Book chapters will be unavailable on Saturday 24th August between 8am-12pm BST. This is for essential maintenance which will provide improved performance going forwards. Please accept our apologies for any inconvenience caused.
To send this article to your account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send this article to your Kindle, first ensure firstname.lastname@example.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Psychological medicine (liaison psychiatry) aims to integrate psychiatry
into other areas of medicine. It is currently enjoying considerable
expansion. The degree to which it can take advantage of this opportunity
will be important not only for its own future, but also for the survival of
psychiatry as a medical discipline.
Psychiatric diagnosis is in the spotlight following the recent publication
of DSM-5. In this article we consider both the benefits and limitations of
diagnosis in psychiatry. The use of internationally recognised diagnoses,
although insufficient alone, is part of a psychiatrist's professional
responsibility to provide high-quality, evidence-based care for
Transsexualism is not usually indicative of psychopathology. In carefully
selected individuals, with multidisciplinary support, a change of social
gender role and cross-sex hormone treatment greatly improves the
psychological and social state. Sustained improvement merits gender
reassignment surgery. The key is early referral with subsequent primary care
cooperation in the treatment plan.
The use of benzodiazepines has been advised against in older people, but
prevalence rates remain high.
To review the evidence for interventions aimed at reducing benzodiazepine
use in older people.
We conducted a systematic review, assessment of risk of bias and
meta-analyses of randomised controlled trials of benzodiazepine
withdrawal and prescribing interventions.
Ten withdrawal and eight prescribing studies met the inclusion criteria.
At post-intervention, significantly higher odds of not using
benzodiazepines were found with supervised withdrawal with psychotherapy
(odds ratio (OR) = 5.06, 95% CI 2.68–9.57, P<0.00001)
and withdrawal with prescribing interventions (OR = 1.43, 95% CI
1.02–2.02, P=0.04) in comparison with the control
interventions treatment as usual (TAU), education placebo, withdrawal
with or without drug placebo, or psychotherapy alone. Significantly
higher odds of not using benzodiazepines were also found for multifaceted
prescribing interventions (OR = 1.37, 95% CI 1.10–1.72,
P = 0.006) in comparison with control interventions
(TAU and prescribing placebo).
Supervised benzodiazepine withdrawal augmented with psychotherapy should
be considered in older people, although pragmatic reasons may necessitate
consideration of other strategies such as medication review.
A number of copy number variants (CNVs) have been suggested as
susceptibility factors for schizophrenia. For some of these the data
remain equivocal, and the frequency in individuals with schizophrenia is
To determine the contribution of CNVs at 15 schizophrenia-associated loci
(a) using a large new data-set of patients with schizophrenia
(n = 6882) and controls (n = 6316),
and (b) combining our results with those from previous studies.
We used Illumina microarrays to analyse our data. Analyses were
restricted to 520 766 probes common to all arrays used in the different
We found higher rates in participants with schizophrenia than in controls
for 13 of the 15 previously implicated CNVs. Six were nominally
significantly associated (P<0.05) in this new
data-set: deletions at 1q21.1, NRXN1, 15q11.2 and
22q11.2 and duplications at 16p11.2 and the Angelman/Prader–Willi
Syndrome (AS/PWS) region. All eight AS/PWS duplications in patients were
of maternal origin. When combined with published data, 11 of the 15 loci
showed highly significant evidence for association with schizophrenia
We strengthen the support for the majority of the previously implicated
CNVs in schizophrenia. About 2.5% of patients with schizophrenia and 0.9%
of controls carry a large, detectable CNV at one of these loci. Routine
CNV screening may be clinically appropriate given the high rate of known
deleterious mutations in the disorder and the comorbidity associated with
these heritable mutations.
A single nucleotide polymorphism (rs7914558) within the cyclin M2
(CNNM2) gene was recently identified as a common risk
variant for schizophrenia. The mechanism by which CNNM2
confers risk is unknown.
To determine the impact of the rs7914558 risk ‘A’ allele
on measures of neurocognition, social cognition and brain structure.
