The concept of social exclusion is now widely used in discussions about the nature of disadvantage, and there are ongoing initiatives to promote social inclusion among those with mental health problems.

To conduct a conceptual and methodological review of social exclusion, focusing initially on the origins and definitions of the concept and then on approaches to its measurement, both in general and in relation to mental health.

We used two main strategies. First, we utilised expertise within the study team to identify major texts and reviews on social exclusion and related topics. Second, we searched major bibliographic databases for literature on social exclusion and mental health. We adopted a non-quantitative approach to synthesising the findings.

There is no single accepted definition of social exclusion. However, most emphasise lack of participation in social activities as the core characteristic. There are a number of approaches to measuring social exclusion, including use of indicator lists and dimensions. In the mental health literature, social exclusion is poorly defined and measured.

If social exclusion is a useful concept for understanding the social experiences of those with mental health problems, there is an urgent need for more conceptual and methodological work.

There is evidence to suggest that among young people with mild intellectual disability there are those whose cognitive difficulties may predict the subsequent manifestation of a schizophrenic phenotype. It is suggested that they may be detectable by simple means.

To gain adequate cooperation from educational services, parents and students so as to recruit a sufficiently large sample to test the above hypothesis, and to examine the hypothesis in the light of the findings.

The sample was screened with appropriate instruments, and groups hypothesised as being likely or not likely to have the phenotype were compared in terms of psychopathology and neuropsychology.

Simple screening methods detect a sample whose psychopathological and neuropsychological profile is consistent with an extended phenotype of schizophrenia.

Difficulties experienced by some young people with mild and borderline intellectual disability are associated with enhanced liability to schizophrenia. Clinical methods can both identify those with this extended phenotype and predict those in whom psychosis will occur.

Few studies have employed formal diagnostic criteria to determine the prevalence of psychiatric disorders in contemporaneous samples of children with and without intellectual disabilities.

To establish the prevalence of psychiatric disorders against ICD—10 criteria among children with and without intellectual disabilities, the association with social/environmental risk factors, and risk attributable to intellectual disability.

Secondary analysis of the 1999 and 2004 Office for National Statistics surveys of the mental health of British children and adolescents with (n=641) and without (n = 17774) intellectual disability.

Prevalence of psychiatric disorders was 36% among children with intellectual disability and 8% among children without (OR=6.5). Children with intellectual disabilities accounted for 14% of all British children with a diagnosable psychiatric disorder Increased prevalence was particularly marked for autistic-spectrum disorder (OR=33.4), hyperkinesis (OR=8.4) and conduct disorders (OR=5.7). Cumulative risk of exposure to social disadvantage was associated with increased prevalence.

A significant proportion of the elevated risk for psychopathology among children with intellectual disability may be due to their increased rate of exposure to psychosocial disadvantage.

There is increasing interest in the proposition that residential environment can affect mental health.

To study the degree to which common mental disorder clusters according to postcode units and households. To investigate whether contextual measures of residential environment quality and geographical accessibility are associated with symptoms of common mental disorder.

A total of 1058 individuals aged 16–75 years (response rate 66%) participated in a cross-sectional survey The 12-item General Health Questionnaire measured symptoms of common mental disorder.

Only 2% (95% CI 0–6) of the unexplained variation in symptoms existed at postcode unit level, whereas 37% (95% CI 27–49) existed at household-level, but the postcode unit variation was reduced to zero after adjustments. There was little evidence to suggest that residential quality or accessibility were associated with symptoms.

There was substantial unexplained variation at the household level but we could find no evidence of postcode unit variation and no association with residential environmental quality or geographical accessibility. It is likely that the psychosocial environment is more important than the physical environment in relation to common mental disorder.

Exposure to childhood adversity may explain why only a minority of combatants exposed to trauma develop psychological problems.

To examine the association between self-reported childhood vulnerability and later health outcomes in a large randomly selected male military cohort.

Data are derived from the first stage of a cohort study comparing Iraq veterans and non-deployed UK military personnel. We describe data collected by questionnaire from males in the regular UK armed forces (n=7937).

Pre-enlistment vulnerability is associated with being single, of lower rank, having low educational attainment and serving in the Army. Pre-enlistment vulnerability is associated with a variety of negative health outcomes. Two main factors emerge as important predictors of ill health: a ‘family relationships’ factor reflecting the home environment and an ‘externalising behaviour’ factor reflecting behavioural disturbance.

Pre-enlistment vulnerability is an important individual risk factor for ill health in military men. Awareness of such factors is important in understanding post-combat psychiatric disorder.

Growth abnormalities have been suggested as a precursor to schizophrenia, but previous studies have not assessed growth patterns using repeated measures.

To assess the association between early life/later childhood growth patterns and risk of schizophrenia.

Using prospectively collected data from a birth cohort (born 1959–1967), measurements of height, weight and body mass index (BMI) were analysed to compare growth patterns during early life and later childhood between 70 individuals with schizophrenia-spectrum disorder (SSD) and 7710 without.

For women, growth in the SSD group was approximately 1 cm/year slower during early life (P<0.01); no association was observed for men. Later childhood growth was not associated with SSD. Weight patterns were not associated with SSD, whereas slower change in BMI was observed among the SSD group during later childhood.

