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Excavated over two centuries ago, the Upton Lovell G2a ‘Wessex Culture’ burial has held a prominent place in research on Bronze Age Britain. In particular, was it the grave of a ‘shaman’ or a metalworker? We take a new approach to the grave goods, employing microwear analysis and scanning electron microscopy to map a history of interactions between people and materials, identifying evidence for the presence of Bronze Age gold on five artefacts, four for the first time. Advancing a new materialist approach, we identify a goldworking toolkit, linking gold, stone and copper objects within a chaîne opératoire, concluding that modern categorisations of these materials miss much of their complexity.
In the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.
To evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.
We have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
Most people with bipolar disorder spend a significant percentage of their lifetime experiencing either subsyndromal depressive symptoms or major depressive episodes, which contribute greatly to the high levels of disability and mortality associated with the disorder. Despite the importance of bipolar depression, there are only a small number of recognised treatment options available. Consecutive treatment failures can quickly exhaust these options leading to treatment-resistant bipolar depression (TRBD). Remarkably few studies have evaluated TRBD and those available lack a comprehensive definition of multi-therapy-resistant bipolar depression (MTRBD).
To reach consensus regarding threshold definitions criteria for TRBD and MTRBD.
Based on the evidence of standard treatments available in the latest bipolar disorder treatment guidelines, TRBD and MTRBD criteria were agreed by a representative panel of bipolar disorder experts using a modified Delphi method.
TRBD criteria in bipolar depression was defined as failure to reach sustained symptomatic remission for 8 consecutive weeks after two different treatment trials, at adequate therapeutic doses, with at least two recommended monotherapy treatments or at least one monotherapy treatment and another combination treatment. MTRBD included the same initial definition as TRBD, with the addition of failure of at least one trial with an antidepressant, a psychological treatment and a course of electroconvulsive therapy.
The proposed TRBD and MTRBD criteria may provide an important signpost to help clinicians, researchers and stakeholders in judging how and when to consider new non-standard treatments. However, some challenging diagnostic and therapeutic issues were identified in the consensus process that need further evaluation and research.
Declaration of interest
In the past 3 years, M.B. has received grant/research support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Grunbiotics, Glaxo SmithKline, Janssen Cilag, LivaNova, Lundbeck, Merck, Mylan, Otsuka, Pfizer and Servier. A.J.C. has in the past 3 years received honoraria for speaking from Astra Zeneca and Lundbeck, honoraria for consulting from Allergan, Janssen, Lundbeck and LivaNova and research grant support from Lundbeck. G.M.G. holds shares in P1Vital and has served as consultant, advisor or CME speaker for Allergan, Angelini, Compass pathways, MSD, Lundbeck, Otsuka, Takeda, Medscape, Minervra, P1Vital, Pfizer, Servier, Shire and Sun Pharma. J.G. has received research funding from National Institute for Health Research, Medical Research Council, Stanley Medical Research Institute and Wellcome. H.G. received grants/research support, consulting fees or honoraria from Gedeon Richter, Genericon, Janssen Cilag, Lundbeck, Otsuka, Pfizer and Servier. R.H.M.-W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, Liva Nova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. R.M. has received research support from Big White Wall, Electromedical Products, Johnson and Johnson, Magstim and P1Vital. S.N. received honoraria from Lundbeck, Jensen and Otsuka. J.C.S. has received funds for research from Alkermes, Pfizer, Allergan, J&J, BMS and been a speaker or consultant for Astellas, Abbott, Sunovion, Sanofi. S.W has, within the past 3 years, attended advisory boards for Sunovion and LivaNova and has undertaken paid lectures for Lundbeck. D.J.S. has received honoraria from Lundbeck. T.S. has reported grants from Pathway Genomics, Stanley Medical Research Institute and Palo Alto Health Sciences; consulting fees from Sunovion Pharamaceuticals Inc.; honoraria from Medscape Education, Global Medical Education and CMEology; and royalties from Jones and Bartlett, UpToDate and Hogrefe Publishing. S.P. has served as a consultant or speaker for Janssen, and Sunovion. P.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. E.V. received grants/ research support, consulting fees or honoraria from Abbott, AB-Biotics, Allergan, Angelini, Dainippon Sumitomo, Ferrer, Gedeon Richter, Janssen, Lundbeck, Otsuka and Sunovion. L.N.Y. has received grants/research support, consulting fees or honoraria from Allergan, Alkermes, Dainippon Sumitomo, Janssen, Lundbeck, Otsuka, Sanofi, Servier, Sunovion, Teva and Valeant. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has also previously received funding for investigator-initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth. P.R.A.S. has received research funding support from Corcept Therapeutics Inc. Corcept Therapeutics Inc fully funded attendance at their internal conference in California USA and all related expenses. He has received grant funding from the Medical Research Council UK for a collaborative study with Janssen Research and Development LLC. Janssen Research and Development LLC are providing non-financial contributions to support this study. P.R.A.S. has received a presentation fee from Indivior and an advisory board fee from LivaNova.
Health anxiety and medically unexplained symptoms cost the National
Health Service (NHS) an estimated £3 billion per year in unnecessary
costs with little evidence of patient benefit. Effective treatment is
rarely taken up due to issues such as stigma or previous negative
experiences with mental health services. An approach to overcome this
might be to offer remotely delivered psychological therapy, which can be
just as effective as face-to-face therapy and may be more accessible and
To investigate the clinical outcomes and cost-effectiveness of remotely
delivered cognitive–behavioural therapy (CBT) to people with high health
anxiety repeatedly accessing unscheduled care (trial registration:
A multicentre randomised controlled trial (RCT) will be undertaken in
primary and secondary care providers of unscheduled care across the East
Midlands. One hundred and forty-four eligible participants will be
equally randomised to receive either remote CBT (6–12 sessions) or
treatment as usual (TAU). Two doctoral research studies will investigate
the barriers and facilitators to delivering the intervention and the
factors contributing to the optimisation of therapeutic outcome.