Patients with schizophrenia (n = 400) and healthy
controls (n = 160) completed measures of
neuropsychological function and social cognition. Structural magnetic
resonance imaging data were also acquired from an overlapping sample of
Irish healthy controls (n = 159) and an independent
sample of Italian patients (n = 82) and healthy controls
(n = 39).
No effects of genotype on neuropsychological test performance were
observed. However, a dosage effect of the risk allele was found for an
index of social cognition (i.e. attributional style), such that risk
status was associated with reduced self-serving bias across groups
(GG>AG>AA, P<0.05). Using voxel-based
morphometry to investigate neuroanatomical regions putatively supporting
social cognition, risk carriers had relatively increased grey matter
volume in the right temporal pole and right anterior cingulate cortex
(Pcorrected<0.05) in the Irish healthy controls sample;
neuroanatomical associations between CNNM2 and grey
matter volume in anterior cingulate cortex were also observed in the
Italian schizophrenia and healthy controls samples.
Although the biological role of CNNM2 in schizophrenia
remains unknown, these data suggest that this CNNM2 risk
variant rs7914558 may have an impact on neural systems relevant to social
cognition. How such effects may mediate the relationship between genotype
and disease risk remains to be established.
Bipolar disorder is highly heritable and therefore longitudinal
observation of children of affected parents is important to mapping the
early natural history.
To model the developmental trajectory of bipolar disorder based on the
latest findings from an ongoing prospective study of the offspring of
parents with well-characterised bipolar disorder.
A total of 229 offspring from families in which 1 parent had confirmed
bipolar disorder and 86 control offspring were prospectively studied for
up to 16 years. High-risk offspring were divided into subgroups based on
the parental long-term response to lithium. Offspring were clinically
assessed and DSM-IV diagnoses determined on masked consensus review using
best estimate procedure. Adjusted survival analysis and generalised
estimating equations were used to calculate differences in lifetime
psychopathology. Multistate models were used to examine the progression
through proposed clinical stages.
High-risk offspring had an increased lifetime risk of a broad spectrum of
disorders including bipolar disorder (hazard ratio (HR) = 20.89;
P = 0.04), major depressive disorder (HR = 17.16;
P = 0.004), anxiety (HR = 2.20; P =
0.03), sleep (HR = 28.21; P = 0.02) and substance use
disorders (HR = 2.60; P = 0.05) compared with controls.
However, only offspring from lithium non-responsive parents developed
psychotic disorders. Childhood anxiety disorder predicted an increased
risk of major mood disorder and evidence supported a progressive
transition through clinical stages, from non-specific psychopathology to
depressive and then manic or psychotic episodes.
Findings underscore the importance of a developmental approach in
conjunction with an appreciation of familial risk to facilitate earlier
accurate diagnosis in symptomatic youth.
Changes in corpus callosum area and thickness have been reported in
bipolar disorder. Imaging and limited neuropathological data suggest
possible abnormalities in myelination and/or glial function.
To compare corpus callosum area, thickness and magnetic resonance imaging
(MRI) T1 signal intensity in patients with bipolar disorder and
A total of 48 patients with euthymic bipolar disorder and 46 healthy
controls underwent MRI analysis of callosal midsagittal area, callosal
thickness and T1 signal intensity.
The bipolar group had smaller overall and subregional callosal areas and
correspondingly reduced callosal width than the control group. Age
correlated negatively with callosal area in the control group but not in
the bipolar group. Signal intensity was higher in women than in men in
both groups. Signal intensity was reduced in women, but not in men, in
the bipolar group.
Observed differences probably relate to diagnosis rather than mood state
and bipolar disorder appears to result in morphometric change that
overrides changes seen in normal ageing. Intensity changes are consistent
with possible altered myelination or glial function. A gender-dependent
factor appears to operate and to interact with diagnosis.