The association between slower growth in early life and schizophrenia in women suggests that factors responsible for regulating growth might be important in the pathogenesis of the disorder.

Major depression is an important and costly problem among adolescents, yet evidence to support the provision of cost-effective treatments is lacking.

To assess the short-term cost-effectiveness of combined selective serotonin reuptake inhibitors (SSRIs) and cognitive–behavioural therapy (CBT) together with clinical care compared with SSRIs and clinical care alone in adolescents with major depression.

Pragmatic randomised controlled trial in the UK. Outcomes and costs were assessed at baseline, 12 and 28 weeks.

The trial comprised 208 adolescents, aged 11–17 years, with major or probable major depression who had not responded to a brief initial psychosocial intervention. There were no significant differences in outcome between the groups with and without CBT. Costs were higher in the group with CBT, although not significantly so (P=0.057). Cost-effectiveness analysis and exploration of the associated uncertainty suggest there is less than a 30% probability that CBT plus SSRIs is more cost-effective than SSRIs alone.

A combination of CBT plus SSRIs is not more cost-effective in the short-term than SSRIs alone for treating adolescents with major depression in receipt of routine specialist clinical care.

No systematic attempt has been made to calculate the costs of scaling up mental health services in low-and middle-income countries.

To estimate the expenditures needed to scale up the delivery of an essential mental healthcare package over a 10-year period (2006–2015).

A core package was defined, comprising pharmacological and/or psychosocial treatment of schizophrenia, bipolar disorder, depression and hazardous alcohol use. Current service levels in 12 selected low-and middle-income countries were established using the WHO–AIMS assessment tool. Target-level resource needs were derived from published need assessments and economic evaluations.

The cost per capita of providing the core package attarget coverage levels (in US dollars) ranged from $1.85 to $2.60 per year in low-income countries and $3.20 to $6.25 per year in lower-middle-income countries, an additional annual investment of $0.18–0.55 per capita.

Although significant new resources need to be invested, the absolute amount is not large when considered at the population level and against other health investment strategies.

Reattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms.

To determine if practice-based training of GPs in reattribution changes doctor–patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration.

Cluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual.

With training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference −0.9, 95% CI −1.6 to −0.1; P=0.027) with no other effects on patient outcome or health contacts.

Practice-based training in reattribution changed doctor–patient communication without improving outcome of patients with medically unexplained symptoms.

Therapeutic alliance between clinicians and their patients is important in community mental healthcare. It is unclear whether providing effective interventions influences therapeutic alliance.

To assess the impact of meeting previously unmet mental health needs on the therapeutic alliance between patients and clinicians.

Secondary analysis of data from a longitudinal study assessing 101 patients and paired staff.

Patient-rated unmet need was negatively associated with patient-rated and staff-rated therapeutic alliance. Staff-rated unmet need was positively associated with patient-rated therapeutic alliance only. Reducing patient-rated unmet need increased patient-rated but not staff-rated therapeutic alliance, even when controlling for other variables. Reducing staff-rated unmet need increased staff-rated but not patient-rated therapeutic alliance, but the effect became insignificant when controlling for other variables.

Patient-rated therapeutic alliance will be maximised by focusing assessment and interventions on patient-rated rather than staff-rated unmet need.

Repetition of self-poisoning is common.

To report the 24-month outcomes of a non-obligatory postcard intervention (plus treatment as usual) compared with treatment as usual.

In a randomised-controlled trial (Zelen design) conducted in Newcastle, Australia, eight postcards were sent to participants over a 12-month period. The principal outcomes were the proportion of participants with one or more repeat episodes of self-poisoning and the number of repeat episodes per person.

No significant reduction was observed in the proportion of people repeating self-poisoning in the intervention group (21.2%, 95% CI 17.0–25.3) compared with the control group (22.8%, 95% CI 18.7–27.0; χ2=0.32, d.f. = 1, P= 0.57); the difference between groups was −1.7% (95% CI −7.5 to 4.2). There was a significant reduction in the rate of repetition, with an incidence risk ratio of 0.49 (95% CI 0.33–0.73).

A postcard intervention maintained the halving of the rate of repetition of hospital-treated self-poisoning events over a 2-year period, although it did not significantly reduce the proportion of individuals who repeated self-poisoning.

Screening instruments for autistic-spectrum disorders have not been compared in the same sample.

To compare the Social Communication Questionnaire (SCQ), the Social Responsiveness Scale (SRS) and the Children's Communication Checklist (CCC).

Screen and diagnostic assessments on 119 children between 9 and 13 years of age with special educational needs with and without autistic-spectrum disorders were weighted to estimate screen characteristics for a realistic target population.

The SCQ performed best (area under receiver operating characteristic curve (AUC)=0.90; sensitivity 0.86; specificity 0.78). The SRS had a lower AUC (0.77) with high sensitivity (0.78) and moderate specificity (0.67). The CCC had a high sensitivity but lower specificity (AUC=0.79; sensitivity 0.93; specificity 0.46). The AUC of the SRS and CCC was lower for children with IQ < 70. Behaviour problems reduced specificity for all three instruments.

The SCQ, SRS and CCC showed strong to moderate ability to identify autistic-spectrum disorder in this at-risk sample of school-age children with special educational needs.