This paper discusses some key aspects of the debate on the difficulties of incorporating scientific evidence into the daily work of clinicians in mental health services (MHS). It highlights the topics of: the utility of guidelines in this field, the ethical principles that should guide their utilisation, their limitations, obstacles impeding the diffusion of guidelines in psychiatry, and strategies that can be useful for overcoming the barriers to guideline implementation. The SIEP-DIRECT's ((DIscrepancy between Routine practice and Evidence in psychiatric Community Treatments on Schizophrenia) Project's potential role in fostering this advancement is discussed in detail. This Project developed a set of 103 indicators that operationalised the NICE clinical guidelines for schizophrenia recommendations and tested them in 19 MHS in Italy. A multi-step design was used to assess recommendation and indicator acceptability in the Italian context; provide an assessment of any current discrepancies between routine practice and guideline recommendations in the treatment of schizophrenia; and understand the reasons for any discrepancies that might emerge. This process, moreover, was instrumental in keeping the debate arising during conduction of this Project far from the excesses of hostility - and excesses of “bright-eyed enthusiasm” - that frequently influence discussion on topic. This Project therefore showed potential to serve in the search for a happy medium, that can facilitate the pursuit of a fundamental advancement in guideline implementation in mental health services.

Declaration of Interest: None.

The continuous performance test (CPT) is a behavioural assessment of attentional modulation of the motor system (Rosvold et al., 1956). It has firstly been used in patients with brain injuries and then applied to assess sustained attention and vigilance in epilepsy, brain tumor, dementia, schizophrenia and other psychiatric diseases, such as attention-deficit hyperactivity disorder (ADHD) and anxiety disorders (Rosvold et al., 1956; Honey et al., 2005; Kanaka et al., 2008). There are several versions of the test. For instance, the X-CPT version presents randomly different stimuli and subjects are asked to push a button only on presentation of the target stimuli (X). In the AX-CPT version, the subjects are required to push the button only when a cue stimulus is presented before the target one (A before X). The following items are measured for the X and AX tasks: omission errors (number of times subjects fail to respond to target stimulation), commission errors (number of times subjects respond to non target stimulation), average reaction time and coefficient of variance for both correct reactions and commission errors (Suwa et al., 2004). There are other versions, such as the CPT-not X version where the subjects are asked not to push a button when the target stimulus (X) is presented; the Degraded Stimuli (DS)-CPT (Nuechterlein, 1983); the CPT playing card version (Rutschmann et al., 1977); and the CPT Identical Pairs version (Cornblatt et al., 1988), which is a more difficult task prepared to assess high risk population. Interestingly, the Identical Pairs version has been included in the Matrics neurocognitive assessment, a consensus cognitive battery for clinical trials of cognition in schizophrenia (Nuechterlein et al., 2008).

Background – Seasonal Affective Disorder (SAD) is supposed to be caused by lack of daylight in winter. Yet the population of Northern Norway, living without sun for two winter months, does not spontaneously complain about depression during the dark period. Aims – To summarize research bearing upon the validity of the concept of SAD. Method – Review of relevant literature concerning the epidemiology of SAD and the questionnaire developed to measure it in general populations, the Seasonal Pattern Assessment Questionnaire (SPAQ). Results – Large population studies from northern Norway do not point to a higher prevalence of depression in winter than expected in any other general population. The psychometric properties of SPAQ are rather poor, and the diagnosis of SAD based on SPAQ bears little relationship to a meaningful concept of depression. Conclusions – Seasonal Affective Disorder is not a valid medical construct. Instead, “Recurrent depression with seasonal pattern” as defined in the DSM-IV and the ICD-10 should be used as terms. However, more research is needed to establish whether it is at all fruitful to single out such a subtype of recurrent depression.

Declaration of Interest: None.

