Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics.

This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services.

Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points.

A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine.

Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.

Social disability is a hallmark of severe mental illness yet individual differences and factors predicting outcome are largely unknown.

To explore trajectories and predictors of social recovery following a first episode of psychosis (FEP).

A sample of 764 individuals with FEP were assessed on entry into early intervention in psychosis (EIP) services and followed up over 12 months. Social recovery profiles were examined using latent class growth analysis.

Three types of social recovery profile were identified: Low Stable (66%), Moderate-Increasing (27%), and High-Decreasing (7%). Poor social recovery was predicted by male gender, ethnic minority status, younger age at onset of psychosis, increased negative symptoms, and poor premorbid adjustment.

Social disability is prevalent in FEP, although distinct recovery profiles are evident. Where social disability is present on entry into EIP services it can remain stable, highlighting a need for targeted intervention.

Early intervention services (EIS) comprise low-stigma, youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice.

By analysing carers' accounts of their daily lives and affective challenges during a relative's FEP against the background of wider research into EIS, this paper explores relationships between carers' experiences and EIS.

Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS.

Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these user-focused engagements also emerge; they risk leaving carers' emotions unacknowledged and compounding an existing lack of help-seeking.

By focusing on EIS's engagements with carers, this paper draws attention to an urgent broader question: as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?

Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.

To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.

Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.

A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.

Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.

None.

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.

Suicide prevention is a health service priority. Suicide risk may be greatest during psychiatric in-patient admission and following discharge.

To describe the social and clinical characteristics of a comprehensive sample of in-patient and post-discharge cases of suicide.

A national clinical survey based on a 4-year (1996–2000) sample of cases of suicide in England and Wales who had been in recent contact with mental health services (n=4859).

There were 754 (16%) current in-patients and a further 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Nearly a quarter of the in-patient deaths occurred within the first 7 days of admission; 236 (31%) occurred on the ward, the majority by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day.

Suicide might be prevented among in-patients by improving ward design and removing fixtures that can be used in hanging. Prevention of suicide after discharge requires early community follow-up and closer supervision of high-risk patients.

Suicide prevention is a health service priority but the most effective approaches to prevention may differ between different patient groups.

To describe social and clinical characteristics in cases of suicide from different age and diagnostic groups.

A national clinical survey of a 4-year (1996–2000) sample of cases of suicide in England and Wales where there had been recent (< 1 year) contact with mental health services (n=4859).

Deaths of young patients were characterised by jumping from a height or in front of a vehicle, schizophrenia, personality disorder, unemployment and substance misuse. In older patients, drowning, depression, living alone, physical illness, recent bereavement and suicide pacts were more common. People with schizophrenia were often in-patients and died by violent means. About athird of people with depressive disorder died within a year of illness onset. Those with substance dependence or personality disorder had high rates of disengagement from services.

Prevention measures likely to benefit young people include targeting schizophrenia, dual diagnosis and loss of service contact; those aimed at depression, isolation and physical ill-health should have more effect on elderly people.

Previous studies of people convicted of homicide have used different definitions of mental disorder.

To estimate the rate of mental disorder in people convicted of homicide; to examine the relationship between definitions, verdict and outcome in court.

A national clinical survey of people convicted of homicide (n=1594) in England and Wales (1996–1999). Rates of mental disorder were estimated based on: lifetime diagnosis, mental illness at the time of the offence, contact with psychiatric services, diminished responsibility verdict and hospital disposal.

Of the 1594, 545 (34%) had a mental disorder: most had not attended psychiatric services; 85 (5%) had schizophrenia (lifetime); 164 (10%) had symptoms of mental illness at the time of the offence; 149 (9%) received a diminished responsibility verdict and 111 (7%) a hospital disposal – both were associated with severe mental illness and symptoms of psychosis.

The findings suggest an association between schizophrenia and conviction for homicide. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Some perpetrators receive prison sentences despite having severe mental illness.

The main aim of the study was to establish the proportion of hospital trusts in England and Wales in which training in the assessment of suicide risk and risk of harm to others is available to mental health professionals. A questionnaire was sent to clinical directors covering training on these subjects and in mental health legislation, details of training and the existence of risk-related policies.

Seventy-six per cent of trusts said they provided training in suicide risk assessment for junior psychiatrists; for hospital and community nurses, the figure was just over 50%. Between 50% and 60% of trusts said they provided training in the assessment of risk of harm to others. Provision of training in mental health legislation was said to occur in most trusts. In some key areas of risk management, hospital policies were uncommon.

Despite the current importance of risk assessment in mental health services, many hospital trusts do not provide their staff with relevant training.

The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour.

To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).

Analysis, using Poisson regression, of the number of suicides and open verdicts (suicides’) in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992–1996. Similar analysis on DSH presentations to a general hospital.

Suicides increased during the month following the Princess's funeral (+ 17.4%). This was particularly marked in females (+33.7%), especially those aged 25–44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.

The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

In the past two decades the suicide rate in young people has risen in the UK and other countries.

To identify the characteristics of people aged under 35 who commit suicide.

Psychological autopsy study with case–control design. Cases were 84 suicides and probable suicides (open verdicts). Controls were 64 age- and gender-matched non-suicides obtained through the general practices of the matched cases. Main variables: social, including employment status, marital status and living circumstances; life events and interpersonal difficulties; clinical, including current psychiatric disorder, alcohol and drug misuse, previous self-harm and personality disorder.

A large number of highly significant social, interpersonal and clinical differences between suicides and controls was found. Factor analysis identified two groups of variables within each of the social, interpersonal and clinical domains which were independently linked to suicide, corresponding to: acute, severe mental disorder and chronic disorder of behaviour; rootlessness and social withdrawal; chronic and recent interpersonal problems.

A broad prevention strategy is needed to reverse the recent rise in the suicide rate in young people.

The suicide rate in young men, but not young women, is rising. One possible route to suicide prevention is through general practice but recent evidence suggests that young suicides are not likely to attend GP surgeries prior to death.

We carried out a retrospective examination of general practice contacts by a 2-year sample of suicides under 35 years of age in the 12 health districts of Greater Manchester. In the 61 young suicides who were known to attend a GP in the three months before death, we recorded (a) the number of consultations each week in the three months before suicide; (b) sex differences in rates of and reasons for consultation; (c) frequency of recorded risk assessment at the last GP visit before suicide.

The number of GP visits increased significantly before death. A monthly increase was more evident in males, but the increase in the week before death was more marked in females. There was no sex difference in the rate of GP visits before suicide; both sexes were most likely to attend for psychological reasons. Significant suicide risk had been noted at none of the final GP visits.

There remains a potential role for GPs in preventing suicides by young people of both sexes. The recent increase in suicide by young males does not appear to be related to a lower rate of GP attendance before death. Future training of GPs in this area should focus on risk assessment.