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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.
Pregnant women and their fetuses are increasingly likely to be exposed to
antipsychotics. However, safety data remain limited. This editorial suggests
that, in future, well-designed observational pharmaco-epidemiology is our
best chance of illuminating risk for exposed populations and of informing
decision-making for women and clinicians.
Nomenclature used to describe acts of self-harm without fatal consequences
varies considerably. The term ‘non-suicidal self-injury’ (NSSI) offers an
opportunity to clarify study in this field, dichotomising the presence or
absence of suicidal intent. This may improve consistency in reporting
suicide and self-injurious behaviour with implications for management and
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.
Late-life depression may increase the risk of incident dementia, in
particular of Alzheimer's disease and vascular dementia.
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
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.
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).
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.
Teacher-pupil relationships have been found to mediate behavioural,
social and psychological outcomes for children at different ages
according to teacher and child report but most studies have been
To explore later psychiatric disorder among children with problematic
Secondary analysis of a population-based cross-sectional survey of
children aged 5-16 with a 3-year follow-up.
Of the 3799 primary-school pupils assessed, 2.5% of parents reported
problematic teacher-pupil relationships; for secondary-school pupils
(n=3817) this rose to 6.6%. Among secondary-school
pupils, even when children with psychiatric disorder at baseline were
excluded and we adjusted for baseline psychopathology score, problematic
teacher-pupil relationships were statistically significantly related to
higher levels of psychiatric disorder at 3-year follow-up (odds ratio
(OR) = 1.93, 95% CI 1.07-3.51 for any psychiatric disorder, OR=3.00, 95%
CI 1.37-6.58 for conduct disorder). Results for primary-school pupils
were similar but non-significant at this level of adjustment.
This study underlines the need to support teachers and schools to develop
positive relationships with their pupils.
Reactive attachment disorder (RAD) is associated with early childhood
maltreatment and has unknown population prevalence beyond infancy.
To estimate RAD prevalence in a deprived population of children.
All 1646 children aged 6-8 years old in a deprived sector of an urban UK
centre were screened for RAD symptoms. Parents of high and low scorers
were interviewed using semi-structured interviews probing for
psychopathology and individuals likely to have RAD were offered
Questionnaire data were available from 92.8% of teachers and 65.8% of
parents. Assessments were conducted with 50% of those invited and missing
data were imputed - based on the baseline data - for the rest. We
calculated that there would be 23 children with definite RAD diagnoses,
suggesting that the prevalence of RAD in this population was 1.40% (95%
In this deprived general population, RAD was not rare.
Use of antidepressants during pregnancy has been associated with a low
Apgar score in infants but a contribution from the underlying depressive
disorder might influence this association.
To estimate the effects of maternal depression and use of antidepressants
during pregnancy on low Apgar scores (<7) 5min after birth.
Register study on all pregnant women in Denmark from 1996 to 2006 linking
nationwide individualised data from the Medical Birth Register, the
Psychiatric Central Register and the National Prescription database.
Infants exposed to antidepressants during pregnancy had an increased rate
of a low Apgar score (odds ratio (OR) = 1.72, 95% CI 1.34-2.20). The
increased rate was only found among infants exposed to selective
serotonin reuptake inhibitors (SSRIS) (OR =1.96, 95% CI 1.52-2.54), not
among those exposed to newer (OR = 0.83, 95% CI 0.40-1.74) or older
antidepressants (OR=0.53, 95% CI 0.19-1.45). Maternal depression before
or during pregnancy, without prescription of antidepressants, was not
associated with a low Apgar score (OR=0.44, 95% CI 0.11-1.74). Women who
had only used antidepressants prior to pregnancy had no increased rate of
a low Apgar score in their subsequent pregnancy, regardless of depression
Use of SSRls during pregnancy increases the risk of a low Apgar score
independently of maternal depression.
Bright light therapy is an effective treatment for seasonal affective
disorder and non-seasonal depression. Depression and anxiety are common
psychiatric comorbidities in epilepsy.
To examine the efficacy of bright light therapy for symptoms of anxiety
and depression in adults with focal epilepsy (trial registration at
We recruited 101 adults with medically intractable focal epilepsy.
Participants completed the Hospital Anxiety and Depression Scale (HADS)
at the beginning (T1) and end of a 12-week baseline period
(T2) and again after 12 weeks of daily light therapy
(T3), with 51 participants using a high-intensity light box
and 50 using a low-intensity one. Seizure diaries were kept throughout
the baseline and trial period.
A total of 58 patients completed the trial. Anxiety and depression scores
were significantly reduced following the light therapy at T3
in both the high- and low-intensity groups.
