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People who suffer from post-traumatic stress disorder (PTSD) are likely
to find that their quality of life is substantially impaired. However,
unlike other diagnoses, in order for clinicians to make a diagnosis of
PTSD people have to be able to accurately recall the details of a
traumatic incident. Yet recent evidence suggests that recall of such
incidents is often unreliable. Clinicians should therefore exercise
caution to avoid making inaccurate diagnoses.
Although hypochondriasis is currently classified as a somatoform
disorder, the underlying cognitive processes may be more consistent with
an anxiety disorder. This observation has important implications for
treatment and subsequent revisions of the diagnostic classification of
Early worsening of anxiety, agitation and irritability are thought to be
common among people commencing antidepressants, especially for anxiety
disorders. This phenomenon, which may be termed jitteriness/anxiety
syndrome, is cited as an explanation for early treatment failure and
caution in using selective serotonin reuptake inhibitors (SSRIs).
However, we believe that it is inconsistently defined and that robust
evidence to support the phenomenon is lacking.
To review systematically all evidence relating to jitteriness/ anxiety
syndrome to identify: constituent symptoms; medications implicated;
disorders in which it was reported; incidence; time course; management
strategies; relationship of this syndrome to therapeutic response;
distinction between syndrome and akathisia; relationship between syndrome
and suicide; and genetic predispositions.
A systematic search identified articles and these were included in the
review if they addressed one of the above aspects of jitteriness/anxiety
Of 245 articles identified, 107 articles were included for review. No
validated rating scales for jitteriness/anxiety syndrome were identified.
There was no robust evidence that the incidence differed between SSRIs
and tricyclic antidepressants, or that there was a higher incidence in
anxiety disorders. Published incidence rates varied widely from 4 to 65%
of people commencing antidepressant treatment. Common treatment
strategies for this syndrome included a slower titration of
antidepressant and the addition of benzodiazepines. Conclusive evidence
for the efficacy of these strategies is lacking. There was conflicting
and inconclusive evidence as to whether the emergence of this syndrome
had a predictive value on the response to treatment. It appears to be a
separate syndrome from akathisia, but evidence for this assertion was
limited. The effect of jitteriness/anxiety syndrome on suicide rates has
not been evaluated. Three studies examined genetic variations and
side-effects from treatment, but none was specifically designed to assess
Jitteriness/anxiety syndrome remains poorly characterised. Despite this,
clinicians' perception of this syndrome influences prescribing and it is
cited to support postulated mechanisms of drug action. We recommend
systematised evaluation of side-effects at earlier time points in
antidepressant trials to further elucidate this clinically important
There has been long-standing concern about the quality of medical care
offered to people with mental illness.
To investigate whether the quality of medical care received by people
with mental health conditions, including substance misuse, differs from
the care received by people who have no comparable mental disorder.
A systematic review of studies that examined the quality of medical care
in those with and without mental illness was conducted using robust
critical appraisal techniques.
Of 31 valid studies, 27 examined receipt of medical care in those with
and without mental illness and 10 examined medical care in those with and
without substance use disorder (or dual diagnosis). Nineteen of 27 and 10
of 10, respectively, suggested inferior quality of care in at least one
domain. Twelve studies found no appreciable differences in care or failed
to detect a difference in at least one key area. Several studies showed
an increase in healthcare utilisation but without any increase in
quality. Three studies found superior care for individuals with mental
illness in specific subdomains. There was inadequate information
concerning patient satisfaction and structural differences in healthcare
delivery. There was also inadequate separation of delivery of care from
uptake in care on which to base causal explanations.
Despite similar or more frequent medical contacts, there are often
disparities in the physical healthcare delivered to those with
psychiatric illness although the magnitude of this effect varies
There is strong evidence to support inequalities in medical care
disadvantaging those who have a psychiatric illness or a substance use
disorder. Despite promising approaches to shared care there is a
substantial gap in routine medical care for many individuals with mental
illness or substance use disorders.2,99,100 This is most
apparent in general (internal) medicine and cardiovascular care but may
also be present in diabetes care and cancer care. There is little
evidence to suggest that the recommended enhanced medical care for
individuals with mental illness has been successfully implemented. Future
work must focus on the type and severity of mental illness, patient
factors such as adherence and systems interventions to increase the
quality of care for those with chronic mental illness.
Recent reports estimate the prevalence of autism-spectrum conditions in
the UK to be 1%.
