is associated with a substantially reduced risk for some, but not all, mental disorders and also seems to reduce the degree of co-morbidity. Further examination of the evidently complex mechanisms and pathways underlying these associations might reveal promising new research targets and procedures for targeted prevention.

Parental separation, loss and psychosis in different ethnic groups: a case-control study

Abstract: Background. Numerous studies have reported high rates of psychosis in the Black Caribbean and Black African populations in the UK. However, few studies have investigated the role of specific risk factors in different ethnic groups. We sought to investigate the relationship between long-term separation from, and death of, a parent before the age of 16 and risk of adult psychosis in different ethnic groups. Method. All patients with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were included in the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study. Data relating to clinical and social variables, including parental separation and loss, were collected from patients and controls. Results. Separation from, and death of, a parent before the age of 16 were both strongly associated with a two- to threefold increased risk of psychosis. The strength of these associations were similar for White British and Black Caribbean (but not Black African) subjects. Separation from (but not death of) a parent was more common among Black Caribbean controls than White British controls. Conclusions. Early separation may have a greater impact in the Black Caribbean population, because it is more common, and may contribute to the excess of psychosis in this population.

The cognitive neuropsychology of depression in the elderly.

Abstract: BackgroundThe cognitive impairment of older depressed patients with late- as opposed to early-onset illness may show important differences, in that patients with early onset may suffer predominantly from impaired episodic memory, and those with late onset mainly from reductions of executive function and processing speed.MethodWe searched Medline and EMBASE as well as individual papers' reference lists for relevant publications, recording comparisons in neuropsychological test results between early-onset depression (EOD), late-onset depression (LOD) and healthy volunteers. Effect sizes are presented for cognitive domains, such as executive function, processing speed, episodic memory, semantic memory and mental state examination.ResultsPatients with LOD showed greater reductions in processing speed and executive function than patients with EOD and controls. Both patient groups showed reduced function in all domains, except mental state, compared with controls.ConclusionPronounced executive deficits are typical of the late-onset patients described in published studies, while episodic memory impairment is not specific to early-onset illness. Possible reasons and confounders are discussed.

A nationwide US study of post-traumatic stress after hospitalization for physical injury.

Abstract: BackgroundInjured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings.MethodA total of 2931 injured trauma survivors aged 18–84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury.ResultsApproximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1·17, 95% confidence interval (CI) 1·02–1·34], pre-injury depression (RR 1·33, 95% CI 1·15–1·54), benzodiazepine prescription (RR 1·46, 95% CI 1·17–1·84) and intentional injury (RR 1·32, 95% CI 1·04–1·67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals.ConclusionsNationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.

Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis

Abstract: Background. Hopelessness is considered a pre-eminent risk factor for suicide and non-fatal self-harm. We aimed to quantify the ability of the Beck Hopelessness Scale (BHS) to predict these two outcomes.Method. Medline, Embase, PsycINFO and Cinahl were searched to January 2006. We included cohort studies in which the BHS was applied and patients were followed-up to establish subsequent suicide or non-fatal self-harm. Four studies provided usable data on suicide, and six studies provided data on non-fatal self-harm. Summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios (DORs) were calculated for each study. Random effects meta-analytic pooling across studies at the standard cut-off point ([ges ]9) was undertaken and summary receiver operating characteristic (ROC) curves constructed.Results. For suicide, pooled sensitivity was 0·80 [95% confidence interval (CI) 0·68–0·90], pooled specificity was 0·42 (95% CI 0·41–0·44), and the pooled DOR was 3·39 (95% CI 1·29–8·88). For non-fatal self-harm, pooled sensitivity was 0·78 (95% CI 0·74–0·82), pooled specificity was 0·42 (95% CI 0·38–0·45), and the pooled DOR was 2·27 (95% CI 1·53–3·37).Conclusion. The standard cut-off point on the BHS identifies a high-risk group for potential suicide, but the magnitude of the risk is lower than previously reported estimates. The standard cut-off point is also capable of identifying those who are at risk of future self-harm, but the low specificity rate means it is unlikely to be of use in targeting treatment designed to lower the rate of repetition.

Development of a new measure of health-related quality of life for people with dementia: DEMQOL.

