Early intervention in psychosis, while not a new concept, has seen great development over the last 15 years. Growth in this time has occurred in a number of areas and has attracted a broad coalition of researchers, consumers, clinicians, carers and policy makers. In this time the concept of early intervention has moved from the fringes to the mainstream of clinical approaches to psychosis in many places, and is doing so in even more. After a decade and a half, this paper reviews some of the key issues that have been addressed and points to areas where further growth and reform is still required. Some issues that have created controversy are examined here including pre-onset intervention and identification, the relationship of duration of untreated psychosis (DUP) to outcome and whether or not early intervention is an effective and economically viable model. Areas that are only now developing or which require further investigation are considered, including the concept of stages of mental illness and concomitant interventions, closing the efficacy-effectiveness gap and an increased focus on functioning as part of the recovery process. Early intervention in psychosis started as a reformist movement, agitating for change from outside the mainstream. Change has occurred and now early intervention is part of the mainstream approach to psychotic illness. In order to continue to develop, while enjoying the benefits of being a mainstream intervention, early intervention must not stray too far from its reformist roots.

Longitudinal assessment of the course of major psychiatric disorders has been advanced by studies from onset, but only rarely have large numbers of patients with a range of psychotic and major affective disorders been studied simultaneously and systematically from illness-onset. The decade-long McLean-Harvard First Episode Project & International Consortium for Bipolar Disorder Research has systematically followed-up large numbers of patients with DSM-IV bipolar or psychotic disorders from first hospitalization. Major findings among patients with bipolar I disorder include: [a] full functional recovery from initial episodes was uncommon, and full symptomatic recovery, much slower than early syndromal recovery; [b] risks of relapse, recurrence, and switching were very high in the first two years; [c] most early morbidity was depressive-dysphoric, as reported in mid-course; [d] initial depression or mixed-states predicted more later depressive and overall morbidity, whereas initial mania or psychosis predicted later mania and a better prognosis; [e] based on within-subject modeling, most patients did not show progressive cycling over time, and illness-course was rather chaotic within and among patients; [f] treatment-latency or episode-counts were unassociated with responsiveness to long-term mood-stabilizing treatment; [g] very high rates of suicidal behavior and accidents occurred early; [h] early substance-use comorbidity associated with anxiety; [i] factor-analysis of prodromal symptoms predicted bipolar disorder much better than non-affective psychotic disorders. Project findings indicate that the course of bipolar I disorder is much less favorable than had been believed formerly, despite clinical treatment with modern mood-stabilizing and other treatments.

In this paper we aim to provide an overview of initial findings from the UK ÆSOP study concerning ethnicity, social risk factors and psychosis, and to set the findings from this study within the context of other related research. Our focus is primarily on the UK African-Caribbean population. ÆSOP is a multi-centre population based incidence and case-control study of first episode psychosis, conducted initially over a three-year period. The study sample comprises: a) all patients with a first episode of psychosis who presented to secondary and tertiary services within tightly defined catchment areas in south-east London, Nottingham and Bristol, UK over defined time periods; and b) a random sample of healthy community controls. Findings from the ÆSOP study to date have confirmed that the African-Caribbean and Black African populations in the UK are at increased risk of schizophrenia and other psychoses, compared with the White British population. Analyses of data relating to social risk factors suggest that various forms of early childhood and adult adversity, and neighbourhood characteristics, including ethnic density, may be particularly important in contributing to increased risk in these populations. These data suggest that adverse social experiences maybe aetiologically relevant in schizophrenia and other psychoses. A more complete understanding of these factors may help us to clarify why there are differences in rates between populations.

