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The two-dimensional bipolar spectrum described here comprises a continuum of
severity from normal to psychotic and a continuum from depression, via three
bipolar subgroups to mania. This combination of dimensional and categorical
principles for classifying mood disorders may help alleviate the problems of
underdiagnosis and undertreatment of bipolar disorders.
The term stigma refers to problems of knowledge (ignorance), attitudes
(prejudice) and behaviour (discrimination). Most research in this area has
been based on attitude surveys, media representations of mental illness and
violence, has only focused upon schizophrenia, has excluded direct
participation by service users, and has included few intervention studies.
However, there is evidence that interventions to improve public knowledge
about mental illness can be effective. The main challenge in future is to
identify which interventions will produce behaviour change to reduce
discrimination against people with mental illness.
Schizophrenia is widely held to stem from the combined effects of multiple
common polymorphisms, each with a small impact on disease risk. We suggest
an alternative view: that schizophrenia is highly heterogeneous genetically
and that many predisposing mutations are highly penetrant and individually
rare, even specific to single cases or families. This ‘common disease – rare
alleles' hypothesis is supported by recent findings in human genomics and by
allelic and locus heterogeneity for other complex traits. We review the
implications of this model for gene discovery research in schizophrenia.
Psychosis, like other major psychiatric disorders, is both genetically and
clinically complex. Increasingly powerful molecular genetic studies have the
potential to identify DNA variation that influences susceptibility to
genetically complex disorders. There is a need to use a range of genetic
approaches appropriate to identifying a spectrum of risk variants from the
common through to the rare. Some variants might have large effects at the
level of the individual but most are likely to have modest or small effects
at both population and individual level. Extensive clinical heterogeneity is
likely to have a significant impact on the power of even the largest studies
and, more importantly, will lead to extensive variability between studies
and hamper attempts at replication. If we are to realise the potential of
molecular genetics, we need to overcome the major limitations imposed by
current psychiatric diagnostic classifications and identify clinical
phenotypes that reflect the presence of underlying entities with biological
Case–control studies are vulnerable to selection and information biases
which may generate misleading findings.
To assess the quality of methodological reporting of case–control studies
published in general psychiatric journals.
All the case–control studies published over a 2-year period in the six
general psychiatric journals with impact factors of more than 3 were
assessed by a group of psychiatrists with training in epidemiology using
a structured assessment devised for the purpose. The measured study
quality was compared across type of exposure and journal.
The reporting of methods in the 408 identified papers was generally poor,
with basic information about recruitment of participants often absent.
Reduction of selection bias was described best in the ‘pencil and paper’
studies and worst in the genetic studies. Neuroimaging studies reported
the most safeguards against information bias. Measurement of exposure was
reported least well in studies determining the exposure with a biological
Poor reporting of recruitment strategies threatens the validity of
reported results and reduces the generalisability of studies.
Psychiatric disorders are among the top causes worldwide of disease
burden and disability. A major criterion for validating diagnoses is
stability over time.
To evaluate the long-term stability of the most prevalent psychiatric
diagnoses in a variety of clinical settings.
A total of 34 368 patients received psychiatric care in the catchment
area of one Spanish hospital (1992–2004). This study is based on 10 025
adult patients who were assessed on at least ten occasions (360 899
psychiatric consultations) in three settings: in-patient unit, 2000–2004
(n=546); psychiatric emergency room, 2000–2004
(n=1408); and out-patient psychiatric facilities,
1992–2004 (n=10 016). Prospective consistency,
retrospective consistency and the proportion of patients who received
each diagnosis in at least 75% of the evaluations were calculated for
each diagnosis in each setting and across settings.
The temporal consistency of mental disorders was poor, ranging from 29%
for specific personality disorders to 70% for schizophrenia, with
stability greatest for in-patient diagnoses and least for out-patient
The findings are an indictment of our current psychiatric diagnostic
A limited case-load size is considered crucial for some forms of
intensive case management and many countries have undertaken extensive
reorganisation of mental health services to achieve this. However, there
has been limited empirical work to explore this specifically.