Abstract: Background. We identified the need to develop a scientifically rigorous measure of health-related quality of life (HRQL) in dementia that would be appropriate for use at all stages of dementia severity and would be available in both self- and proxy-report versions.Method. We used standard psychometric methods to eliminate items with poor psychometric properties (item-reduction field test) and to assess the acceptability, reliability and validity of the item-reduced instruments (psychometric evaluation field test). We developed and validated two versions of DEMQOL: a 28-item interviewer-administered questionnaire that is self-reported by the person with dementia (DEMQOL) and a 31-item interviewer-administered questionnaire that is proxy-reported by a caregiver (DEMQOL-Proxy).Results. DEMQOL shows high reliability (internal consistency and test–retest) and moderate validity in people with mild/moderate dementia. DEMQOL-Proxy shows good acceptability and internal consistency and moderate evidence of validity in people with mild/moderate and severe dementia. Test–retest reliability and performance in people with severe dementia need further testing.Conclusions. DEMQOL and DEMQOL-Proxy show psychometric properties that are comparable with the best available dementia-specific measures of HRQL. We recommend that DEMQOL and DEMQOL-Proxy are used together. Reliability and validity need to be confirmed in independent samples and responsiveness needs to be evaluated.

A new scale to assess the therapeutic relationship in community mental health care: STAR

Abstract: Background. No instrument has been developed specifically for assessing the clinician-patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction. Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction. test-retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden. Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test-retest reliability was r = 0(.)76 for STAR-P and r = 0(.)68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit. Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care. (Less)

Anxiety disorders and suicidal behaviours in adolescence and young adulthood: findings from a longitudinal study.

Abstract: Background. The aim of this study was to estimate the extent to which anxiety disorders contribute to an increase in suicidal behaviour after controlling for both observed and non-observed sources of confounding.Methods. Data were collected from the Christchurch Health and Development Study (CHDS), a 25-year longitudinal study of over 1000 participants. Measures of anxiety disorders [phobia, generalized anxiety disorder (GAD), panic disorder], major depression (MD), substance use disorders, conduct/antisocial personality disorder, stressful life events, unemployment, and suicidal ideation/attempts for subjects aged 16-18, 18-21 and 21-25 years were used to fit random and fixed effects regression models of the associations between anxiety disorders and suicidal behaviours.Results. Anxiety disorders were strongly associated with suicidal ideation/attempts. Any single anxiety disorder increased the odds of suicidal ideation by 7.96 times [95% confidence interval (CI) 5.69-11.13] and increased the rate of suicide attempts by 5.85 times (95% CI 3.66-9.32). Control for co-occurring mental disorders, non-observed fixed confounding factors and life stress reduced these associations [suicidal ideation odds ratio (OR) 2.80, 95% CI 1.71-4.58; suicide attempts incidence rate ratio (IRR) 1.90, 95% CI 1.07-3.39]. Rates of suicidal behaviour also increased with the number of anxiety disorders. Estimates of the population attributable risk suggested that anxiety disorders accounted for 7-10% of the suicidality in the cohort.Conclusions. Anxiety disorders may be a risk factor for suicidality, even after controlling for confounding, with risks increasing with multiple anxiety disorders. Management of anxiety disorders may be an important component in strategies to reduce population rates of suicide. Language: en

Functional and psychosocial impairment in adults with undiagnosed ADHD.

