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Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.
Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.
Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).
We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients’ needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.
To determine the baseline individual characteristics that predicted symptom recovery and functional recovery at 10-years following the first episode of psychosis.
AESOP-10 is a 10-year follow up of an epidemiological, naturalistic population-based cohort of individuals recruited at the time of their first episode of psychosis in two areas in the UK (South East London and Nottingham). Detailed information on demographic, clinical, and social factors was examined to identify which factors predicted symptom and functional remission and recovery over 10-year follow-up. The study included 557 individuals with a first episode psychosis. The main study outcomes were symptom recovery and functional recovery at 10-year follow-up.
At 10 years, 46.2% (n = 140 of 303) of patients achieved symptom recovery and 40.9% (n = 117) achieved functional recovery. The strongest predictor of symptom recovery at 10 years was symptom remission at 12 weeks (adj OR 4.47; CI 2.60–7.67); followed by a diagnosis of depression with psychotic symptoms (adj OR 2.68; CI 1.02–7.05). Symptom remission at 12 weeks was also a strong predictor of functional recovery at 10 years (adj OR 2.75; CI 1.23–6.11), together with being from Nottingham study centre (adj OR 3.23; CI 1.25–8.30) and having a diagnosis of mania (adj OR 8.17; CI 1.61–41.42).
Symptom remission at 12 weeks is an important predictor of both symptom and functional recovery at 10 years, with implications for illness management. The concepts of clinical and functional recovery overlap but should be considered separately.
Outcome measures for mental health services need to adopt a service-user recovery focus.
To develop and validate a 10- and 20-item self-report recovery-focused quality of life outcome measure named Recovering Quality of Life (ReQoL).
Qualitative methods for item development and initial testing, and quantitative methods for item reduction and scale construction were used. Data from >6500 service users were factor analysed and item response theory models employed to inform item selection. The measures were tested for reliability, validity and responsiveness.
ReQoL-10 and ReQoL-20 contain positively and negatively worded items covering seven themes: activity, hope, belonging and relationships, self-perception, well-being, autonomy, and physical health. Both versions achieved acceptable internal consistency, test–retest reliability (>0.85), known-group differences, convergence with related measures, and were responsive over time (standardised response mean (SRM) > 0.4). They performed marginally better than the Short Warwick-Edinburgh Mental Well-being Scale and markedly better than the EQ-5D.
Both versions are appropriate for measuring service-user recovery-focused quality of life outcomes.
Declaration of interest
M.B. and J.Co. were members of the research group that developed the Clinical Outcomes in Routine Evaluation (CORE) outcome measures.
The incidence of psychotic disorders is elevated in some minority ethnic populations. However, we know little about the outcome of psychoses in these populations.
To investigate patterns and determinants of long-term course and outcome of psychoses by ethnic group following a first episode.
ÆSOP-10 is a 10-year follow-up of an ethnically diverse cohort of 532 individuals with first-episode psychosis identified in the UK. Information was collected, at baseline, on clinical presentation and neurodevelopmental and social factors and, at follow-up, on course and outcome.
There was evidence that, compared with White British, Black Caribbean patients experienced worse clinical, social and service use outcomes and Black African patients experienced worse social and service use outcomes. There was evidence that baseline social disadvantage contributed to these disparities.
These findings suggest ethnic disparities in the incidence of psychoses extend, for some groups, to worse outcomes in multiple domains.
The assessment of ‘general health and well-being’ in public mental health research stimulates debates around relative merits of questionnaire instruments and their items. Little evidence regarding alignment or differential advantages of instruments or items has appeared to date.
Population-based psychometric study of items employed in public mental health narratives.
Multidimensional item response theory was applied to General Health Questionnaire (GHQ-12), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and EQ-5D items (Health Survey for England, 2010–2012; n = 19 290).
A bifactor model provided the best account of the data and showed that the GHQ-12 and WEMWBS items assess mainly the same construct. Only one item of the EQ-5D showed relevant overlap with this dimension (anxiety/depression). Findings were corroborated by comparisons with alternative models and cross-validation analyses.
The consequences of this lack of differentiation (GHQ-12 v. WEMWBS) for mental health and well-being narratives deserves discussion to enrich debates on priorities in public mental health and its assessment.
There are limited data on detection disparities of common mental
disorders in minority ethnic women.
Describe the natural history of common mental disorders in primary care
in the maternal period, characterise women with, and explore ethnic
disparities in, detected and potentially missed common mental
Secondary analyses of linked birth cohort and primary care data involving
8991 (39.4% White British) women in Bradford. Common mental disorders
were characterised through indications in the electronic medical record.