To use different methods to estimate the prevalence of autism-spectrum
conditions, including previously undiagnosed cases, in
We carried out a survey of autism-spectrum conditions using the Special
Educational Needs (SEN) register. A diagnosis survey was distributed to
participating schools to be handed out to parents of all children aged
5–9 years. The mainstream primary school population was screened for
The prevalence estimates generated from the SEN register and diagnosis
survey were 94 per 10 000 and 99 per 10 000 respectively. A total of 11
children received a research diagnosis of an autism-spectrum condition
following screening and assessment. The ratio of known:unknown cases is
about 3:2 (following statistical weighting procedures). Taken together,
we estimate the prevalence to be 157 per 10 000, including previously
This study has implications for planning diagnostic, social and health
Post-traumatic stress disorder (PTSD) diagnosis often depends on a
retrospective, self-report of exposure to a life-threatening event.
To examine the stability of recalled perceived life threat in a community
sample exposed to a distinct stressful event.
Five hundred and thirty-two Norwegian citizens who experienced the 2004
South-East Asia tsunami completed a self-report questionnaire 6 and 24
months post-disaster. The questionnaire measured perceived life-threat
intensity, exposure, immediate stress response, psychopathology,
personality dimensions, self-efficacy and social support.
Recalled threat intensity increased from 6 to 24 months
(P <0.001). Recall amplification was associated
with lack of PTSD symptom improvement (P < 0.05), but
not with degree of exposure, immediate stress response, mood or stress
symptoms, personality, self-efficacy or social support.
Recall amplification of perceived life threat from a single stressful
event occurs in the general population, it may hinder PTSD symptom
improvement and it questions the diagnostic validity of PTSD.
Only limited empirical data support the existence of delayed-onset
post-traumatic stress disorder (PTSD).
To expand our understanding of delayed-onset PTSD prevalence and
A cross-sectional, epidemiological design (n = 747) incorporating
structured interviews to obtain relevant information for analyses in a
multisite study of military veterans.
A small percentage of veterans with identified current PTSD (8.3%, 7/84),
current subthreshold PTSD (6.9%, 2/29), and lifetime PTSD only (5.4%,
2/37) met criteria for delayed onset with PTSD symptoms initiating more
than 6 months after the index trauma. Altogether only 0.4% (3/747) of the
entire sample had current PTSD with delayed-onset symptoms developing
more than 1 year after trauma exposure, and no PTSD symptom onset was
reported more than 6 years posttrauma.
Retrospective reports of veterans reveal that delayed-onset PTSD
(current, subthreshold or lifetime) is extremely rare 1 year post-trauma,
and there was no evidence of PTSD symptom onset 6 or more years after
Previous studies have suggested that impaired fetal and childhood growth
are associated with an increased risk of schizophrenia, but the
association of pre-adult growth with non-clinical psychotic symptoms
(psychosis-like symptoms) in children is not known.
To explore the associations of body size at birth and age 7.5 years with
childhood psychosis-like symptoms.
Prospective cohort of children followed up from birth to age 12: the
Data on 6000 singleton infants born after 37 weeks of gestation. A one
standard deviation increase in birth weight was associated with an 18%
reduction in the risk of definite psychosis-like symptoms after adjusting
for age and gestation (Odds ratio (OR) = 0.82, 95% CI = 0.73–0.92,
P = 0.001). This association was partly confounded by
maternal anthropometry, smoking during pregnancy, socioeconomic status
and IQ. A similar association was seen for birth length and
psychosis-like symptoms, which disappeared after controlling for birth
weight. There was little evidence for an association of 7-year height or
adiposity with psychosis-like symptoms.
Measures of impaired fetal, but not childhood, growth are associated with
an increased risk of psychosis-like symptoms in 12-year-olds.
Subtle abnormalities in frontal white matter have been reported in
To assess whether impaired integrity of white matter tracts is associated
with bipolar disorder and genetic liability for the disorder.
A total of 19 patients with psychotic bipolar I disorder from multiply
affected families, 21 unaffected first-degree relatives and 18 comparison
individuals (controls) underwent diffusion tensor imaging. Whole brain
voxel-based analyses compared fractional anisotropy between patients and
relatives with controls, and its relationship with a quantitative measure
of genetic liability.
Patients had decreased fractional anisotropy compared with controls in
the genu of the corpus callosum, right inferior longitudinal fasciculus
and left superior longitudinal fasciculus. Increased genetic liability
for bipolar disorder was associated with reduced fractional anisotropy
across distributed regions of white matter in patients and their
Disturbed structural integrity within key intra- and interhemispheric
tracts characterises both bipolar disorder and genetic liability for this
Selective serotonin reuptake inhibitors (SSRIs) are typically thought to
have a delay of several weeks in the onset of their clinical effects.