Aims – The aims of the SIEP-DIRECT'S Project (DIscrepancy betweenRoutine practice andEvidence in psychiatricCommunityTreatments onSchizophrenia) are: 1) To evaluate the appropriateness of the NICE guidelines for schizophrenia in Italian Departments of Mental Health; 2) to develop and to test a set of SIEP indicators, based on the NICE recommendations, useful to evaluate their real application in mental health services. Methods – Based on the NICE recommendations, 103 indicators have been developed, some of them qualitative and the rest quantitative. These indicators investigate five different areas: 14 indicators concern the common elements in all phases of mental health care; 11 the treatment of first episode; 24 the crisis treatment; 41 the recovery promotion; 13 the urgency, including management of violent behaviours and fast soothing. After a pilot study conducted in 2 community mental health services, the indicators were tested in 19 Italian Departments of Mental Health, to obtain a self-evaluation of the quality of care and to verify the application of NICE recommendations in the clinical routine of these Services. Data for the self-evaluation have been obtained from the DSM'ls psychiatric informative system and from the Direction of the local health authorities or of the DSM. Moreover, for some indicators, information has been gathered from the clinical records, and by means of questionnaires administered to a sample of patients and relatives. Finally, “multidisciplinary” (i.e. involving different types of professionals) or “specialized” (i.e. involving only psychiatrists) focus groups have assessed the degree of similarity between practice and recommendation for 33 indicators. Finally, the focus group methodology has been applied in all services with the aim to judge the appropriateness of each NICE recommendation in the context of the Italian Departments of Mental Health. Results and Conclusions – Most NICE recommendations have been considered useful and appropriated to measure quality of care in the context of the Italian services. The SIEP indicators have been easily used by the services participating in the DIRECT's Project. The self-evaluation process has provided several data of great relevance to improve the quality of care for schizophrenia and implement clinical guidelines in Italy.

Declaration of Interest: None.

Introduction – There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain). Method – Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas. Results – Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas. Discussion – Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Declaration of Interest: None.

Aims – Many people suffering from serious mental illness do not seek appropriate medical help. The stigma of mental illness has often been considered a potential cause for reluctance in seeking help. We review recent evidence on this topic. Methods – Narrative review of the recent literature on stigma and helpseeking for psychiatric disorders. Results – There is proof of a particular stigma attached to seeking help for a mental problem. Anticipated individual discrimination and discrimination qua self-stigmatisation are associated with a reduced readiness to seek professional help for mental disorders. Intervention studies show that destigmatisation may lead to increased readiness to seek professional help, but other aspects like knowledge about mental diseases seem to be at least as important. The belief that seeking help for a mental health problem is actually helpful has been shown to be at the core of help-seeking intentions and thus offers a promising target for information programmes. Population based time-trend studies show that public attitudes towards help-seeking have improved over the last decade. Discussion – The relationship between help-seeking intentions and actual help-seeking needs further exploration. While many studies have been able to relate attitudes to intentions, predicting actual help-seeking has proved more difficult.

Declaration of Interest: None.

Aims – This paper aims at presenting the most significant results emerging from the work carried out by the focus groups of the multi-centre Project SIEP-DIRECT's. The Project is aimed at assessing the existing discrepancies between the evidence-based NICE guidelines for schizophrenia and the usual practices of care given by Italian mental health services. Each focus group was requested to give an evaluation on: a) appropriateness of the English NICE guidelines in the context of the Italian mental health services; b) clarity and usefulness of the 103 indicators developed on the basis of the NICE recommendations to measure their level of application within the services. Methods - In each of the 19 mental health departments or psychiatric services participating in the Project there were organized “multidisciplinary” focus groups and “specialistic” focus groups. The former included, amongst others, professional operators of the mental health services, patients, their relatives, representatives of patient organizations and general practitioners. They examined the recommendations and indicators upon which the participants could express their opinion or judgment based on their knowledge, experience or information in their possession. The latter group, composed only of psychiatrists, examined the recommendations and indicators relative to pharmacological treatments that regarded the specific competences of their professional category. Results – Most NICE recommendations seemed appropriate to the working context of the Italian services. However, some perplexity emerged as regards specific organizational models of the services, such as the specific services for psychotic onsets or the assertive outreach teams, which were believed not to be strictly pertinent to the traditional organization of mental health care in our Country. There were also some criticisms regarding the cognitive-behavioural treatments which the NICE Guidelines recommend as the principle psychotherapeutic option for patients with schizophrenia, since in many Italian services, when the use of psychological interventions are needed, the tendency is to prefer interventions based on psychodynamic theories. The SIEP indicators were generally held to be clear and acceptable. Conclusions – In the view of the focus groups, the NICE guidelines are on the whole useful and suitable for orientating the services in the choice of more efficacious practices in the treatment of patients with schizophrenia. Moreover, the results obtained legitimate the use of the set of SIEP indicators for the evaluation of good practices and the quality of care offered by Italian services. Finally, the use of focus groups delines to a different context as well as the verification of the comprehensibility and applicability of SIEP indicators.

Declaration of Interest: None.