Potentially missed common mental disorders were defined as an elevated
General Health Questionnaire (GHQ-28) score during pregnancy with no
corresponding common mental disorder markers in the medical record.
Estimated prevalence of pre-birth common mental disorders was 9.5%,
rising to 14.0% 3 years postnatally. Up to half of cases were potentially
missed. Compared with White British women, minority ethnic women were
twice as likely to have potentially missed common mental disorders and
half as likely to have a marker of screening for common mental
Common mental disorder detection disparities exist for minority ethnic
women in the maternal period.
Within a longitudinal study of 1,005 adolescents, we investigated how exposure to childhood psychosocial adversities was associated with the emergence of depressive symptoms between 14 and 17 years of age. The cohort was classified into four empirically determined adversity subtypes for two age periods in childhood (0–5 and 6–11 years). One subtype reflects normative/optimal family environments (n = 692, 69%), while the other three subtypes reflect differential suboptimal family environments (aberrant parenting: n = 71, 7%; discordant: n = 185, 18%; and hazardous: n = 57, 6%). Parent-rated child temperament at 14 years and adolescent self-reported recent negative life events in early and late adolescence were included in models implementing path analysis. There were gender-differentiated associations between childhood adversity subtypes and adolescent depressive symptoms. The discordant and hazardous subtypes were associated with elevated depressive symptoms in both genders but the aberrant parenting subtype only so in girls. Across adolescence the associations between early childhood adversity and depressive symptoms diminished for boys but remained for girls. Emotional temperament was also associated with depressive symptoms in both genders, while proximal negative life events related to depressive symptoms in girls only. There may be neurodevelopmental factors that emerge in adolescence that reduce depressogenic symptoms in boys but increase such formation in girls.
Lower cognitive ability in childhood is associated with increased risk of
future schizophrenia, but its relationship with adult psychotic-like
experiences and other psychopathology is less understood.
To investigate whether this childhood risk factor is shared with adult
subclinical psychiatric phenotypes including psychotic-like experiences
and general psychiatric morbidity.
A population-based sample of participants born in Great Britain during 1
week in March 1946 was contacted up to 20 times between ages 6 weeks and
53 years. Cognition was assessed at ages 8, 11 and 15 years using a
composite of age-appropriate verbal and non-verbal cognitive tests. At
age 53 years, psychotic-like experiences were self-reported by 2918
participants using four items from the Psychosis Screening Questionnaire
and general psychiatric morbidity was assessed using the scaled version
of the General Health Questionnaire (GHQ-28).
Psychotic-like experiences were reported by 22% of participants, and were
highly comorbid with other psychopathology. Their presence in adults was
significantly associated with poorer childhood cognitive test scores at
ages 8 and 15 years, and marginally so at age 11 years. In contrast, high
GHQ scores were not associated with poorer childhood cognition after
adjustment for the presence of psychotic-like experiences.
Psychotic and non-psychotic psychopathologic symptoms are highly comorbid
in the general population. Lower childhood cognitive ability is a risk
factor for psychotic-like experiences in mid-life; these phenomena may be
one end of a continuum of phenotypic expression driven by variation in
A growing number of studies suggest a link between timing of menarche and risk of depressive symptoms in adolescence, but few have prospectively examined the emergence of depressive symptoms from late childhood into adolescence.
To examine whether girls who experience earlier menarche than their peers have higher levels of depressive symptoms in adolescence.
The study sample comprised 2184 girls from the Avon Longitudinal Study of Parents and Children. The association between timing of menarche and depressive symptoms at 10.5, 13 and 14 years was examined within a structural equation model.
Girls with early menarche (<11.5 years) had the highest level of depressive symptoms at 13 (P = 0.007) and 14 years (P<0.001) compared with those with normative and late timing of menarche.
Early maturing girls are at increased risk of depressive symptoms in adolescence and could be targeted by programmes aimed at early intervention and prevention.
There is increasing evidence for genetic effects on the hypothalamic–pituitary axis system. More than one gene is likely to moderate corticoid-mediated activity.
To investigate whether the brain-derived neurotrophic factor (BDNF) polymorphism (rs6265, Val66Met) is associated with morning waking salivary cortisol and moderates the corticoid-mediated risk for subsequent depressive episode onset independently of the known effects of 5-HTTLPR (the serotonin transporter gene promoter).
