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Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance.
EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs).
Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication.
In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.
To quantify and compare the resource consumption and direct costs of medical mental health care of patients suffering from schizophrenia in France, Germany and the United Kingdom.
In the European Cohort Study of Schizophrenia, a naturalistic two-year follow-up study, patients were recruited in France (N = 288), Germany (N = 618), and the United Kingdom (N = 302). Data about the use of services and medication were collected. Unit cost data were obtained and transformed into United States Dollar Purchasing Power Parities (USD-PPP). Mean service use and costs were estimated using between-effects regression models.
In the French/German/UK sample estimated means for a six-month period were respectively 5.7, 7.5 and 6.4 inpatient days, and 11.0, 1.3, and 0.7 day-clinic days. After controlling for age, sex, number of former hospitalizations and psychopathology (CGI score), mean costs were 3700/2815/3352 USD-PPP.
Service use and estimated costs varied considerably between countries. The greatest differences were related to day-clinic use. The use of services was not consistently higher in one country than in the others. Estimated costs did not necessarily reflect the quantity of service use, since unit costs for individual types of service varied considerably between countries.
Ethnic inequalities in health outcomes are often explained by socioeconomic status and concentrated poverty. However, ethnic disparities in psychotic experiences are not completely attenuated by these factors.
We investigated whether disparities are better explained by interactions between individual risk factors and place-based clustering of disadvantage, termed a syndemic.
We performed a cross-sectional survey of 3750 UK men, aged 18–34 years, oversampling Black and minority ethnic (BME) men nationally, together with men residing in London Borough of Hackney. Participants completed questionnaires covering psychiatric symptoms, substance misuse, crime and violence, and risky sexual health behaviours. We included five psychotic experiences and a categorical measure of psychosis based on the Psychosis Screening Questionnaire.
At national level, more Black men reported psychotic experiences but disparities disappeared following statistical adjustment for social position. However, large disparities for psychotic experiences in Hackney were not attenuated by adjustment for social factors in Black men (adjusted odds ratio, 3.24; 95% CI 2.14–4.91; P < 0.002), but were for South Asian men. A syndemic model of joint effects, adducing a four-component latent variable (psychotic experiences and anxiety, substance dependence, high-risk sexual behaviour and violence and criminality) showed synergy between components and explained persistent disparities in psychotic experiences. A further interaction confirmed area-level effects (Black ethnicity × Hackney residence, 0.834; P < 0.001).
Syndemic effects result in higher rates of non-affective psychosis among BME persons in certain inner-urban settings. Further research should investigate how syndemics raise levels of psychotic experiences and related health conditions in Black men in specific places with multiple deprivations.
Mental health problems are often said to affect one in four people in Britain, although with no consistent explanation of what the figure includes. We used three English national population surveys of psychiatric morbidity from 2000, 2007 and 2014 to provide prevalence rates for recent psychiatric problems. We combined disorders progressively to demonstrate the effects of cumulation. Psychosis had a prevalence of around 1%, severe common mental disorders added about 8%, and including less-severe common mental disorders gave a value around one in six. The figure of one in four required the inclusion of various other disorders. These values were strikingly stable over the surveys.
The interaction between positive, negative and depressive symptoms experienced by people with schizophrenia is complex. We used longitudinal data to test the hypothesis that depressive symptoms mediate the links between positive and negative symptoms.
We analyzed data from the European Schizophrenia Cohort, randomly sampled from outpatient services in France, Germany and the UK (N = 1208). Initial measures were repeated after 6 and 12 months. Depressive symptoms were identified using the Calgary Depression Scale for Schizophrenia (CDSS), while positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Latent variable structural equation modelling was used to investigate the mediating role of depression assessed at 6 months in relation to the longitudinal association between positive symptoms at baseline and negative symptoms at 12 months.
We found longitudinal associations between positive symptoms at baseline and negative symptoms at 12 months, as well as between both of these and CDSS levels at 6 months. However depression did not mediate the longitudinal association between PANSS scores; all the effect was direct.
Our findings are incompatible with a mediating function for depression on the pathway from positive to negative symptoms, at least on this timescale. The role of depression in schizophrenic disorders remains a challenge for categorical and hierarchical diagnostic systems alike. Future research should analyze specific domains of both depressive and negative symptoms (e.g. motivational and hedonic impairments). The clinical management of negative symptoms using antidepressant treatments may need to be reconsidered.
There is growing risk from terrorism following radicalisation of young
men. It is unclear whether psychopathology is associated.
To investigate the population distribution of extremist views among UK
Cross-sectional study of 3679 men, 18–34 years, in Great Britain.
Multivariate analyses of attitudes, psychiatric morbidity, ethnicity and
Pro-British men were more likely to be White, UK born, not religious;
anti-British were Muslim, religious, of Pakistani origin, from deprived
areas. Pro- and anti-British views were linearly associated with violence
(adjusted odds ratio (OR) = 1.51, 95% CI 1.38–1.64,
P<0.001, adjusted OR = 1.33, 95% CI 1.13–1.58,
P<0.001, respectively) and negatively with
depression (adjusted OR = 0.72, 95% CI 0.61–0.85,
P<0.001, adjusted OR = 0.64, 95% CI 0.48–0.86,
P = 0.003, respectively).
