The British Journal of Psychiatry

Our major classification systems (DSM and ICD) face three main problems: the high rates of ‘comorbidity’ that are produced by our present diagnostic rules, the increasing use of ‘not elsewhere classified’ (NEC) by practising clinicians, and the fact that each new edition is longer and more complex than the one preceding it. A major simplification of the chapter structure used by each classification might pave the way to address these problems.

A recent study found that people with depression identified in the community recovered equally well given unsupported computerised cognitive–behavioural therapy (CBT), general practitioner treatment or a combination of the two, even if they did not comply. The results are different from those reported elsewhere. Could natural remission explain the finding?

There is a long history of research into the attributes of carers of people with psychosis, but few interventions target their distress or their difficulties.

To describe an empirically based model of the relationships of those caring for people with psychosis to inform clinical and theoretical advances.

We developed a model of informal carer relationships in psychosis, based on an integration of the literature elaborating the concept of expressed emotion. The model accounts for divergent outcomes of three relationship types: positive, overinvolved and critical/hostile relationships.

Good evidence supports a number of hypotheses concerning the origin and maintenance of these relationship outcomes, which relate to specific differences in carer attributions, illness perceptions, coping behaviour, social support, distress, depression and low self-esteem predicted by our model. We propose that interventions aimed at modifying the specific maintenance factors involved in the different styles of relationships will optimise therapeutic change both for service users with psychosis and for their carers.

Family work in psychosis, which improves relationships through problem-solving, reduces service user relapse. It is now time to consider theory-based interventions focused on improving carer outcomes.

Although people with bipolar disorder spend more time in a depressed than manic state, little evidence is available to guide the treatment of acute bipolar depression.

To compare the efficacy, acceptability and safety of mood stabiliser monotherapy with combination and antidepressant treatment in adults with acute bipolar depression.

Systematic review and meta-analysis of randomised, double-blind controlled trials.

Eighteen studies with a total 4105 participants were analysed. Mood stabiliser monotherapy was associated with increased rates of response (relative risk (RR) = 1.30, 95% CI 1.16–1.44, number needed to treat (NNT) = 10, 95% CI 7–18) and remission (RR = 1.51, 95% CI 1.27–1.79, NNT = 8, 95% CI 5–14) relative to placebo. Combination therapy was not statistically superior to monotherapy. Weight gain, switching and suicide rates did not differ between groups. No differences were found between individual medications or drug classes for any outcome.

Mood stabilisers are moderately efficacious for acute bipolar depression. Extant studies are few and limited by high rates of discontinuation and short duration. Further study of existing and novel agents is required.

A growing number of European studies, particularly from Nordic countries, suggest an increased frequency of autism in children of immigrant parents. In contrast, North American studies tend to conclude that neither maternal ethnicity nor immigrant status are related to the rate of autism-spectrum disorders.

To examine the hypotheses that maternal ethnicity and/or immigration are linked to the rate of childhood autism-spectrum disorders.

Retrospective case-note analysis of all 428 children diagnosed with autism-spectrum disorders presenting to the child development services in two centres during a 6-year period.

Mothers born outside Europe had a significantly higher risk of having a child with an autism-spectrum disorder compared with those born in the UK, with the highest risk observed for the Caribbean group (relative risks (RRs) in the two centres: RR = 10.01, 95% CI 5.53–18.1 and RR = 8.89, 95% CI 5.08–15.5). Mothers of Black ethnicity had a significantly higher risk compared with White mothers (RR = 8.28, 95% CI 5.41–12.7 and RR = 3.84, 95% CI 2.93–5.02). Analysis of ethnicity and immigration factors together suggests the increased risk is predominately related to immigration.

Maternal immigration is associated with substantial increased risk of autism-spectrum disorders with differential risk according to different region of birth and possibly ethnicity.

Parent and teacher data, from questionnaire surveys, suggest that school-identified disruptive children often have pragmatic language deficits of an autistic type.

This replication study aimed to confirm earlier findings, using individual clinical assessment to investigate traits of autism-spectrum disorder in disruptive children.

Persistently disruptive children (n = 26) and a comparison group (n = 22) were recruited from primary schools in a deprived inner-city area. Measures included standardised autism diagnostic interviews (with parents) and tests of IQ, social cognition, theory of mind and attention (with children).

The disruptive children possessed poorer pragmatic language skills (P<0.0001) and mentalising abilities (P<0.05) than comparisons. Nine disruptive children (35%) met ICD–10 criteria for atypical autism or Asperger syndrome.

Many persistently disruptive children have undetected disorders of social communication, which are of potential aetiological significance.

Regular adolescent cannabis use predicts a range of later drug use and psychosocial problems. Little is known about whether occasional cannabis use carries similar risks.

To examine associations between occasional cannabis use during adolescence and psychosocial and drug use outcomes in young adulthood; and modification of these associations according to the trajectory of cannabis use between adolescence and age 20 years, and other potential risk factors.

A 10-year eight-wave cohort study of a representative sample of 1943 secondary school students followed from 14.9 years to 24 years.

Occasional adolescent cannabis users who continued occasional use into early adulthood had higher risks of later alcohol and tobacco dependence and illicit drug use, as well as being less likely to complete a post-secondary qualification than non-users. Those using cannabis at least weekly either during adolescence or at age 20 were at highest risk of drug use problems in young adulthood. Adjustment for smoking in adolescence reduced the association with later educational achievement, but associations with drug use problems remained.