Aims – Genetics can offer new resources to epidemiology. This review will consider recent findings regarding the link between stress and depression as an example to illustrate the added value of employing genetics in epidemiological studies. Methods – Systematic review of medical and psychological databases. Results – Genetic and environmental factors may correlate. This suggests the potential for genetic mediation of the exposure to the environment. Gene-environment correlations can help epidemiologists to better understand causal pathways and suggest effective therapeutic strategies. Genetic and environmental factors may also interact. This suggests the potential for genetic modification of environmental effects on disease risk. Gene-environment interactions can help epidemiologists to identify vulnerable individuals and strata-specific environmental effects. Conclusions – New models of disease based on the interplay between genes and environments are providing epidemiology with a new set of testable hypotheses that will advance our understanding of mental health and illness.

Declaration of Interest: Dr. Danese is holder of the Wellcome Trust Research Training Fellowship in Clinical Science.

Aims – Psychiatric hospitals remain the main venue for long-term mental health care and, despite widespread closures and downsizing, no country that built asylums in the last century has done away with them entirely – with the recent exception of Italy. Differentiated community-based residential alternatives have been developed over the past decades, with staffing levels that range from full-time professional, to daytime only, to part-time/on-call. Methods – This paper reviews the characteristics of community-based psychiatric residential care facilities as an alternative to long-term care in psychiatric hospitals. It describes five factors decision makers should consider: 1. number of residential places needed; 2. staffing levels; 3. physical setting; 4. programming; and 5. governance and financing. Results – In Italy, facilities with full-time professional staff have been developed since the mid-1990s to accommodate the last cohorts of patients discharged from psychiatric hospitals. In the United Kingdom, experiments with hostel wards since the 1980s have shown that home-like, small-scale facilities with intensive treatment and rehabilitation programming can be effective for the most difficult-to-place patients. More recently in Australia, Community Care Units (CCUs) have been applying this concept. In the Canadian province of British Columbia (BC), Tertiary Psychiatric Residential Facilities (TPRFs) have been developed as part of an effort to regionalise health and social services and downsize and ultimately close its only psychiatric hospital. Conclusions – This type of service must be further developed in addition to the need for forensic, acute-care and intermediate-level beds, as well as for community-based care such as assertive community treatment and intensive case management. All these types of services, together with long-term community-based residential care, constitute the elements of a balanced mental health care system. As part of a region's balanced mental health care plan, these Tertiary Psychiatric Care Facilities have the potential to act as hubs of expertise not only for treatment, rehabilitation, community integration and ser-vice co-ordination for the severely mentally ill, but also for research and training.

Declaration of Interest: None.

Aims – To review developments in recovery-focussed mental health services internationally. Methods – Two forms of ‘recovery’ which have been used in the literature are considered, and international examples of recovery-focussed initiatives reviews. A ‘litmus test’ for a recovery-focussed service is proposed. Results – ‘Clinical recovery’ has emerged from professional literature, focuses on sustained remission and restoration of functioning, is invariant across individuals, and has been used to establish rates of recovery. ‘Personal recovery’ has emerged from consumer narratives, focuses on living a satisfying, hopeful and contributing life even with limitations caused by the illness, varies across individuals, and the empirical evidence base relates to stages of change more than overall prevalence rates. Clinical and personal recovery are different. Two innovative, generalisable and empirically investigated examples are given of implementing a focus on personal recovery: the Collaborative Recovery Model in Australia, and Trialogues in German-speaking Europe. The role of medication is an indicator: services in which all service users are prescribed medication, in which the term ‘compliance’ is used, in which the reasoning bias is present of attributing improvement to medication and deterioration to the person, and in which contact with and discussion about the service user revolves around medication issues, are not personal recovery-focussed services. Conclusions – The term ‘Recovery’ has been used in different ways, so conceptual clarity is important. Developing a focus on personal recovery is more than a cosmetic change – it will entail fundamental shifts in the values of mental health services.

Declaration of Interest: None.

Aims – To evaluate the quality of psychiatric care in Italian community-based services and the discrepancy between real practices and NICE recommendations for the treatment of schizophrenia concerning the elements common to all phases of care and the first episode of psychosis. Methods – Data concerning 14 indicators on common aspects of care in all phases and 11 indicators concerning psychosis onset, drawn from NICE Recommendations, were collected in 19 Departments of Mental Health. Results – An optimistic attitude seems to prevail in the staff in all phases of care, while remarkable discrepancies between service practice and recommendations have been found in relation to systematic assessment, availability of informative leaflets and support to relatives. Concerning the treatment of first episode, a lack of specific services and differentiated activities, and paucity of practices based on specific guidelines has been detected. However, Italian community based services proved to have a good capacity to provide help quickly to those seeking help for a psychotic onset, to maintain regular contact with them in the subsequent year, and provide pharmacological treatment reasonably in line with the scientific evidence. Instead, little specific support is provided to the relatives. Conclusions – The results show critical points concerning capacity of assessment and treatment standardization, in all aspects of care and specifically in the treatment for the first episode. Differentiation of activities specifically dedicated to the patients at their first episode should be promoted as well as strategies to support relatives in a more specific way.

