Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both.

To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment.

Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24, 95% CI 1.02–1.52) or psychotherapy (RR=1.16, 95%CI 1.03–1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61, 95% CI 1.23–2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79–1.16).

Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

Efficacy trials suggest that structured psychological therapies may significantly reduce recurrence rates of major mood episodes in individuals with bipolar disorders.

To compare the effectiveness of treatment as usual with an additional 22 sessions of cognitive–behavioural therapy (CBT).

We undertook a multicentre, pragmatic, randomised controlled treatment trial (n=253). Patients were assessed every 8 weeks for 18 months.

More than half of the patients had a recurrence by 18 months, with no significant differences between groups (hazard ratio=1.05; 95% CI 0.74–1.50). Post hoc analysis demonstrated a significant interaction (P=0.04) such that adjunctive CBT was significantly more effective than treatment as usual in those with fewer than 12 previous episodes, but less effective in those with more episodes.

People with bipolar disorder and comparatively fewer previous mood episodes may benefit from CBT. However, such cases form the minority of those receiving mental healthcare.

The cost-utility of brief therapy compared with cognitive–behavioural therapy (CBT) and care as usual in the treatment of depression and anxiety has not yet been determined.

To assess the cost-utility of brief therapy compared with CBT and care as usual.

A pragmatic randomised controlled trial involving 702 patients was conducted at 7 Dutch mental healthcare centres (MHCs). Patients were interviewed at baseline and then every 3 months over a period of 1.5 years, during which time data were collected on direct costs, indirect costs and quality of life.

The mean direct costs of treatment at the MHCs were significantly lower for brief therapy than for CBT and care as usual. However, after factoring in other healthcare costs and indirect costs, no significant differences between the treatment groups could be detected. We found no significant differences in quality-adjusted life-years between the groups.

Cost-utility did not differ significantly between the three treatment groups.

Little is known about the cost-effectiveness of preventing mental disorders.

To study the cost-effectiveness of care as usual plus minimal contact psychotherapy relative to usual care alone in preventing depressive disorder.

An economic evaluation was conducted alongside a randomised clinical trial. Primary care patients with sub-threshold depression were assigned to minimal contact psychotherapy plus usual care (n=107) or to usual care alone (n=109).

Primary care patients with sub-threshold depression benefited from minimal contact psychotherapy as it reduced the risk of developing a full-blown depressive disorder from 18% to 12%. In addition, this intervention had a 70% probability of being more cost-effective than usual care alone. A sensitivity analysis indicated the robustness of these results.

Over 1 year adjunctive minimal contact psychotherapy improved outcomes and generated lower costs. This intervention is therefore superior to usual care alone in terms of cost-effectiveness.

The cost-effectiveness of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) has not been compared in a prospective study in primary care.

To determine the relative cost-effectiveness of TCAs, SSRIs and lofepramine in UK primary care.

An open-label, three-arm randomised trial with a preference arm. Practitioners referred 327 patients with incident depression.

No significant differences were found in effectiveness or cost-effectiveness. The numbers of depression-free weeks over 12 months (on the Hospital Anxiety and Depression Scale) were 25.3 (95% CI 21.3–29.0) for TCAs, 28.3 (95% CI 24.3–32.2) for SSRIs and 24.6 (95% CI 20.6–28.9) for lofepramine. Mean health service costs per patient were $762 (95% CI 553–1059) for TCAs, $875 (95% CI 675–1355) for SSRIs and $867 (95% CI 634–1521) for lofepramine. Cost-effectiveness acceptability curves suggested SSRIs were most cost-effective (with a probability of up to 0.6).

The findings support a policy of recommending SSRIs as first-choice antidepressants in primary care.

Relapse rates may be as high as 50% in people with major depressive disorder (MDD) previously treated to remission.

Duloxetine, an inhibitor of serotonin and noradrenaline reuptake that is licensed in Europe, the USA and elsewhere for the treatment of depressive episodes, was evaluated with regard to its efficacy, safety and tolerability in the prevention of relapse of MDD.

Adult out-patients with MDD received duloxetine (60 mg daily) for 12 weeks (n=533). Patients who responded to the drug were then randomised to duloxetine (60 mgdaily) (n=136) or placebo (n=142) for 26 weeks. The primary measure of efficacy was time to relapse.

Patients who received duloxetine (60 mg daily) experienced significantly longer times to relapse of MDD, and better efficacy global well-being, and quality-of-life outcomes compared with patients who received placebo. It should be noted that adverse events which occur in discontinuation may mimic some signs of depressive relapse, and were not specifically elicited in this study.

Duloxetine (60 mg daily) is effective in the prevention of relapse of MDD during continuation treatment.

The effect of recent increases in antidepressant prescribing on population suicide rates is uncertain.

To investigate the relationship between antidepressant sales and trends in suicide rates.

Graphical and quantitative assessment of trends in suicide and antidepressant sales in Norway, Sweden, Denmark and Finland.