Occasional adolescent cannabis use predicts later drug use and educational problems. Partial mediation by tobacco use raises a possibility that differential peer affiliation may play a role.

The nature of the relationship between duration of the pre-diagnostic interval in schizophrenia and better outcomes remains unclear.

To re-examine data from one of the earliest studies suggesting an association between long pre-treatment interval and compromised outcome, assessing the relationship between symptomatic and social variables and increased relapse risk at 1 year.

Symptomatic, social and demographic data from participants in the Northwick Park Study of First Episodes who completed 12-month follow-up (n = 101) were re-analysed in the context of duration of untreated illness (DUI).

At admission, those with long DUI were more likely to have lower scores on tension derived from the Present State Examination, exhibited more behaviour threatening to others and more bizarre behaviour, were more likely to be single, to live alone or dependently, to be unemployed and to have experienced more adverse life events prior to admission. Logistic regression showed that diminished tension, bizarre behaviour and unemployed status independently increased the risk of relapse, bizarre behaviour making the single biggest contribution. Tension did not remain significant with log-transformation of data.

Findings are consistent with the conclusion that long DUI can reflect characteristics of the psychosis itself rather than delay in treatment.

The World Health Organization (WHO) has stated that the three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depression and ischaemic heart disease.

To estimate health-related quality of life (HRQoL) and quality-adjusted life-year (QALY) losses associated with mental disorders and chronic physical conditions in primary healthcare using data from the diagnosis and treatment of mental disorders in primary care (DASMAP) study, an epidemiological survey carried out with primary care patients in Catalonia (Spain).

A cross-sectional survey of a representative sample of 3815 primary care patients. A preference-based measure of health was derived from the 12-item Short Form Health Survey (SF–12): the Short Form–6D (SF–6D) multi-attribute health-status classification. Each profile generated by this questionnaire has a utility (or weight) assigned. We used non-parametric quantile regressions to model the association between both mental disorders and chronic physical condition and SF–6D scores.

Conditions associated with SF–6D were: mood disorders, β =−0.20 (95% CI −0.18 to −0.21); pain, β = −0.08 (95%CI −0.06 to −0.09) and anxiety, β =−0.04 (95% CI −0.03 to −0.06). The top three causes of QALY losses annually per 100 000 participants were pain (5064), mood disorders (2634) and anxiety (805).

Estimation of QALY losses showed that mood disorders ranked second behind pain-related chronic medical conditions.

Evidence about the cost-effectiveness and cost utility of computerised cognitive–behavioural therapy (CCBT) is still limited. Recently, we compared the clinical effectiveness of unsupported, online CCBT with treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus TAU) for depression. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).

To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus TAU.

Costs, depression severity and quality of life were measured for 12 months. Cost-effectiveness and cost-utility analyses were performed from a societal perspective. Uncertainty was dealt with by bootstrap replications and sensitivity analyses.

Costs were lowest for the CCBT group. There are no significant group differences in effectiveness or quality of life. Cost-utility and cost-effectiveness analyses tend to be in favour of CCBT.

On balance, CCBT constitutes the most efficient treatment strategy, although all treatments showed low adherence rates and modest improvements in depression and quality of life.

There is an urgent need for the development of cost-effective preventive strategies to reduce the onset of mental disorders.

To establish the cost-effectiveness of a stepped care preventive intervention for depression and anxiety disorders in older people at high risk of these conditions, compared with routine primary care.

An economic evaluation was conducted alongside a pragmatic randomised controlled trial (ISRCTN26474556). Consenting individuals presenting with subthreshold levels of depressive or anxiety symptoms were randomly assigned to a preventive stepped care programme (n = 86) or to routine primary care (n = 84).

The intervention was successful in halving the incidence rate of depression and anxiety at €563 (£412) per recipient and €4367 (£3196) per disorder-free year gained, compared with routine primary care. The latter would represent good value for money if the willingness to pay for a disorder-free year is at least €5000.

The prevention programme generated depression- and anxiety-free survival years in the older population at affordable cost.

Many people suffer from subthreshold and mild panic disorder and are at risk of developing more severe panic disorder.

This study (trial registration: ISRCTN33407455) was conducted to evaluate the effectiveness of an early group intervention based on cognitive–behavioural principles to reduce panic disorder symptomatology.

Participants with subthreshold or mild panic disorder were recruited from the general population and randomised to the intervention (n = 109) or a waiting-list control group (n = 108). The course was offered by 17 community mental health centres.

In the early intervention group, 43/109 (39%) participants presented with a clinically significant change on the Panic Disorder Severity Scale–Self Report (PDSS–SR) v. 17/108 (16%) in the control group (odds ratio (OR) for favourable treatment response 3.49, 95% CI 1.77–6.88, P = 0.001). The course also had a positive effect on DSM–IV panic disorder status (OR = 1.96, 95% CI=1.05–3.66, P = 0.037). The PDSS–SR symptom reduction was also substantial (between-group standardised mean difference of 0.68). The effects were maintained at 6-month follow-up.

People presenting with subthreshold and mild panic disorder benefit from this brief intervention.