Aims - To examine earlier uses and abuses of artworks by individuals living with severe mental illnesses, and particularly schizophrenia by both the psychiatric and arts communities and prevailing stereotypes associated with such practices. Further, to explore alternative constructions of the artworks and roles of the artist with schizophrenia and other severe mental illnesses, which may be more consistent with amore contemporary recovery orientation, encompassing their potentials for empowerment, social inclusion as citizens and legitimacy of their cultural role in the community. Results - Earlier practices with regardto the artworks of captive patients of psychiatrists, psychotherapists, art therapists, occupational and diversional therapists, often emphasised diagnostic or interpretive purposes, or were used to gauge progress or exemplify particular syndromes. As artists and art historians began to take an interest in such artworks, they emphasised their expressive, communicative and aesthetic aspects, sometimes in relation to primitive art. These efforts to ascribe value to these works, while well-meaning, were sometimes patronising and vulnerable to perversion by totalitarian regimes, which portrayed them as degenerate art, often alongside the works of mainstream modernist artists. This has culminated in revelations that the most prominent European collection of psychiatric art still contains, and appears to have only started to acknowledge since these revelations, unattributed works by hospital patients who were exterminated in the so-called “euthanasia” program in the Nazi era. Conclusions - Terms like Psychiatric Art, Art Therapy, Art Brut and Outsider Art may be vulnerable to abuse and are a poor fit with the aspirations of artists living with severe mental illnesses, who are increasingly exercising their rights to live and work freely, without being captive, or having others controlling their lives, or mediating and interpreting their works. They sometimes do not mind living voluntarily marginal lives as artists, but they prefer to live as citizens, without being involuntarily marginalised by stigma. They also prefer to live with culturally valued roles which are recognised as legitimate in the community, where they are also more likely to heal and recover.

Declaration of Interest: This paper was completed during a Visiting Fellowship, Department of Social Medicine, School of Public Health, & Department of Medical Anthropology, Faculty of Arts & Sciences, Harvard University, Cambridge, Mass, USA. A condensed version of this paper is published in “For Matthew & Others: Journeys with Schizophrenia”, Dysart, D, Fenner, F, Loxley, A, eds. Sydney, University of New South Wales Press in conjunction with Campbelltown Arts Centre & Joan Sutherland Performing Arts Centre, Penrith, 2006, to accompany with a large exhibition of the same name, with symposia & performances, atseveral public art galleries in Sydney & Melbourne, Australia. The author is also a printmaker, partly trained at Ruskin School, Oxford, Central St. Martin's School, London, and College of Fine Arts, University of New South Wales, Sydney.

Aims - The article describes the evolution of Outsider Art from the birth of its term in 1972 to the present and its emancipation from the margin to the markets, still in progress. Results - Tracing the evolution of Outsider Art evidences a stark contradiction. On one hand the art world of collectors, historians, art dealers and admirateurs, accepts without reservation artwork that for many years was kept in a marginal position, compared to the “insider” art establishment. On the other hand art experts can not agree on a universal definition of this category of art. The particular status of the outsider artists is one of the reasons that causes difficulty in reaching a definition of Outsider Art. Significant atelier experiences with psychiatric patients delineate the difference between an Outsider Art work and a work produced by Art Therapy. Conclusions - The art market of art dealers and art collectors can be identified as the place where these contradictions dissolve, and where the Outsider Art category finds its ultimate legitimation and international recognition.

Several discernible trends have changed the outlook of psychiatric resources available to the general public during the last 50 years in Western countries and particularly in Italy. Among these trends, two conflicting issues are here outlined. On the one side, evidence based medicine is the core of a methodological revolution, which asks for a deeper criticism of subjective judgements in clinical matters; on the other side, the study of emotions and attitudes has stressed the outstanding importance of conscious and unconscious expectations both in patients and in caregivers. Moreover, popular psychology has altered the way mental disorder is commonly perceived and treated. A comprehensive way of taking into account these three diverse trends seems to be still lacking.