Some studies have found an association between elevated cortisol and
subsequent depression, but findings are inconsistent. The cortisol
awakening response may be a more stable measure of
hypothalamic–pituitary–adrenal function and potentially of stress
To investigate whether salivary cortisol, particularly the cortisol
awakening response, is associated with subsequent depression in a large
Young people (aged 15 years, n = 841) from the Avon
Longitudinal Study of Parents and Children (ALSPAC) collected salivary
cortisol at four time points for 3 school days. Logistic regression was
used to calculate odds ratios for developing depression meeting ICD-10
criteria at 18 years.
We found no evidence for an association between salivary cortisol and
subsequent depression. Odds ratios for the cortisol awakening response
were 1.24 per standard deviation (95% CI 0.93–1.66, P =
0.14) before and 1.12 (95% CI 0.73–1.72, P = 0.61) after
adjustment for confounding factors. There was no evidence that the other
cortisol measures, including cortisol at each time point, diurnal drop
and area under the curve, were associated with subsequent depression.
Our findings do not support the hypothesis that elevated salivary
cortisol increases the short-term risk of subsequent depressive illness.
The results suggest that if an association does exist, it is small and
unlikely to be of clinical significance.
Despite depressive disorders being very common there has been little
research to guide primary care physicians on the choice of treatment for
patients with mild to moderate depression.
To evaluate the efficacy of interpersonal counselling compared with
selective serotonin reuptake inhibitors (SSRIs), in primary care
attenders with major depression and to identify moderators of treatment
A randomised controlled trial in nine centres (DEPICS, Australian New
Zealand Clinical Trials Registry number: ACTRN12608000479303). The
primary outcome was remission of the depressive episode (defined as a
Hamilton Rating Scale for Depression score 7 at 2 months). Daily
functioning was assessed using the Work and Social Adjustment Scale.
Logistic regression models were used to identify moderators of treatment
The percentage of patients who achieved remission at 2 months was
significantly higher in the interpersonal counselling group compared with
the SSRI group (58.7% v. 45.1%, P =
0.021). Five moderators of treatment outcome were found: depression
severity, functional impairment, anxiety comorbidity, previous depressive
episodes and smoking habit.
We identified some patient characteristics predicting a differential
outcome with pharmacological and psychological interventions. Should our
results be confirmed in future studies, these characteristics will help
clinicians to define criteria for first-line treatment of depression
targeted to patients' characteristics.
Research into the relationship between gender identity disorder and
psychiatric problems has shown contradictory results.
To investigate psychiatric problems in adults fulfilling DSM-IVTR
criteria for a diagnosis of gender identity disorder.
Data were collected within the European Network for the Investigation of
Gender Incongruence using the Mini International Neuropsychiatric
Interview – Plus and the Structured Clinical Interview for DSM-IV Axis II
Disorders (n = 305).
In 38% of the individuals with gender identity disorder a current
DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and
anxiety disorders. Furthermore, almost 70% had a current and lifetime
diagnosis. All four countries showed a similar prevalence, except for
affective and anxiety disorders, and no difference was found between
individuals with early-onset and late-onset disorder. An Axis II
diagnosis was found in 15% of all individuals with gender identity
disorder, which is comparable to the general population.
People with gender identity disorder show more psychiatric problems than
the general population; mostly affective and anxiety problems are
Most accounts of deployment mental health in UK armed forces personnel
rely on retrospective assessments.
We present data relating to the burden of mental ill health and the
effect of support measures including operational, family, welfare and
medical support obtained on two occasions some 18 months apart.
A total of 2794 personnel completed a survey while deployed to
Afghanistan; 1363 in 2011 and 1431 in 2010. Their responses were compared
The prevalence of self-report mental health disorder was low and not
significantly different between the surveys; the rates of probable
post-traumatic stress disorder (PTSD) were 2.8% in 2010 and 1.8% in 2011;
for common mental health disorders the rates were 17.0% and 16.0%
respectively. Remembering receiving predeployment psychoeducation,
perceptions of good leadership and good family support were all
significantly associated with better mental health. Seeking support from
non-medical sources and reporting sick for medical reasons were both
significantly associated with poorer mental health.
Over a period of 18 months, deployment mental health symptoms in UK armed
forces personnel were fewer than those obtained from a military
population sample despite continuing deployment in a high-threat context
and were associated with perceptions of support.