Suicide rates declined in all four countries during the 1990s, whereas antidepressant sales increased by 3- to 4-fold. Decreasing suicide rates in Sweden and Denmark preceded the rise in anti-depressant sales by over 10 years, although the reductions accelerated between 1988 and 1990. In Norway, a modest but short-lived decline in suicide rates began around the time of the increase in antidepressant sales. In Finland, decreases in male suicide rates and to a lesser extent in female suicide rates began around the time of increased antidepressant sales. In all four countries decreases in suicide rates appeared to precede the widespread use of SSRIs.

We found mixed evidence that increases in antidepressant sales have coincided with a reduction in the number of suicides in Nordic countries.

Relatively little is known about depression in countries that were formerly part of the Soviet Union, especially Russia.

To investigate the rates and distribution of depressive symptoms in urban population samples in Russia, Poland and the Czech Republic.

A cross-sectional study was conducted in randomly selected men and women aged 45–64 years (n=2151 intotal, response rate 69%) in Novosibirsk (Russia), Krakow (Poland) and Karvina (Czech Republic). The point prevalence of depressive symptoms in the past week was defined as a score of at least 16 on the Center for Epidemiological Studies Depression scale.

In men the prevalence of depressive symptoms was 23% in Russia, 21% in Poland and 19% in the Czech Republic; in women the rates were 44%, 40% and 34% respectively. Depressive symptoms were positively associated with material deprivation, being unmarried and binge drinking. The association between education and depression was inverse in Poland and the Czech Republic but positive in Russia.

The prevalence of depressive symptoms in these eastern European urban populations was relatively high; as in other countries, it was associated with alcohol and several sociodemographic factors.

Neurocognitive deficits exist in euthymic patients with bipolar disorder, but relationships between symptoms, psychosocial and neurological factors remain uncertain.

To measure neurocognitive function in bipolar disorder and explore links to sub-syndromal mood symptoms, soft neurological signs and psychosocial impairment.

Attention, memory and executive function were tested in 37 euthymic patients with bipolar disorder and 37 controls. Psychosocial functioning, soft neurological signs and residual mood symptoms were assessed.

Performances on tests reflecting executive function and verbal memory (but not attention) were significantly poorer in the bipolar disorder group. Sub-syndromal mood symptoms produced small cognitive effects, predominantly on verbal memory. Soft neurological signs, especially frontal signs, were marked; some patients showed marked social disability which correlated strongly with soft neurological signs but weakly with executive dysfunction, which was linked to illness episodes.

Cognitive dysfunction, social dysfunction and soft signs occur in euthymic patients with bipolar disorder and may represent trait deficits.

There have been no studies of the co-occurrence of personality and substance use disorders in young community-dwelling adults.

To examine the association between DSM–IV personality disorders and substance use disorders in a large representative sample of young community-dwelling participants.

Young Australian adults (n=1520, mean age=24.1 years) were interviewed to determine the prevalence of substance use disorders; 1145 also had an assessment for personality disorder.

The prevalence of personality disorder was 18.6% (95% CI 16.5–20.7). Personality disorder was associated with indices of social disadvantage and the likely presence of common mental disorders. Independent associations were found between cluster B personality disorders and substance use disorders. There was little evidence for strong confounding or mediating effects of these associations.

In young adults, there are independent associations between cluster B personality disorders and substance use disorders.

Black (Black Caribbean and Black African) patients are over-represented in admissions to general adult and medium-security psychiatric services in England.

To describe the socio-demographic, clinical and offence characteristics of patients in high-security psychiatric hospitals (HSPHs) in England, and to compare admission rates and unmet needs by ethnic group.

A total of 1255 in-patients were interviewed, and their legal status, socio-demographic characteristics and individual treatment needs were assessed.

Black patients in HSPHs are over-represented by 8.2 times (range 3.2–24.4, 95% CI 7.1–9.3), are more often male (P=0.037), and are more often diagnosed with a mental illness and less often diagnosed with a personality disorder or learning disability (P < 0.001) than White patients. Unmet needs were significantly less common among White than among Black patients (mean values of 2.22 v. 2.62, difference=0.40, 95% CI 0.06–0.73).

Compared with the proportion of Black patients in the general population in their region of origin, a much higher proportion of Black patients were admitted to HSPHs, and fewer of their needs were met.

Black individuals in the UK have higher rates of contact with psychiatric emergency services than their White counterparts. It is unknown whether this is also the case in other European countries.

To compare the risk of contact with psychiatric emergency services and of compulsory admission between immigrant groups to The Netherlands and Dutch natives, and to determine the unique contribution of ethnicity to compulsory admission.

Study of 720 people referred to emergency psychiatric services in Greater Rotterdam, The Netherlands.

The relative risks (RRs) for contacts with psychiatric emergency services, for having a psychotic disorder and for compulsory admission were significantly higher in most immigrant groups. Moroccans, Surinamese and Dutch Antilleans had the highest risks of compulsory admission. After controlling for symptom severity, danger, motivation for treatment and level of social functioning, non-Western origin was no longer associated with compulsory admission.

Non-Western immigrant groups were overrepresented in psychiatric emergency care and were admitted compulsorily more frequently, possibly owing to a different clinical presentation.