High-risk adolescents (n = 401) were genotyped for Val66Met BDNF and 5-HTTLPR. Salivary samples were obtained on four consecutive school days within 1 h of waking. There were 365 (91%) remaining participants reassessed at 12 months for episodes of psychiatric disorder in the follow-up period. Of these, 357 (89%) had complete data for multivariate modelling.
There were 41 (11.2%) individuals who reported a new episode of clinical depression over the follow-up period. Increased risk for subsequent depression was found in carriers of the Val66Val genotype in BDNF with higher morning waking cortisol. This remained present when the known interaction between carriers of a short allele of 5-HTTLPR with higher morning salivary cortisol was taken into account.
Both BDNF and 5-HTTLPR genes show evidence of modifying the risk of a subsequent new depressive episode associated with elevated morning salivary cortisol. In adolescents morning salivary cortisol levels may constitute a biomarker for some forms of unipolar depression.
The UK National Institute for Health and Clinical Excellence (NICE) has
recommended that cost-effectiveness analysis includes the EQ–5D; however,
this is often not implemented in the area of mental health.
To assess the appropriateness of using the EQ–5D to measure improvements
in mental health.
Seventy-seven participants with psychosis were rated according to the
EQ–5D and seven measures of mental health at both pre- and
post-intervention. To assess construct validity we compared the
(pre-intervention) mean EQ–5D scores for those with milder and more
severe scores, according to each of the seven measures. To assess
responsiveness we estimated the mean EQ–5D change score for those who
improved (post-intervention), according to each of the measures.
The mean EQ–5D score was more favourable for both those with milder
scores (mean difference: 0.044 to 0.301) and for those who improved
post-intervention (mean change: 0.029 to 0.117).
This suggests the EQ–5D should be considered for use in future
cost-effectiveness studies in the area of mental health.
The short (s) allele of the serotonin transporter gene promoter
(5-HTTLPR) may be associated with exposure to social adversities and the
subsequent onset of depressive illness in adulthood.
To test in adolescents at high risk for depression whether the short ‘s’
allele is associated with levels of morning cortisol and the subsequent
onset of a depressive episode.
High-risk adolescents (n = 403) were genotyped for
5-HTTLPR. Salivary samples were obtained on four consecutive school days
within 1 h of waking from 393 (97.5%) individuals and 367 (91%) underwent
a mental state reassessment at 12 months.
Multilevel analysis revealed higher levels of salivary cortisol in short
allele carriers (s/s>s/l>l/l). A subsequent episode of depression
was increased in those with higher cortisol and the ‘s’ allele, and
independently by depressive symptoms at entry, in both genders.
The short allele of 5-HTTLPR may moderate the association between morning
cortisol and the subsequent onset of a depressive episode.
Antidepressants and anxiolytics have demonstrated short-term efficacy;
however, little is known about the long-term effectiveness of these
To investigate long-term psychiatric outcomes following antidepressant
and/or anxiolytic use during an episode of mental disorder in
Members of the 1946 British birth cohort were assessed for symptoms of
depression and anxiety at age 43. Among 157 with mental disorder, those
using antidepressants and/or anxiolytics were compared with those not
using medications on psychiatric outcomes at age 53.
Use of antidepressants or anxiolytics was associated with a lower
prevalence of mental disorder at age 53 (odds ratio (OR)=0.3, 95% CI
0.1–1.0) after adjustment for eight variables in a
propensity-for-treatment analysis. Only 24% of those being treated with
medications at age 43 were still using them at 53.
Use of antidepressants or anxiolytics during an episode of mental
disorder may have long-term beneficial effects on mental health. This may
be because of a demonstrated willingness to seek help rather than
long-term maintenance therapy.
Despite considerable research investigating the relationship between a
long duration of untreated psychosis (DUP) and outcomes, there has been
much less considering predictors of a long DUP.
To investigate the clinical and social determinants of DUP in a large
sample of patients with a first episode of psychosis.
All patients with a first episode of psychosis who made contact with
psychiatric services over a 2-year period and were living in defined
catchment areas in London and Nottingham, UK were included in the ÆSOP
study Data relating to clinical and social variables and to DUP were
collected from patients, relatives and case notes.
An insidious mode of onset was associated with a substantially longer DUP
compared with an acute onset, independent of other factors. Unemployment
had a similar, if less strong, effect. Conversely family involvement in
help-seeking was independently associated with a shorter duration. There
was weak evidence that durations were longer in London than in
These findings suggest that DUP is influenced both by aspects of the
early clinical course and by the social context.