Declaration of Interest: none.

Over the last thirty to forty years, psychiatric care in England has relocated from hospital-based settings to community mental health teams (CMHTs) and supported accommodation. Since the 1980s, two forms of intensive home based treatment have evolved in addition to CMHTS, assertive community treatment (ACT) and crisis resolution teams (CRTs). On the basis of evidence for their efficacy in the US and other countries, they have been implemented across England through the Government's National Service Framework for Mental Health. This paper describes this evidence and the first UK studies that were carried out to evaluate these newly implemented services. Methods – Descriptions of the evaluations of ACT and CRTs in the inner London boroughs of Camden and Islington. Results – The implementation of CRTs in North London were associated with reduced use of inpatient services, but the ACT teams were not. Both types of team were associated with greater patient satisfaction with services and the ACTs were better able to engage patients than CMHTs. Conclusions – The authors comment on the implications of the findings for service planners in terms of the difficulties in implementing innovative approaches based on the best available evidence when it originates outside the local context.

Declaration of Interest: These studies were funded by Camden and Islington Health Authority, the King's Fund and the Department of Health.

Background – The purpose of this article is to review the procedures to establish measurement validity in crosscultural comparative research, including recent developments in the quantitative assessment of cross-cultural construct validity. Methods – A narrative review, illustrated by selected examples, of methods in four areas – formative conceptual research, translation and adaptation, criterion validity and construct validity. Results – Valid assessment across cultures requires qualitative research to investigate the cultural relevance of the construct, a careful translation and adaptation of a common measure, followed by pre-testing and cognitive interviews on the populations to be tested. Full criterion validation across diverse cultures may be a chimera given the difficulty in establishing a universally applicable ‘gold standard'. Quantitative analyses can, however, have a part to play in establishing construct validity across cultures. Scale internal consistency, inter-item and item-total correlations and test-retest reliability provide basic support for the viability of a measure in a new cultural setting. Exploratory factor analysis can be used to compare factors and factor loadings. The hypothesis of ‘measurement invariance’ across countries and cultures can be tested explicitly using confirmatory factor analysis (common underlying factors and factor loadings) and Rasch models (common hierarchality of items). Despite measurement invariance, threshold effects arising from cultural differences in norms, or expectations, or expressions of mental distress may still be a problem. Conclusions – There are few examples in the cross-cultural mental health literature of demonstrably valid culture-fair comparison. Much more, could, in principle, be done either to demonstrate measurement invariance, or to identify and explore sources of heterogeneity.

Declaration of Interest: None.

Aims – To analyse factors that differentiate patients who attend follow-up assessments versus those who do not, and to identify predictors for drop-out within the context of the European Day Hospital Evaluation Study (EDEN-Study). Methods – The EDEN-Study, a multi-center RCT comparing acute psychiatric day care with inpatient care, required re-assessment of patients at discharge, 3 and 12 months after discharge. Follow-up rates varied between 54.0% and 99.5%. Socio-demographic and clinical characteristics of patients who did and did not attend follow-up were analysed using uni- and multivariate statistical methods. Results – Univariate analyses showed differences between patients regarding study site, treatment setting, living situation, employment, age, psychopathological symptoms and treatment satisfaction. They were not confirmed in multivariate analyses thus meaningful predictors of drop-out could not be identified. Conclusions – Results emphasize the general need to compare patients re-assessed and not re-assessed in terms of their most relevant socio-demographic and clinical variables to assess the generalizability of results.

Declaration of Interest: EDEN (Psychiatric day hospital treatment: An alternative to inpatient treatment, being cost-effective and minimizing post-treatment needs for care? An evaluative study in European countries with different care systems) was funded by the European Commission (Quality of Life and Management of Living Resources Programme: QLG4-CT-2000-01700). Additional national grants supporting the project were provided by Roland-Ernst-Stiftung für Gesundheitswesen and the Faculty of Medicine at the Dresden University of Technology, the National Health Service Executive Organization and Management Programme, the Polish National Committee of Scientific Affairs, and the Slovak Ministry of Education. Pfizer Pharmaceutical Company supported travel and accommodation for EDEN project meetings.

