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Our major classification systems (DSM and ICD) face three main problems:
the high rates of ‘comorbidity’ that are produced by our present
diagnostic rules, the increasing use of ‘not elsewhere classified’ (NEC)
by practising clinicians, and the fact that each new edition is longer
and more complex than the one preceding it. A major simplification of the
chapter structure used by each classification might pave the way to
address these problems.
A recent study found that people with depression identified in the
community recovered equally well given unsupported computerised
cognitive–behavioural therapy (CBT), general practitioner treatment or a
combination of the two, even if they did not comply. The results are
different from those reported elsewhere. Could natural remission explain
There is a long history of research into the attributes of carers of
people with psychosis, but few interventions target their distress or
To describe an empirically based model of the relationships of those
caring for people with psychosis to inform clinical and theoretical
We developed a model of informal carer relationships in psychosis, based
on an integration of the literature elaborating the concept of expressed
emotion. The model accounts for divergent outcomes of three relationship
types: positive, overinvolved and critical/hostile relationships.
Good evidence supports a number of hypotheses concerning the origin and
maintenance of these relationship outcomes, which relate to specific
differences in carer attributions, illness perceptions, coping behaviour,
social support, distress, depression and low self-esteem predicted by our
model. We propose that interventions aimed at modifying the specific
maintenance factors involved in the different styles of relationships
will optimise therapeutic change both for service users with psychosis
and for their carers.
Family work in psychosis, which improves relationships through
problem-solving, reduces service user relapse. It is now time to consider
theory-based interventions focused on improving carer outcomes.
Although people with bipolar disorder spend more time in a depressed than
manic state, little evidence is available to guide the treatment of acute
To compare the efficacy, acceptability and safety of mood stabiliser
monotherapy with combination and antidepressant treatment in adults with
acute bipolar depression.
Systematic review and meta-analysis of randomised, double-blind
Eighteen studies with a total 4105 participants were analysed. Mood
stabiliser monotherapy was associated with increased rates of response
(relative risk (RR) = 1.30, 95% CI 1.16–1.44, number needed to treat
(NNT) = 10, 95% CI 7–18) and remission (RR = 1.51, 95% CI 1.27–1.79, NNT
= 8, 95% CI 5–14) relative to placebo. Combination therapy was not
statistically superior to monotherapy. Weight gain, switching and suicide
rates did not differ between groups. No differences were found between
individual medications or drug classes for any outcome.
Mood stabilisers are moderately efficacious for acute bipolar depression.
Extant studies are few and limited by high rates of discontinuation and
short duration. Further study of existing and novel agents is
A growing number of European studies, particularly from Nordic countries,
suggest an increased frequency of autism in children of immigrant
parents. In contrast, North American studies tend to conclude that
neither maternal ethnicity nor immigrant status are related to the rate
of autism-spectrum disorders.
To examine the hypotheses that maternal ethnicity and/or immigration are
linked to the rate of childhood autism-spectrum disorders.
Retrospective case-note analysis of all 428 children diagnosed with
autism-spectrum disorders presenting to the child development services in
two centres during a 6-year period.
Mothers born outside Europe had a significantly higher risk of having a
child with an autism-spectrum disorder compared with those born in the
UK, with the highest risk observed for the Caribbean group (relative
risks (RRs) in the two centres: RR = 10.01, 95% CI 5.53–18.1 and RR =
8.89, 95% CI 5.08–15.5). Mothers of Black ethnicity had a significantly
higher risk compared with White mothers (RR = 8.28, 95% CI 5.41–12.7 and
RR = 3.84, 95% CI 2.93–5.02). Analysis of ethnicity and immigration
factors together suggests the increased risk is predominately related to
Maternal immigration is associated with substantial increased risk of
autism-spectrum disorders with differential risk according to different
region of birth and possibly ethnicity.
Parent and teacher data, from questionnaire surveys, suggest that
school-identified disruptive children often have pragmatic language
deficits of an autistic type.
This replication study aimed to confirm earlier findings, using
individual clinical assessment to investigate traits of autism-spectrum
disorder in disruptive children.
Persistently disruptive children (n = 26) and a
comparison group (n = 22) were recruited from primary
schools in a deprived inner-city area. Measures included standardised
autism diagnostic interviews (with parents) and tests of IQ, social
cognition, theory of mind and attention (with children).
The disruptive children possessed poorer pragmatic language skills
(P<0.0001) and mentalising abilities
(P<0.05) than comparisons. Nine disruptive
children (35%) met ICD–10 criteria for atypical autism or Asperger
Many persistently disruptive children have undetected disorders of social
communication, which are of potential aetiological significance.
Regular adolescent cannabis use predicts a range of later drug use and
psychosocial problems. Little is known about whether occasional cannabis
use carries similar risks.
To examine associations between occasional cannabis use during
adolescence and psychosocial and drug use outcomes in young adulthood;
and modification of these associations according to the trajectory of
cannabis use between adolescence and age 20 years, and other potential
A 10-year eight-wave cohort study of a representative sample of 1943
secondary school students followed from 14.9 years to 24 years.
Occasional adolescent cannabis users who continued occasional use into
early adulthood had higher risks of later alcohol and tobacco dependence
and illicit drug use, as well as being less likely to complete a
post-secondary qualification than non-users. Those using cannabis at
least weekly either during adolescence or at age 20 were at highest risk
of drug use problems in young adulthood. Adjustment for smoking in
adolescence reduced the association with later educational achievement,
but associations with drug use problems remained.