Psychotropic medication use is common and increasing. Use of such drugs
at the individual level over long periods has not been reported.
To describe antidepressant, anxiolytic and hypnotic drug use, and
associations between such medication use and common mental disorder, over
a 22-year period.
Questions about psychotropic medication use and symptoms of common mental
disorder were asked of more than 3000 members of the 1946 British birth
cohort at multiple time points between ages 31 and 53 years.
Prevalence of any antidepressant, anxiolytic or hypnotic use increased
significantly from 1977 (30.6 per 1000) to 1999 (59.1 per 1000) as the
cohort aged. Less than 30% with mental disorder used antidepressants,
anxiolytics or hypnotics. Previous use of antidepressant, anxiolytic or
hypnotic was a strong predictor of future use during an episode of mental
disorder (odds ratios 3.0–8.4); this association became weaker over
Pharmacotherapy is infrequently used by individuals with common mental
disorder in Britain; this has not changed in the past three decades.
The World Health Organization (WHO) ICD–10 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (1996) have not been evaluated in a pragmatic randomised controlled trial (RCT).
To evaluate the effect of local adaptation and dissemination of the guidelines.
Guideline practices were less sensitive but more specific in identifying morbidity, but these differences were not significant. Guideline patients did not differ from usual-care patients on 12-item General Health Questionnaire scores at 3-month follow-up or in the proportion who were still cases. There were no significant differences in secondary outcomes.
Attempts to influence clinician behaviour through a process of adaptation and extension of guidelines are unlikely to change detection rates or outcomes.
Recent research has reported increased risk of aggressive incidents by individuals with psychotic illness.
To examine acts of aggression in first-episode psychosis.
Subjects with a first-episode psychosis were ascertained from a defined catchment area (Nottingham, UK) and reassessed at 3 years (n=166) using clinical interview, informants, health care and forensic records.
Of the subjects, 9.6% demonstrated at least one act of serious aggression (defined as weapon use, sexual assault or victim injury) during at least one psychotic episode and 23.5% demonstrated lesser acts of aggression (defined as all other acts of aggression). For all aggressive subjects (33.1%), unemployment (OR=3.6, 95%CI 1.6–8.0), comorbid substance misuse (OR=3.1, CI 1.1–8.8) and symptoms of overactivity at service contact (OR=6.9, CI 2.7–17.8) had independent effects on risk of aggression.
We confirmed some previously reported demographic and clinical associations with aggression in first-episode psychosis but no relationship with specific psychotic symptoms or diagnostic groups was observed.
Changes in service provision, secular trends in substance misuse and changing social structures might affect outcome in psychosis.
To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD–10 diagnostic criteria.
Three-year follow-up (1995–1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980–1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.
On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.
In a modern community service, 30–60% of patients with first-episode psychoses experience a good three-year outcome. The ICD–10 criteria have good predictive validity.
An increased incidence of psychotic disorders has repeatedly been reported among African–Caribbeans in the UK.
To test whether the increased incidence of psychotic disorders in first-and second-generation African–Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.
Thirty-three patients of African–Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.
There was a trend for better outcomes in African–Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio=0.9 (–0.50 to –2.00)). Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio=0.59 (–0.21 to –1.66)). Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African–Caribbean group.
Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African–Caribbeans.
Outcome is important in the validation of psychiatric diagnosis, as most disorders lack clinicopathological correlates. We describe the predictive validity of four definitions of schizophrenia (DSM-III-R, ICD-10, ICD-9 and CATEGO S+), in a representative cohort of patients selected during their first episode of psychosis.
Each definition of schizophrenia was applied to 99 patients. Their respective ability to predict 13-year outcome (Global Assessment of Functioning scales) was assessed.
DSM-III-Rand ICD-10 diagnoses of schizophrenia have high predictive validity for long-term outcome, and both provide relatively stable diagnoses. ICD-9 is reasonably good at predicting disability, but not symptoms, and CATEGO S+ showed no predictive validity. Adding six-month duration criteria to ICD-10, ICD-9 and CATEGO S+ improved their predictive validity, and removing the six-month duration criterion from DSM-III-R commensurately reduced predictive validity.
Modern diagnostic systems (DSM-III-Rand ICD-10) have high predictive validity, and are superior to ICD-9. The six-month duration criterion of DSM-III-R schizophrenia accounts for its predictive validity and stability over 13 years, but restricts its use in first-episode studies. The one-month duration criterion of ICD-10 is less restrictive, without major compromises in predictive validity or stability.