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Autism is a neurodevelopmental condition associated with differences in social communication and interaction, as well as a restricted, repetitive repertoire of behaviours and interests. Autistic people will have areas of interest and can possess abilities that are of potential benefit to both themselves and wider society. However, many find that their opportunities are limited. Here, we will discuss how a social model of care can help meet the needs of autistic people.
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.
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.
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.
Little is known about olfactory identification (OI) function in early-onset Alzheimer’s disease (EOAD) and early-onset mild cognitive impairment (eoMCI) with age of onset <65 years. We aimed to study OI in EOAD compared with eoMCI and age-matched healthy controls (HC). Nineteen EOAD subjects with mild to moderate dementia, 17 with eoMCI, and 21 HC recruited as a convenience sample from memory services were assessed for cognition, behavioral symptoms, and activities for daily living. The OI was tested using the University of Pennsylvania smell identification test (UPSIT). EOAD participants performed worse compared with eoMCI and HC on cognitive tests and OI (p < 0.001). Although eoMCI had poorer cognitive scores compared to HC, they were similar in their OI function. OI correlated with attention (r = 0.494, p = 0.031), executive functions (r = 0.508, p = 0.026), and praxis (r = 0.455, p = 0.05) within the EOAD group. OI impairment was significantly associated with the diagnosis of EOAD versus eoMCI, but not with eoMCI when compared with HC. OI could potentially be useful in differentiating EOAD from eoMCI. Studies with late-life MCI patients showing OI impairment relative to HC may be attributed to a different disease process. Independent replication in a larger sample is needed to validate these findings.
Adults with autism spectrum disorder (ASD) are thought to be at disproportionate risk of developing mental health comorbidities, with anxiety and depression being considered most prominent amongst these. Yet, no systematic review has been carried out to date to examine rates of both anxiety and depression focusing specifically on adults with ASD. This systematic review and meta-analysis examined the rates of anxiety and depression in adults with ASD and the impact of factors such as assessment methods and presence of comorbid intellectual disability (ID) diagnosis on estimated prevalence rates. Electronic database searches for studies published between January 2000 and September 2017 identified a total of 35 studies, including 30 studies measuring anxiety (n = 26 070; mean age = 30.9, s.d. = 6.2 years) and 29 studies measuring depression (n = 26 117; mean age = 31.1, s.d. = 6.8 years). The pooled estimation of current and lifetime prevalence for adults with ASD were 27% and 42% for any anxiety disorder, and 23% and 37% for depressive disorder. Further analyses revealed that the use of questionnaire measures and the presence of ID may significantly influence estimates of prevalence. The current literature suffers from a high degree of heterogeneity in study method and an overreliance on clinical samples. These results highlight the importance of community-based studies and the identification and inclusion of well-characterized samples to reduce heterogeneity and bias in estimates of prevalence for comorbidity in adults with ASD and other populations with complex psychiatric presentations.
There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal.
Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12).
In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%).
PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.
The principles underlying the creation and long-term development of the Present State Examination (PSE), now incorporated, with its glossary of definitions of symptoms and other components, in a shell known as the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), are derived from standards of clinical assessment gradually developed from the late 18th century onwards. A form of ‘mental state examination’ is now an established part of the standard curriculum in most medical schools. To conduct such an examination requires the clinician to meet a demanding list of requirements. The first essential is a sound grasp of clinical psychopathology. This confers an ability to recognise, and distinguish within and between, an extensive range of symptoms, such as delusions, hallucinations, obsessional ruminations, irrational fears of harmless stimuli and feelings of excessive guilt. A technique of ‘cross-examination’, based on the glossary of differential definitions of symptoms, must be learned in the first place by observing experienced practitioners interviewing their patients. It is only after completing a comprehensive clinical symptom base that diagnostic procedures should, if needed, be brought into play with the help of algorithms laid down in international standards, as well as those of any other system in local use. These specifics differentiate SCAN from methods such as fully structured questionnaires or self-report forms, which have other purposes.
The aims of SCAN
The three central aims of SCAN can be summarised very simply, in one sentence. They are to provide comprehensive, accurate and technically specifiable means of describing and classifying clinical phenomena in order to make comparisons. Making comparisons is at the heart of all clinical, educational and scientific activities.