To test whether there is a discrete threshold for changes in intensive
case management practice determined by case-load size.
‘Virtual’ case-load sizes were calculated for patients from their actual
contacts over a 2-year period and were compared with the proportions of
contacts devoted to medical and non-medical care (as a proxy for a more
comprehensive service model).
There were 39 025 recordings for 545 patients over 2 years, with a mean
rate of contacts per full-time case manager per month of 48 (range
35–60). There was no variation in the proportion of non-medical contacts
when case-load sizes were over 1:20 but there was a convincing linear
relationship when sizes were between 1:10 and 1:20.
Case-load size between 1:10 and 1:20 does affect the practice of case
management. However, there is no support for a paradigm shift in practice
at a discrete level.
Treatment within medium secure forensic psychiatry services is expected
to reduce risk to the public.
To measure the period prevalence and incidence of offending following
discharge and identify associated risk factors.
Follow-up of patients from 7 of 14 regional services in England and Wales
who spent time at risk (n=1344) for a mean of 6.2 years.
Outcome was obtained from offenders index, hospital case-files and the
central register of deaths.
One in 8 men and 1 in 16 women were convicted of grave offences.
Incidence rates indicated low density and most patients were not
subsequently convicted. Offence predictors included gender, younger age,
early-onset offending, previous convictions and a comorbid or primary
diagnosis of personality disorder. Longer in-patient stay and restriction
on discharge were protective.
Risks of reoffending remain for a subgroup of discharged patients. Future
research should aim to improve their identification and risk management
Despite the high prevalence of cannabis use in schizophrenia, few studies
have examined the potential relationship between cannabis exposure and
brain structural abnormalities in schizophrenia.
To investigate prefrontal grey and white matter regions in patients
experiencing a first episode of schizophrenia with an additional
diagnosis of cannabis use or dependence (n=20) compared
with similar patients with no cannabis use (n=31) and
healthy volunteers (n=56).
Volumes of the superior frontal gyrus, anterior cingulate gyrus and
orbital frontal lobe were outlined manually from contiguous magnetic
resonance images and automatically segmented into grey and white
Patients who used cannabis had less anterior cingulate grey matter
compared with both patients who did not use cannabis and healthy
A defect in the anterior cingulate is associated with a history of
cannabis use among patients experiencing a first episode of schizophrenia
and could have a role in poor decision-making and in choosing more risky
Long-term mortality and the risk factors for premature death among
patients with schizophrenia living in rural communities are unknown.
To explore the 10-year mortality and its risk factors among patients with
We used data from a 10-year prospective follow-up study (1994–2004) of
mortality among people with schizophrenia, and death registration data
for Xinjin County, Chengdu, China.
The mortality rate was 2228 per 100 000 person-years during follow-up.
Both all-cause mortality and suicide rates were significantly greater in
male than in female patients. Age at illness onset (>45 years),
duration of illness (⩾10 years), age greater than 50 years, physical
illness, inability to work, male gender, and never having received
treatment were identified as independent predictors of increased
Higher mortality rates in male patients may contribute to the higher
prevalence of schizophrenia in women compared with men in China. The
findings of risk factors for mortality should be taken into account when
developing interventions to improve outcomes among people with
Lack of insight has been observed in people with schizophrenia across
cultures but assessment of insight must take into account prevailing
To determine whether culturally specific and Western biomedical
interpretations of insight and psychosis can be reconciled.
Patients with schizophrenia (n=131) were assessed during
their first contact with psychiatric services in Vellore, South India.
Patients' explanatory models, psychopathology and insight were
investigated using a standard schedule translated into Tamil.
Supernatural explanations of symptoms were frequent. Some insight
dimensions were weakly associated (inversely) with severity of symptoms
whereas preserved insight was associated with anxiety, help-seeking and
perception of change. Willingness to attribute symptoms to disease, in
others and in one's self, but not to supernatural forces was strongly
associated with insight.