Abstract: Background. Identify a group of adults with ‘undiagnosed’ attention deficit hyperactivity disorder(ADHD) and compare their personal and family medical histories, psychosocial profiles, functionalimpairment and quality of life with non-ADHD controls. Additionally, compare adults with un-diagnosedanddiagnosedADHDtoinvestigatepossiblereasonswhytheundiagnosedavoidclinicaldetection.Method. ICD-9 codes for ADHD in administrative claims records and responses to a telephone-administered adult ADHD screener [the Adult ADHD Self-Report Scale (ASRS)] were used toclassify approximately 21000 members of two large managed health-care plans as ‘undiagnosed’(no coded diagnosis; ASRS positive) or ‘non-ADHD’ controls (no coded diagnosis; ASRS nega-tive). Patients identified as ‘undiagnosed’ ADHD were compared with samples of non-ADHDcontrols and ‘diagnosed’ ADHD patients (ICD-9 coded ADHD diagnoses) on the basis of demo-graphics, socio-economic status, past and present mental health conditions, and self-reportedfunctional and psychosocial impairment and quality of life.Results. A total of 752 ‘undiagnosed’ ADHD subjects, 199 ‘non-ADHD’ controls and 198‘diagnosed’ ADHD subjects completed a telephone interview. Overall, the ‘undiagnosed’ ADHDcohort demonstrated higher rates of co-morbid illness and greater functional impairment than‘non-ADHD’ controls, including significantly higher rates of current depression, and problemdrinking, lower educational attainment, and greater emotional and interpersonal difficulties.‘Undiagnosed’ ADHD subjects reported a different racial composition and lower educationalattainment than ‘diagnosed’ ADHD subjects.Conclusion. Individuals with ‘undiagnosed’ ADHD manifest significantly greater functional andpsychosocial impairment than those screening negative for the disorder, suggesting that ADHDposes a serious burden to adults even when clinically unrecognized.INTRODUCTIONAttentiondeficithyperactivitydisorder(ADHD)is a neuropsychiatric disorder characterized bysymptoms of inattention with or without evi-dence of impulsivity and hyperactivity (APA,2000). ADHD is most often recognized and bestdescribed in school-aged children (AACAP,1997), and until recently was assumed to resolveafter puberty (Hill & Schoener, 1996; Barkley,2002). However, recently conducted long-termfollow-up studies suggest that ADHD in factpersists into adulthood in a majority of patients.(Landgraf et al. 2002; Weiss & Murray, 2003).ADHD in children may remain undiagnosedfor a variety of reasons. ADHD is highly co-morbid with other psychiatric conditions andmay be overlooked in the presence of coexistinganxiety, depression, learning disabilities or a

State affective instability in borderline personality disorder assessed by ambulatory monitoring

Abstract: BACKGROUND: Although affective instability is an essential criterion for borderline personality disorder (BPD), it has rarely been reported as an outcome criterion. To date, most of the studies assessing state affective instability in BPD using paper-pencil diaries did not find indications of this characteristic, whereas in others studies, the findings were conflicting. Furthermore, the pattern of instability that characterizes BPD has not yet been identified. METHOD: We assessed the affective states of 50 female patients with BPD and 50 female healthy controls (HC) during 24 hours of their everyday life using electronic diaries. RESULTS: In contrast to previous paper-and-pencil diary studies, heightened affective instability for both emotional valence and distress was clearly exhibited in the BPD group but not in the HC group. Inconsistencies in previous papers can be explained by the methods used to calculate instability (see Appendix). In additional, we were able to identify a group-specific pattern of instability in the BPD group characterized by sudden large decreases from positive mood states. Furthermore, 48% of the declines from a very positive mood state in BPD were so large that they reached a negative mood state. This was the case in only 9% of the HC group, suggesting that BPD patients, on average, take less time to fluctuate from a very positive mood state to a negative mood state. CONCLUSION: Future ambulatory monitoring studies will be useful in clarifying which events lead to the reported, sudden decrease in positive mood in BPD patients.

The concept of recovery in major depression.

Abstract: In clinical medicine, the term recovery connotes the act of regaining or returning to a normal or usual state of health. However, there is lack of consensus about the use of this term (which may indicate both a process and a state), as well as of the related word remission, which indicates a temporary abatement of symptoms. Such ambiguities also affect the concepts of relapse (the return of a disease after its apparent cessation) and recurrence (the return of symptoms after a remission).