Occasional adolescent cannabis use predicts later drug use and
educational problems. Partial mediation by tobacco use raises a
possibility that differential peer affiliation may play a role.
The nature of the relationship between duration of the pre-diagnostic
interval in schizophrenia and better outcomes remains unclear.
To re-examine data from one of the earliest studies suggesting an
association between long pre-treatment interval and compromised outcome,
assessing the relationship between symptomatic and social variables and
increased relapse risk at 1 year.
Symptomatic, social and demographic data from participants in the
Northwick Park Study of First Episodes who completed 12-month follow-up
(n = 101) were re-analysed in the context of duration
of untreated illness (DUI).
At admission, those with long DUI were more likely to have lower scores
on tension derived from the Present State Examination, exhibited more
behaviour threatening to others and more bizarre behaviour, were more
likely to be single, to live alone or dependently, to be unemployed and
to have experienced more adverse life events prior to admission. Logistic
regression showed that diminished tension, bizarre behaviour and
unemployed status independently increased the risk of relapse, bizarre
behaviour making the single biggest contribution. Tension did not remain
significant with log-transformation of data.
Findings are consistent with the conclusion that long DUI can reflect
characteristics of the psychosis itself rather than delay in
The World Health Organization (WHO) has stated that the three leading
causes of burden of disease in 2030 are projected to include HIV/AIDS,
unipolar depression and ischaemic heart disease.
To estimate health-related quality of life (HRQoL) and quality-adjusted
life-year (QALY) losses associated with mental disorders and chronic
physical conditions in primary healthcare using data from the diagnosis
and treatment of mental disorders in primary care (DASMAP) study, an
epidemiological survey carried out with primary care patients in
A cross-sectional survey of a representative sample of 3815 primary care
patients. A preference-based measure of health was derived from the
12-item Short Form Health Survey (SF–12): the Short Form–6D (SF–6D)
multi-attribute health-status classification. Each profile generated by
this questionnaire has a utility (or weight) assigned. We used
non-parametric quantile regressions to model the association between both
mental disorders and chronic physical condition and SF–6D scores.
Conditions associated with SF–6D were: mood disorders, β =−0.20 (95% CI
−0.18 to −0.21); pain, β = −0.08 (95%CI −0.06 to −0.09) and anxiety, β
=−0.04 (95% CI −0.03 to −0.06). The top three causes of QALY losses
annually per 100 000 participants were pain (5064), mood disorders (2634)
and anxiety (805).
Estimation of QALY losses showed that mood disorders ranked second behind
pain-related chronic medical conditions.
Evidence about the cost-effectiveness and cost utility of computerised
cognitive–behavioural therapy (CCBT) is still limited. Recently, we
compared the clinical effectiveness of unsupported, online CCBT with
treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus
TAU) for depression. The study is registered at the Netherlands Trial
Register, part of the Dutch Cochrane Centre (ISRCTN47481236).
To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus
Costs, depression severity and quality of life were measured for 12
months. Cost-effectiveness and cost-utility analyses were performed from
a societal perspective. Uncertainty was dealt with by bootstrap
replications and sensitivity analyses.
Costs were lowest for the CCBT group. There are no significant group
differences in effectiveness or quality of life. Cost-utility and
cost-effectiveness analyses tend to be in favour of CCBT.
On balance, CCBT constitutes the most efficient treatment strategy,
although all treatments showed low adherence rates and modest
improvements in depression and quality of life.
There is an urgent need for the development of cost-effective preventive
strategies to reduce the onset of mental disorders.
To establish the cost-effectiveness of a stepped care preventive
intervention for depression and anxiety disorders in older people at high
risk of these conditions, compared with routine primary care.
An economic evaluation was conducted alongside a pragmatic randomised
controlled trial (ISRCTN26474556). Consenting individuals presenting with
subthreshold levels of depressive or anxiety symptoms were randomly
assigned to a preventive stepped care programme (n = 86)
or to routine primary care (n = 84).
The intervention was successful in halving the incidence rate of
depression and anxiety at €563 (£412) per recipient and €4367 (£3196) per
disorder-free year gained, compared with routine primary care. The latter
would represent good value for money if the willingness to pay for a
disorder-free year is at least €5000.
The prevention programme generated depression- and anxiety-free survival
years in the older population at affordable cost.
Many people suffer from subthreshold and mild panic disorder and are at
risk of developing more severe panic disorder.
This study (trial registration: ISRCTN33407455) was conducted to evaluate
the effectiveness of an early group intervention based on
cognitive–behavioural principles to reduce panic disorder
Participants with subthreshold or mild panic disorder were recruited from
the general population and randomised to the intervention
(n = 109) or a waiting-list control group
(n = 108). The course was offered by 17 community
mental health centres.
In the early intervention group, 43/109 (39%) participants presented with
a clinically significant change on the Panic Disorder Severity Scale–Self
Report (PDSS–SR) v. 17/108 (16%) in the control group
(odds ratio (OR) for favourable treatment response 3.49, 95% CI
1.77–6.88, P = 0.001). The course also had a positive
effect on DSM–IV panic disorder status (OR = 1.96, 95% CI=1.05–3.66,
P = 0.037). The PDSS–SR symptom reduction was also
substantial (between-group standardised mean difference of 0.68). The
effects were maintained at 6-month follow-up.
People presenting with subthreshold and mild panic disorder benefit from
this brief intervention.