Aims – To evaluate the quality of psychiatric care during the acute psychotic episode and the early post-acute period. Methods – Data concerning 24 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project to evaluate the implementation of NICE recommendations in Italian Mental Health Services. Results – The treatment of the acute episode in the Italian Mental Health Services is not based only on admissions in Psychiatric Ward in General Hospitals, but also on intensive home based care. The utilization of day hospital facilities for treating acute episodes is less frequent, as the presence of home based follow up after discharge. About of Departments of Mental Health did not have clinical guidelines concerning the pharmacological treatment in this area. However usually the standard practices followed NICE recommendations in terms of prescribed dosages, monitoring side effects and rationale for shifting to atypical antipsychotic drugs. Antipsychotic drugs, atypical or conventional, were frequently prescribed concurrently, while utilization of atypical antipsychotic drugs was increasing. Conclusions – The results show critical points concerning on one hand the scarce diffusion of clinical guidelines, on other hand the connection between standard practices, clinical guidelines and marketing of atypical antipsychotic drugs. It should be reinforced the role of the community and particularly at service level the capacity of community mental health teams to treat the acute patients.

Declaration of Interest: none.

Aims – We wanted to investigate to what extent and in what characteristics the patients cared in the psychiatric residential facilities (RF) were similar to those in the day-centres (DC), and whether 6-month improvements in the two settings were comparable. Methods – We described 141 patients admitted to the RF and 180 in DC of three mental health service networks in Milan and near Milan. They were evaluated again after six months. Results – In both groups, we identified subgroups of more intensive treatment: 45% of those in residential treatment were in high intensity rehabilitation facilities, and those who followed a residential program of >12 hours/week were 53%. The mean duration of treatment in the residential treatment was 40 months (SD 55.7) and in DC 49.6 months (49.3). The two groups differed in the overall scores of the HoNOS, but differences emerged in the subscales relative to daily life activities and living conditions. Among those in RF, about half had a house, versus 99% among those in DC. After six months, clinically significant modifications were small in both groups. Conclusions – Residential patients had more needs than DC patients. It is possible that some of the residential patients might be treated with intensive DC program, but the absence of a home for the majority of residential facilities patients makes this unlikely.

Declaration of Interest: None.

Aims The aim of this paper is to summarise the effects of cannabis use on appetite and energy balance, and to subsequently investigate the possible implications this may have in patients with psychosis, in whom a high prevalence of cannabis use has been reported. Methods – A narrative review based on the recent literature regarding cannabis use in the gen-eral population and patients with psychosis. Results – The short-term abilities of cannabis to increase appetite and body weight, through actions on the endogenous endocannabinoid system, have been well characterised throughout the literature. The long term effects of cannabis use are however unclear and only a minority of studies have been conducted in the general population with overall conflicting results. In terms of the effects of cannabis in patients with psychosis, there has only been one study to date that has investigated this and interestingly found cannabis use to be associated with increased body weight and blood glucose levels, thus providing evidence that cannabis use may be an important contributing factor to the reduced life expectancy, as is currently observed in this vulnerable patient group. Conclusions – It is clear from the literature that patients with psychosis are at a high risk of metabolic and cardiovascular disease in comparison to the general population. However the contribution of cannabis use to this risk is as of yet undetermined and further long term studies are need to confirm current findings and evaluate hypothesised mechanisms.

Declaration of Interest: None.

Aims – To assess the validity and reliability of the GHQ-12 in Portugal. Methods – Using a standard ‘forwardbackward’ translation procedure, the English language version of the questionnaire was translated into Portuguese. To test reliability the internal consistency was assessed by Cronbach's alpha coefficient. Validity was performed using convergent validity. Finally, the factor structure of the questionnaire was extracted by performing principal component analysis using varimax rotation. Results – In all 790 undergraduates entered into the study. Reliability analysis showed satisfactory result (Cronbach's alpha coefficient = 0.91). Convergent validity indicated a significant negative correlation between the GHQ-12 and social support scores as expected (r = -0.54, P < 0.001). The principal component analysis showed that the GHQ-12 was a measure with two-factor structure. Conclusion – The Portuguese version of the GHQ-12 has a good structural characteristic for measuring psychological well being.

Declaration of Interest: None.