Light therapy resulted in a significant reduction in symptoms of anxiety
and depression but we did not find any differences between high- v.
low-intensity treatment This may, therefore, be an effective treatment
for symptoms of low mood in epilepsy at lower intensities than those
typically used to treat seasonal affective disorder. Further work is
needed to investigate this possibility with an adequate placebo
People with borderline personality disorder frequently experience crises.
To date, no randomised controlled trials (RCTs) of crisis interventions
for this population have been published.
To examine the feasibility of recruiting and retaining adults with
borderline personality disorder to a pilot RCT investigating the
potential efficacy and cost-effectiveness of using a joint crisis
An RCT of joint crisis plans for community-dwelling adults with
borderline personality disorder (trial registration: ISRCTN12440268). The
primary outcome measure was the occurrence of self-harming behaviour over
the 6-month period following randomisation. Secondary outcomes included
depression, anxiety, engagement and satisfaction with services, quality
of life, well-being and cost-effectiveness.
In total, 88 adults out of the 133 referred were eligible and were
randomised to receive a joint crisis plan in addition to treatment as
usual (TAU; n=46) or TAU alone (n=42).
This represented approximately 75% of our target sample size and
follow-up data were collected on 73 (83.0%) participants.
Intention-to-treat analysis revealed no significant differences in the
proportion of participants who reported self-harming (odds ratio (OR)
=1.9, 95% CI 0.53-6.5,P = 0.33) or the frequency of
self-harming behaviour (rate ratio (RR)=0.74, 95% CI 0.34-1.63,
P=0.46) between the two groups at follow-up. No
significant differences were observed between the two groups on any of
the secondary outcome measures or costs.
It is feasible to recruit and retain people with borderline personality
disorder to a trial of joint crisis plans and the intervention appears to
have high face validity with this population. However, we found no
evidence of clinical efficacy in this feasibility study.
Forensic psychiatry aims to reduce recidivism and makes use of risk
assessment tools to achieve this goal. Various studies have reported on
the predictive qualities of these instruments, but it remains unclear
whether their use is associated with actual prevention of recidivism in
To test whether an intervention combining risk assessment and shared care
planning is associated with a reduction in violent and criminal
A cluster randomised controlled trial (Netherlands Trial Register number
NTR1042) was conducted in three outpatient forensic psychiatric clinics.
The intervention comprised risk assessment with the Short Term Assessment
of Risk and Treatability (START) and a shared care planning protocol
formulated according to shared decision-making principles. The control
group received usual care. The outcome consisted of the proportion of
clients with violent or criminal incidents at follow-up.
In total 58 case managers and 632 of their clients were included, in the
intervention group (n=310), 65% received the
intervention at least once. Findings showed a general treatment effect
(22% of clients with an incident at baseline v. 15% at
follow-up, P<0.01) but no significant difference
between the two treatment conditions (odds ratio (OR)=1.46, 95% CI
0.89-2.44, P = 0.15).
Although risk assessment is common practice in forensic psychiatry, our
results indicate that the primary goal of preventing recidivism was not
reached through risk assessment embedded in shared decision-making.
Repetition of hospital-treated self-poisoning and admission to
psychiatric hospital are both common in individuals who self-poison.
To evaluate efficacy of postcard intervention after 5 years.
A randomised controlled trial of individuals who have self-poisoned:
postcard intervention (eight in 12 months) plus treatment as usual
v. treatment as usual. Our primary outcomes were
self-poisoning admissions and psychiatric admissions (proportions and
There was no difference between groups for any repeat-episode
self-poisoning admission (intervention group: 24.9%, 95% CI 20.6-29.5;
control group: 27.2%, 95% CI 22.8-31.8) but there was a significant
reduction in event rates (incidence risk ratio (IRR)=0.54, 95% CI
0.37-0.81), saving 306 bed days. There was no difference for any
psychiatric admission (intervention group: 38.1%, 95% CI 33.1-43.2;
control group: 35.5%, 95% CI 30.8-40.5) but there was a significant
reduction in event rates (IRR=0.66, 95% CI 0.47-0.91), saving 2565 bed
A postcard intervention halved self-poisoning events and reduced
psychiatric admissions by a third after 5 years. Substantial savings
occurred in general hospital and psychiatric hospital bed days.
Anandamide is a ligand of the endocannabinoid system. Animals show a
depletion following repeated Δ9-tetrahydrocannabinol (THC)
administration but the effect of cannabis use on central nervous system
levels of endocannabinoids has not been previously examined in humans.
Cerebrospinal fluid (CSF) levels of the endocannabinoids anandamide,
2-arachidonoylglycerol (2-AG) and related lipids were tested in 33
volunteers (20 cannabis users). Lower levels of CSF anandamide and higher
levels of 2-AG in serum were observed in frequent compared with infrequent
cannabis users. Levels of CSF anandamide were negatively correlated with
persisting psychotic symptoms when drug-free. Higher levels of anandamide
are associated with a lower risk of psychotic symptoms following cannabis