The relationship between insight, awareness of illness and other clinical
variables is similar in South India to elsewhere. However, the assessment
of insight might have failed to capture locally accepted explanatory
frameworks. An inclusive conceptual model which emphasises help-seeking
There is concern about the stigma of mental illness, but it is difficult
to measure stigma consistently.
To develop a standardised instrument to measure the stigma of mental
We used qualitative data from interviews with mental health service users
to develop a pilot scale with 42 items. We recruited 193 service users in
order to standardise the scale. Of these, 93 were asked to complete the
questionnaire twice, 2 weeks apart, of whom 60 (65%) did so. Items with a
test–retest reliability kappa coefficient of 0.4 or greater were retained
and subjected to common factor analysis.
The final 28-item stigma scale has a three-factor structure: the first
concerns discrimination, the second disclosure and the third potential
positive aspects of mental illness. Stigma scale scores were negatively
correlated with global self-esteem.
This self-report questionnaire, which can be completed in 5–10 min, may
help us understand more about the role of stigma of psychiatric illness
in research and clinical settings.
Low birth weight, prematurity and higher miscarriage rates have
previously been reported in women with eating disorders.
To determine whether women with a history of eating disorders are at
higher risk of major adverse perinatal outcomes.
Adjusted birth weight, preterm delivery and miscarriage history were
compared in those with a history of eating disorders (anorexia nervosa
(n=171), bulimia nervosa (n=199) and
both (n=82)) and those with other
(n=1166) and no psychiatric disorders
(n=10 636) in a longitudinal cohort study.
The group with bulimia nervosa had significantly higher rates of past
miscarriages (relative risk ratio 2.0, P=0.01) and the
group with anorexia nervosa delivered babies of significantly lower birth
weight than the general population (P=0.01), which was
mainly explained by lower pre-pregnancy body mass index. Preterm delivery
rates were comparable across groups.
Women with a history of eating disorders are at higher risk of major
adverse obstetric outcomes. Antenatal services should be aware of this
Executive dysfunction is common after stroke and may impair long-term
outcome. Remedies for this condition are limited.
To examine the effect of antidepressants on executive function after
Forty-seven patients who had had a stroke during the prior 6 months
received 12 weeks of antidepressant treatment in double-blind
placebo-controlled fashion, followed by assessment of executive function
at the end of treatment and after 2 years.
No significant group effect was found at the end of treatment. However,
21 months after the end of treatment the placebo group showed
deterioration of executive function, whereas the active treatment group
showed clear and significant improvement independent of depressive
symptoms (F=12.1, d.f.=1,45, P=
Antidepressant treatment fosters long-term improvement of executive
function following stroke. This phenomenon is consistent with a
reorganisation of neuronal networks associated with prefrontal functions
based on modulation of monoaminergic neurotransmission and the activity
We assessed the effect of the installation of barriers on the Clifton
suspension bridge, Bristol, England, in 1998 on local suicides by jumping.
Deaths from this bridge halved from 8.2 per year (1994–1998) to 4.0 per year
(1999–2003; P=0.008). Although 90% of the suicides from the bridge were by
males, there was no evidence of an increase in male suicide by jumping from
other sites in the Bristol area after the erection of the barriers. This
study provides evidence for the effectiveness of barriers on bridges in
preventing site-specific suicides and suicides by jumping overall in the
In a survey of 1794 UK NHS hospital consultants 1308 (73%) responded.
Psychiatric morbidity (General Health Questionnaire—12 score ⩾4) was present
in 32% of responders, who were twice as likely to report drinking hazardous
levels of alcohol, being irritable with patients and colleagues, reducing
their standards of care and intending to retire early (all
P<0.001). Male and mid-aged consultants were also
particularly at risk. Approaches that support consultants to practice
medicine safely throughout their careers are required.