Men at risk of depression may experience protection from strong cultural
or religious identity. Antisocial behaviour increases with extremism.
Religion is protective but may determine targets of violence following
Anxiety disorders are prevalent yet under-recognized in late life. We examined the prevalence of anxiety disorders in a representative sample of community dwelling older adults in Hong Kong.
Data on 1,158 non-demented respondents aged 60–75 years were extracted from the Hong Kong Mental Morbidity survey (HKMMS). Anxiety was assessed with the revised Clinical Interview Schedule (CIS-R).
One hundred and thirty-seven respondents (11.9%, 95% CI = 10–13.7%) had common mental disorders with a CIS-R score of 12 or above. 8% (95% CI = 6.5–9.6%) had anxiety, 2.2% (95% CI = 1.3–3%) had an anxiety disorder comorbid with depressive disorder, and 1.7% (95% CI = 1–2.5%) had depression. Anxious individuals were more likely to be females (χ2 = 25.3, p < 0.001), had higher chronic physical burden (t = −9.3, p < 0.001), lower SF-12 physical functioning score (t = 9.2, p < 0.001), and poorer delayed recall (t = 2.3, p = 0.022). The risk of anxiety was higher for females (OR 2.8, 95% C.I. 1.7–4.6, p < 0.001) and those with physical illnesses (OR 1.4, 95% C.I. 1.3–1.6, p < 0.001). The risk of anxiety disorders increased in those with disorders of cardiovascular (OR 1.9, 95% C.I. 1.2–2.9, p = 0.003), musculoskeletal (OR 2.0, 95% C.I. 1.5–2.7, p < 0.001), and genitourinary system (OR 2.0, 95% C.I. 1.3–3.2, p = 0.002).
The prevalence of anxiety disorders in Hong Kong older population was 8%. Female gender and those with poor physical health were at a greater risk of developing anxiety disorders. Our findings also suggested potential risk for early sign of memory impairment in cognitively healthy individuals with anxiety disorders.
The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007.
To evaluate frequency of common mental disorders (CMDs), service contact and treatment.
Common mental disorders were identified with the Clinical Interview Schedule – Revised (CIS-R). Service contact and treatment were established in structured interviews.
There were 8615, 6126 and 5385 participants aged 16–64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment.
Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions.
Caregivers make a significant and growing contribution to the social and
medical care of people with long-standing disorders. The effective
provision of this care is dependent on their own continuing health.
To investigate the relationship between weekly time spent caregiving and
psychiatric and physical morbidity in a representative sample of the
population of England.
Primary outcome measures were obtained from the Adult Psychiatric
Morbidity Survey 2007. Self-report measures of mental and physical health
were used, along with total symptom scores for common mental disorder
derived from the Clinical Interview Schedule – Revised.
In total, 25% (n = 1883) of the sample identified
themselves as caregivers. They had poorer mental health and higher
psychiatric symptom scores than non-caregivers. There was an observable
decline in mental health above 10 h per week. A twofold increase in
psychiatric symptom scores in the clinical range was recorded in those
providing care for more than 20 h per week. In adjusted analyses, there
was no excess of physical disorders in caregivers.
We found strong evidence that caregiving affects the mental health of
caregivers. Distress frequently reaches clinical thresholds, particularly
in those providing most care. Strategies for maintaining the mental
health of caregivers are needed, particularly as demographic changes are
set to increase involvement in caregiving roles.
Background: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. Aims: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. Method: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. Results: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. Conclusions: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.
Psychotic phenomena appear to form a continuum with normal experience and beliefs, and may build on common emotional interpersonal concerns.
We tested predictions that paranoid ideation is exponentially distributed and hierarchically arranged in the general population, and that persecutory ideas build on more common cognitions of mistrust, interpersonal sensitivity and ideas of reference.
Items were chosen from the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) questionnaire and the Psychosis Screening Questionnaire in the second British National Survey of Psychiatric Morbidity (n = 8580), to test a putative hierarchy of paranoid development using confirmatory factor analysis, latent class analysis and factor mixture modelling analysis.
Different types of paranoid ideation ranged in frequency from less than 2% to nearly 30%. Total scores on these items followed an almost perfect exponential distribution (r = 0.99). Our four a priori first-order factors were corroborated (interpersonal sensitivity; mistrust;ideas of reference; ideas of persecution). These mapped onto four classes of individual respondents:a rare, severe, persecutory class with high endorsement of all item factors, including persecutory ideation; a quasi-normal class with infrequent endorsement of interpersonal sensitivity, mistrust and ideas of reference, and no ideas of persecution; and two intermediate classes, characterised respectively by relatively high endorsement of items relating to mistrust and to ideas of reference.
The paranoia continuum has implications for the aetiology, mechanisms and treatment of psychotic disorders, while confirming the lack of a clear distinction from normal experiences and processes.
Religious participation or belief may predict better mental health but most research is American and measures of spirituality are often conflated with well-being.