The first, clinical, aim is to promote and use high-quality clinical observation. The PSE is designed to allow comparison of each respondent's experiences and behaviour against the examiner's glossary-defined concepts by a process of controlled clinical ‘cross-examination’. The resulting outputs in the form of single symptoms, profiles, scores and rule-based categories of disorder can be compared with each other wherever in the world they are elicited. Thus, they can be used as a comparable base for clinical audit, needs assessment and monitoring the progress of individual respondents. It is essential to understand that the SCAN database is not tied exclusively to systems such as ICD–10 (World Health Organization, 1992) or DSM–IV (American Psychiatric Association, 1994).
The epidemiology of autism in adults has relied on untested projections
using childhood research.
To derive representative estimates of the prevalence of autism and key
associations in adults of all ages and ability levels.
Comparable clinical diagnostic assessments of 7274 Adult Psychiatric
Morbidity Survey participants combined with a population case-register
survey of 290 adults with intellectual disability.
The combined prevalence of autism in adults of all ages in England was
11/1000 (95% CI 3–19/1000). It was higher in those with moderate to
profound intellectual disability (odds ratio (OR) = 63.5, 95% CI
27.4–147.2). Male gender was a strong predictor of autism only in those
with no or mild intellectual disability (adjusted OR = 8.5, 95% CI
2.0–34.9; interaction with gender, P = 0.03).
Few adults with autism have intellectual disability; however, autism is
more prevalent in this population. Autism measures may miss more women
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.
People with severe mental illness (SMI) have high rates of chronic disease and premature death.
To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI.
In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews).
Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking.
Improved adherence to pharmacological and physical health management guidelines is indicated.
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.
Health expectancies, taking into account both quality and quantity of life, have generally been based on disability and physical functioning.
To compare mental health expectancies at age 25 and 55 based on common mental disorders both across countries and between males and females.
Mental health expectancies were calculated by combining mortality data from population life tables and the age-specific prevalence of selected common mental disorders obtained from the European Study of the Epidemiology of Mental Disorders (ESEMeD).
For the male population aged 25 (all countries combined) life expectancy was 52 years and life expectancy spent with a common mental disorder was 1.8 years (95% CI 0.7-2.9),3.4% of overall life expectancy. In comparison, for the female population life expectancy at age 25 was higher (57.9 years) as was life expectancy spent with a common mental disorder (5.1 years, 95% CI 3.6-6.6) and as a proportion of overall life expectancy, 8.8%. By age 55 life expectancy spent with a common mental disorder had reduced to 0.7 years (males) and 2.3 years (females).
Age and gender differences underpin our understanding of years spent with common mental disorders in adulthood. Greater age does not mean living relatively more years with common mental disorder. However, the female population spends more years with common mental disorders and a greater proportion of their longer life expectancy with them (and with each studied separate mental disorder).
Relatively little is known of the use of systematic review and synthesis
methods of non-randomised psychiatric epidemiological studies, which play
a vital role in aetiological research, planning and policy-making.
To evaluate reviews of psychiatric epidemiological studies of functional
mental disorders that employed synthesis methods such as systematic
review or meta-analysis, or other forms of quantitative review.
We searched the literature to identify appropriate reviews published
during the period 1996 to April 2009. Selected reviews were evaluated
using published review guidelines.
We found 106 reviews in total, of which 38 (36%) did not mention method
of data abstraction from primary studies at all. Many failed to mention
study quality, publication bias, bias and confounding. In 73 studies that
performed a meta-analysis, 58 (79%) tested for heterogeneity and of
these, 47 found significant heterogeneity. Studies that detected
heterogeneity made some allowance for this. A major obstacle facing
reviewers is the wide variation between primary studies in the use of
instruments to measure outcomes and in sampling methods used.
Many deficiencies found in systematic reviews are potentially remediable,
although synthesis of primary study findings in a field characterised by
so many sources of heterogeneity will remain challenging.
Routine outcome measures are essential to chart individual patient progress and evaluate models of service provision. The Health of the Nation Outcome Scales (HoNOS) were commissioned by the Royal College of Psychiatrists as a simple, brief measure for this purpose. It is one of the most widely used outcome measures in mental health services globally and has been translated into at least seven languages. Its use has broadened beyond its original purpose and in several countries collection of HoNOS data is mandatory. We review 585 potential articles to chart the development and evolution of HoNOS, as well as its psychometric properties, qualitative attributes and uses in clinical practice and research. The potential barriers to implementation of HoNOS on a wide scale are considered and its future role in evaluating effectiveness and benchmarking of services are discussed.
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