However, recent reports suggest they may have a much earlier therapeutic
onset. A reduction in amygdala responsivity has been implicated in the
therapeutic action of SSRIs.
To investigate the effect of a single dose of an SSRI on the amygdala
response to emotional faces.
Twenty-six healthy volunteers were randomised to receive a single oral
dose of citalopram (20 mg) or placebo. Effects on the processing of
facial expressions were assessed 3 h later using functional magnetic
Volunteers treated with citalopram displayed a significantly reduced
amygdala response to fearful facial expressions compared with
Such an immediate effect of an SSRI on amygdala responses to threat
supports the idea that antidepressants have an earlier onset of
therapeutically relevant effects than conventionally thought.
Naltrexone has considerable potential in helping to prevent relapse in
heroin dependency. A longer-lasting formulation for naltrexone treatment
is desirable to further reduce non-adherence and relapse during treatment
of opiate dependence.
To evaluate the safety and effectiveness of a 6-month naltrexone implant
in reducing opioid use after in-patient treatment.
A group of 56 abstinence-oriented patients who completed in-patient
treatment for opioid dependence were randomly and openly assigned to
receive either a 6-month naltrexone implant or their usual aftercare.
Drug use and other outcomes were assessed at 6-month follow-up.
Patients receiving naltrexone had on average 45 days less heroin use and
60 days less opioid use than controls in the 180-day period (both
P<0.05). Blood tests showed naltrexone levels
above 1 ng/ml for the duration of 6 months. Two patients died, neither of
whom had received an implant.
Naltrexone implant treatment safely and significantly reduces opioid use
in a motivated population of patients.
Mental health units in England had to become smoke-free by law from July
2008. Concerns regarding the implementation and enforcement of smoke-free
policies in these settings have been raised.
To study difficulties and challenges associated with smoke-free policy
implementation in English National Health Service (NHS) mental health
Questionnaire survey of all 72 English NHS trusts providing mental health
in-patient services and facilities, supplemented by semi-structured
telephone interviews at a systematic sample of 7 trusts and site visits
at a convenience sample of 5 trusts.
Questionnaires were returned by 79% of the trusts, all of whom had
implemented smoke-free policies. Most respondents (91%) believed that
mental health settings faced particular challenges, arising from the high
smoking prevalence among patients (81%), related safety risks (70%),
adverse effects on the clinician–patient relationship (36%), and
potential interactions with antipsychotic medication (34%). Interviews
indicated that sustained policy enforcement was perceived as difficult,
but that despite challenges and concerns, the impact of the policy was
regarded as beneficial, with some evidence of positive behavioural
changes occurring in people.
Many mental health trusts across England have implemented comprehensive
smoke-free policies but the majority state that they are facing specific
difficulties. Challenges and concerns need to be explored in depth and
addressed to ensure that smoke-free policies implemented under the terms
of the Health Act in July 2008 are not undermined.
Routine outcome monitoring may improve clinical services but remains
controversial, partly because the absence of a control group makes
To test a computer algorithm designed to allow practitioners to compare
their outcomes with epidemiological data from a population sample against
data from a randomised controlled trial, to see if it accurately
predicted the trial's outcome.
We developed an ‘added value’ score using epidemiological data on the
Strengths and Difficulties Questionnaire (SDQ). We tested whether it
correctly predicted the effect size for the control and intervention
groups in a randomised controlled trial.
As compared with the a priori expectation of zero, the Added Value Score
applied to the control group predicted an effect size of 70.03 (95% CI
70.30 to 0.24, t = 0.2, P = 0.8). As
compared with the trial estimate of 0.37, the Added Value Score applied
to the intervention group predicted an effect size of 0.36 (95% CI 0.12
to 0.60, t = 0.1, P = 0.9).
Our findings provide preliminary support for the validity of this
approach as one tool in the evaluation of interventions with groups of
children who have, or are at high risk of developing, significant
This study aimed to investigate the relationship between age at onset and
time to first pharmacological treatment in patients with either bipolar I
or II disorder. A total of 146 consecutive in-patients acutely admitted
from the same catchment area were included. Patients were divided into
four age groups: 0–12 years (23%); 13–18 years (32%); 19–29 years (26%);
and 30 years (18%). Mean age at first affective episode was 20.2 years
(s.d.=11.8). This represents a similar pattern to the age at onset seen
in out-patients in the USA. Early age at onset predicted a longer time to
first pharmacological treatment (ρ =0.695, P