Aims — To assess in a national sample the ability of GPs to detect psychiatric disorders using a clinical vs. a standardized interview and to characterize the patients that were falsely diagnosed with an anxiety or affective disorder. Methods — This is a national, cross—sectional, epidemiological survey, carried out by GPs on a random sample of their patients. The GPs were randomly divided into two groups. Apart from the routine clinical interview, the experimental group (group A) had to administer the Mini—International Neuropsychiatric Interview (MINI). Results — Data was collected by 143 GPs. 17.2% of all patients had a clinical diagnosis of an affective disorder, and 25.4% a clinical diagnosis of an anxiety disorder. In group A, the number of clinical diagnoses was about twice that of MINI diagnoses for affective disorders and one and a half times that for anxiety disorders. The majority of clinical diagnoses were represented by MINI subsyndromal cases (52.3%). Females showed a higher OR of being over—detected by GPs with anxiety disorders or of not being diagnosed with an affective disorder. Being divorced/separated/widowed increased the OR of over—detection of affective and anxiety disorders. The OR of over—detection of an affective or an anxiety disorder was higher for individuals with a moderate to poor quality of life. Conclusions — In the primary care a gap exists between clinical and standardized interviews in the detection of affective and anxiety disorders. Some experiential and social factors can increase this tendency. The use of a psycho.

Declaration of Interest: GlaxoSmithKline provided unrestricted economic and organizational support to the study. No further declarations on other form of financing or any other involvement that might be considered a conflict of interest in connection with the submitted article.

Aims — To investigate the prevalence of psychotherapy intervention in five Italian Centres for Mental Health. Analysing sociodemographic characteristics, geographical differences, frequencies of psychotherapy interventions, and the costs of these interventions. Methods — Five Italian Community—based Psychiatric Services collected data from 1250 patients during October 2002. Socio—demographic and clinical characteristics and GAF scores were collected at baseline. All psychiatric contacts during the following six months were recorded and categorised into 24 service contact categories. A comparison between patients who received or did not receive psychotherapy was made. Results — The socio—demographic characteristics of patients are very similar to those found in previous studies; there is a great difference in the number of psychotherapy treatments between the five areas. Psychotherapy patients use different services compared to the other patients, and their care cost less. Conclusions — This study provides a description of the provision of psychotherapy by Italian Mental Health Services. Further research is required into this topic.

Declaration of Interest: None.

Aims — Description of students' opinions about schizophrenia and depression. Methods — The study was carried out on a sample of 445 secondary school students, randomly allocated to a “schizophrenia” or a “depression” group (N=221 and N=224, respectively). Each respondent was asked to read a case—vignette describing a case of schizophrenia or depression, and then to fill the Questionnaire on the Opinions about Mental Illness — General Population's version (QO—GP). Results — 35% of students in “schizophrenia” group vs. 85% in “depression” group attributed a correct diagnosis to case—vignette. 19% of students in the “schizophrenia” group vs. 39% in the “depression” group believed that these mental disorders can recover. Affective and civil rights were more frequently acknowledged to patients with depression than to those with schizophrenia. In both groups, the majority of students stated that mentally ill patients were unpredictable and socially dangerous. Students who reported TV stories on people with mentally ill were more frequently convinced on their unpredictability and social dangerousness. Conclusions — These results outline the need to: a) plan educational campaigns for students on mental disorders; b) alert media professionals on the impact that the way they present crimes committed by mentally ill patients may have on general population.

Declaration of Interest: None of the authors has had any interest or she has received any form of support, including that from drug companies and honoraria for lectures and consultancies potentially in conflict with this scientific work in the last two years. None of the authors has received any form of fee for her participation in this study.

Aims - This study aimed to explore psychiatric patients' experiences of involuntary admission and treatment by reviewing qualitative studies. Method - Qualitative studies investigating patients' experiences of involuntary treatment were identified. Relevant databases were searched and authors were contacted. Thematic analysis was applied for the synthesis of emerging issues. Results - Five studies fulfilled the inclusion criteria. The main areas that appear to be of importance are: patients' perceived autonomy and participation in decisions for themselves, their feeling of whether or not they are being cared for and their sense of identity. In these areas both negative and positive consequences from involuntary admission were mentioned. However, methodological weaknesses were also found, such as small sample sizes. Furthermore, it is not described whether these themes are mentioned by all participants as negative and positive aspects of their experience or whether they reflect views supported by distinct groups. Conclusions - Although the perceived impact of involuntary treatment is fairly clearly described, differences between distinct patient groups are not examined. Future research should investigate such differences in order to inform relevant policy decisions for particular groups.

Declaration of Interest: None.