This trial will be the first to test the clinical outcomes and
cost-effectiveness of remotely delivered CBT for the treatment of high
The findings will enable an understanding as to how this intervention
might fit into a wider care pathway to enhance patient experience of
To determine features associated with better perceived quality of training for psychiatrists on advance decision-making in the Mental Capacity Act 2005 (MCA), and whether the quality or amount of training were associated with positive attitudes or use of advance decisions to refuse treatment (ADRTs) by psychiatrists in people with bipolar disorder. An anonymised national survey of 650 trainee and consultant psychiatrists in England and Wales was performed.
Good or better quality of training was associated with use of case summaries, role-play, ADRTs, assessment of mental capacity and its fluctuation. Good or better quality and two or more sessions of MCA training were associated with more positive attitudes and reported use of ADRTs, although many psychiatrists would never discuss them clinically with people with bipolar disorder.
Consistent delivery of better-quality training is required for all psychiatrists to increase use of ADRTs in people with bipolar disorder.
Psychological interventions may be beneficial in bipolar disorder.
To evaluate the efficacy of psychological interventions for adults with
A systematic review of randomised controlled trials was conducted.
Outcomes were meta-analysed using RevMan and confidence assessed using
the GRADE method.
We included 55 trials with 6010 participants. Moderate-quality evidence
associated individual psychological interventions with reduced relapses
at post-treatment (risk ratio (RR) = 0.66, 95% CI 0.48–0.92) and
follow-up (RR = 0.74, 95% CI 0.63–0.87), and collaborative care with a
reduction in hospital admissions (RR =0.68, 95% CI 0.49–0.94).
Low-quality evidence associated group interventions with fewer depression
relapses at post-treatment and follow-up, and family psychoeducation with
reduced symptoms of depression and mania.
There is evidence that psychological interventions are effective for
people with bipolar disorder. Much of the evidence was of low or very low
quality thereby limiting our conclusions. Further research should
identify the most effective (and cost-effective) interventions for each
phase of this disorder.
Many people with mental health problems spend a large proportion of their
life online and an increasing number of apps address mental health and
well-being. This article offers reasons why psychiatrists should learn how
to use mental health apps to enhance patient care and gives some caveats for
both professionals and patients regarding their use.
Digital technology has the potential to transform mental healthcare by
connecting patients, services and health data in new ways. Digital online
and mobile applications can offer patients greater access to information and
services and enhance clinical management and early intervention through
access to real-time patient data. However, substantial gaps exist in the
evidence base underlying these technologies. Greater patient and clinician
involvement is needed to evaluate digital technologies and ensure they
target unmet needs, maintain public trust and improve clinical outcomes.
Functional somatic symptoms associated with persistent frequent attendance
is emotionally demanding, costly and intractable to treat. Such patients are
hard to engage in practice and research by mental health professionals,
whose main role may be indirect training, supporting and advising primary
care professionals rather than direct patient care.
We assessed whether adult Black and minority ethnic (BME) patients detained for involuntary psychiatric treatment experienced more coercion than similar White patients. We found no evidence of this from patient interviews or from hospital records. The area (mental health trust) where people were treated was strongly associated with both the experience of coercion and the recording of a coercive measure in their records. Regarding charges of institutional racism in psychiatry, this study highlights the importance of investigating the role of area characteristics when assessing the relationship between ethnicity and patient management.
Psychological processes in bipolar disorder are of both clinical and theoretical importance.
To examine depressogenic psychological processes and reward responsivity in relation to different mood episodes (mania, depression, remission) and bipolar symptomatology.
One hundred and seven individuals with bipolar disorder (34 in a manic/hypomanic or mixed affective state; 30 in a depressed state and 43 who were euthymic) and 41 healthy controls were interviewed with Structured Clinical Interview for DSM–IV and completed a battery of self-rated and experimental measures assessing negative cognitive styles, coping response to negative affect, self-esteem stability and reward responsiveness.
Individuals in all episodes differed from controls on most depression-related and reward responsivity measures. However, correlational analyses revealed clear relationships between negative cognitive styles and depressive symptoms, and reward responsivity and manic symptoms.
Separate psychological processes are implicated in depression and mania, but cognitive vulnerability to depression is evident even in patients who are euthymic.
Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals.
To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes.
Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year.
At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission.
Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.
The National Strategic Framework for Renal Services introduced the routine reporting of estimated glomerular filtration rates (eGFR) on serum urea and electrolyte tests. Estimated glomerular filtration rates might reduce renal failure induced by lithium and cardiovascular mortality but there are many false positives. We propose how eGFR might be used in lithium monitoring.
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.
Most liaison psychiatry is practised in the general-hospital setting, but increasingly services for the physically ill are becoming community based. Family practitioners play a key role in identifying patients with comorbid physical and psychological distress. This chapter describes the developments over the last 10 years in the detection and treatment of patients with medically unexplained symptoms (MUS) in a primary-care setting. MUS are defined as physical symptoms that doctors cannot explain by physical pathology, which distress or impair the functioning of the patient. Family doctors are faced with the whole range of physical and psychosocial health problems. Four approaches to the management of persistant MUS (PMUS) that might be employed by family doctors have been explored in randomized controlled trials (RCTs): antidepressants, exercise, psychiatric consultation and emotional disclosure. There is a need for simple, effective, evidence-based interventions that family doctors can provide for patients with PMUS.