To examine associations between a spiritual or religious understanding of life and psychiatric symptoms and diagnoses.
We analysed data collected from interviews with 7403 people who participated in the third National Psychiatric Morbidity Study in England.
Of the participants 35% had a religious understanding of life, 19% were spiritual but not religious and 46% were neither religious nor spiritual. Religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former wereless likely to have ever used drugs (odds ratio (OR)=0.73, 95% CI 0.60-0.88) or be a hazardous drinker (OR=0.81, 95% CI 0.69-0.96). Spiritual people were more likely than those who were neither religious nor spiritual to have ever used (OR = 1.24, 95% CI 1.02-1.49) or be dependent on drugs (OR = 1.77, 95% CI 1.20-2.61), and to have abnormal eating attitudes (OR = 1.46, 95% Cl 1.10-1.94), generalised anxiety disorder (OR =1.50, 95% Cl 1.09-2.06), any phobia (OR = 1.72, 95% CI 1.07-2.77) or any neurotic disorder (OR = 1.37, 95% CI 1.12-1.68). They were also more likely to be taking psychotropic medication (OR = 1.40, 95% CI 1.05-1.86).
People who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder.
A substantial number of prisoners have intellectual disabilities. We
analysed data on a sample drawn from all prisons in England and Wales.
Intellectual disability was defined as Quick Test scores equivalent to an IQ
of ⩽65. We found a significantly higher prevalence of probable psychosis,
attempted suicide and cannabis use in prisoners with intellectual
disabilities. Presence of intellectual disability was twice as likely to be
associated with probable psychosis but the relationship was fully mediated
by self-rated health status. It is important to identify this group as early
as possible in order to provide timely interventions to cope in adverse
environments and manage substance misuse.
Mental well-being underpins many aspects of health and social
functioning, and is economically important.
To describe mental well-being in a general population sample and to
determine the extent to which mental well-being and mental illness are
independent of one another.
Secondary analysis of a survey of 7293 adults in England. Nine survey
questions were identified as possible indicators of mental well-being.
Common mental disorders (ICD-10) were ascertained using the Revised
Clinical Interview Schedule (CIS-R). Principal components analysis was
used to describe the factor structure of mental well-being and to
generate mental well-being indicators.
A two-factor solution found eight out of nine items with strong loadings
on well-being. Eight items corresponding to hedonic and eudaemonic
well-being accounted for 36.9% and 14.3% of total variance respectively.
Separate hedonic and eudaemonic well-being scales were created. Hedonic
well-being (full of life; having lots of energy) declined with age, while
eudaemonic well-being (getting on well with family and friends; sense of
belonging) rose steadily with age. Hedonic well-being was lower and
eudaemonic well-being higher in women. Associations of well-being with
age, gender, income and self-rated health were little altered by
adjustment for symptoms of mental illness.
In a large nationally representative population sample, two types of
well-being were distinguished and reliably assessed: hedonic and
eudaemonic. Associations with mental well-being were relatively
independent of symptoms of mental illness. Mental well-being can remain
even in the presence of mental suffering.
A number of studies in a range of samples attest a link between childhood
sexual abuse and psychosis.
To use data from a large representative general population sample (Adult
Psychiatric Morbidity Survey 2007) to test hypotheses that childhood
sexual abuse is linked to psychosis, and that the relationship is
consistent with mediation by revictimisation experiences, heavy cannabis
use, anxiety and depression.
The prevalence of psychosis was established operationally in a
representative cross-sectional survey of the adult household population
of England (n = 7353). Using computer-assisted
self-interview, a history of various forms of sexual abuse was
established, along with the date of first abuse.
Sexual abuse before the age of 16 was strongly associated with psychosis,
particularly if it involved non-consensual sexual intercourse (odds ratio
(OR) = 10.14, 95% CI 4.8–21.3, population attributable risk fraction
14%). There was evidence of partial mediation by anxiety and depression,
but not by heavy cannabis use nor revictimisation in adulthood.
The association between childhood sexual abuse and psychosis was large,
and may be causal. These results have important implications for the
nature and aetiology of psychosis, for its treatment and for primary
There are concerns that the prevalence of mental disorder is
To determine whether the prevalence of common adult mental disorders has
increased over time, using age–period–cohort analysis.
The study consisted of a pseudocohort analysis of a sequence of three
cross-sectional surveys of the English household population. The main
outcome was common mental disorder, indicated by a score of 12 or above
on the Revised Clinical Interview Schedule (CIS-R). Secondary outcomes
were neurotic symptoms likely to require treatment, indicated by a CIS-R
score of 18 or over, and individual subscale scores for fatigue, sleep
problems, irritability and worry.
There were 8670 participants in the 1993 survey, 6977 in the 2000 survey
and 6815 in the 2007 survey. In men a significant increase in common
mental disorder occurred between the cohort born in 1943–9 and that born
in 1950–6 (odds ratio 1.4, 95% CI 1.1–1.9) but prevalence in subsequent
cohorts remained largely stable. More extended increases in prevalence of
sleep problems and mental disorders were observed in women, but not
consistently across cohorts or measures.
We found little evidence that the prevalence of common mental disorder is