Early predictors of chronic post-traumatic stress disorder in assault survivors

Abstract: Background. Some studies suggest that early psychological treatment is effective in preventing chronic post-traumatic stress disorder (PTSD), but it is as yet unclear how best to identify trauma survivors who need such intervention. This prospective longitudinal study investigated the prognostic validity of acute stress disorder (ASD), of variables derived from a meta-analysis of risk factors for PTSD, and of candidate cognitive and biological variables in predicting chronic PTSD following assault. Method. Assault survivors who had been treated for their injuries at a metropolitan Accident and Emergency (A&E) Department were assessed with structured clinical interviews to establish diagnoses of ASD at 2 weeks (n=222) and PTSD at 6 months (n=205) after the assault. Candidate predictors were assessed at 2 weeks. Results. Most predictors significantly predicted PTSD status at follow-up. Multivariate logistic regressions showed that a set of four theory-derived cognitive variables predicted PTSD best (Nagelkerke R 2 =0 . 50), followed by the variables from the meta-analysis (Nagelkerke R 2 =0 . 37) and ASD (Nagelkerke R 2 =0 . 25). When all predictors were considered simultaneously, mental defeat, rumination and prior problems with anxiety or depression were chosen as the best combination of predictors (Nagelkerke R 2 =0 . 47). Conclusion. Questionnaires measuring mental defeat, rumination and pre-trauma psychological problems may help to identify assault survivors at risk of chronic PTSD.

Assessment of complex mental activity across the lifespan: development of the Lifetime of Experiences Questionnaire (LEQ)

Abstract: Background. Brain reserve is a property of the central nervous system related to complex mental activity which may mediate the course and clinical expression of brain injury. Since there is no instrument that comprehensively assesses complex mental activity through the lifespan, we developed and tested the Lifetime of Experiences Questionnaire (LEQ) in a prospective study of healthy ageing. Method. The LEQ assesses educational, occupational and cognitive lifestyle activities at different stages through life. Test–retest, item analysis and Item Response Theory (IRT) were used to determine reliability. Dimensionality was evaluated using factor analysis. Validity was established through IRT analysis of test performance, correlation with an extant contemporaneous instrument (Cognitive Activities Scale ; CAS) and prediction of global cognitive change over 18 months controlling for age, baseline cognition and hypertension. Results. In a sample of healthy older individuals (n=79) the LEQ was found to be consistent, coherent and discriminate between individuals with high and low mental activity levels. Factor analysis revealed a dominant factor which loaded heavily on education, occupation and leisure activity. Total LEQ was significantly correlated with the CAS. Furthermore, individuals with higher LEQ scores showed less cognitive decline over 18 months, independent of covariates (r=0 . 37, p=0 . 003). Conclusions. The LEQ is a reliable and valid instrument for assessing complex lifespan mental activity which is protective against cognitive decline. The LEQ is therefore proposed as a useful tool for estimating brain reserve in older individuals and further development is anticipated.

Neighbourhood-level effects on psychoses: re-examining the role of context.

Abstract: BackgroundThe incidence of schizophrenia varies by individual-level characteristics and neighbourhood-level attributes. Few specific socio-environmental risk factors (SERFs) have been identified at the neighbourhood level. Cross-level interactions are poorly understood. We investigated these issues using data from the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study.MethodAll incidence cases of ICD-10 schizophrenia (F20) and other non-affective psychoses (F21–29), aged 16–64 years, across 33 wards in Southeast London were identified over a 2-year period (1997–1999). Census data provided the denominator for each ward. Multilevel Poisson regression simultaneously modelled individual- and neighbourhood-level SERFs, including socio-economic deprivation, voter turnout (proxy for social capital), ethnic fragmentation (segregation) and ethnic density.ResultsA total of 218 subjects were identified during 565 576 person-years at risk. Twenty-three per cent of variance in incidence of schizophrenia across wards could be attributed to neighbourhood-level risk factors [95% confidence interval (CI) 9·9–42·2]. Thus, 1% increases in voter turnout [incidence rate ratio (IRR) 0·95, 95% CI 0·92–0·99] and ethnic segregation (IRR 0·95, 95% CI 0·92–0·99) were both independently associated with a reduced incidence of 5%, independent of age, sex, ethnicity, deprivation and population density. This was similar for other non-affective psychoses. There was some evidence that ethnic minority individuals were at greater risk of schizophrenia in areas with smaller proportions of minority groups (p=0·07).ConclusionSERFs at individual and neighbourhood levels were implicated in the aetiology of psychosis, but we were unable to determine whether these associations were causal. Individual risk may be mediated by social capital, which could operate as a protective factor, perhaps moderating social stress in the onset of psychoses.