Treatment non-adherence and service disengagement are commonly attributed to impaired insight. There is evidence that recovery style (i.e. psychological adjustment) may underlie service engagement.

We examined whether insight, psychotic symptoms or individuals' recovery style (‘integration’ v. ‘sealing-over’) predicts service engagement.

Fifty patients with schizophrenia were assessed during acute psychosis and at 3-month and 6-month follow-ups. Measures included recovery style, psychosis symptoms, insight and service engagement.

Sealing-over at 3 months following onset of an episode of psychosis predicted low service engagement at 6 months. Neither insight nor symptoms predicted engagement. The clear shift from integration to sealing-over within the first 3 months was independent of changes in symptoms or insight. Sealing-over between 3 and 6 months was associated with improvement in psychosis symptoms.

Recovery style contributed more to engagement than did insight, appears to be dynamic in the short term and is orthogonal to insight. Overall, this study demonstrated the importance of addressing psychological adjustment to psychosis as well as illness status when investigating treatment engagement in people with psychosis.

Despite the application of ablative neurosurgical treatments for intractable mental disorder throughout most of the past century, unequivocal evidence for efficacy has not been provided.

To review the status of ablative neurosurgery for mental disorder and to describe the activities of the Scottish national service.

Relevant literature is reviewed alongside a description of recent clinical activity.

Neurosurgical treatment is offered to a small number of patients severely disabled by otherwise intractable mental disorder. Thereareinequalitiesin the strength of evidence to support the use of some of these procedures. The frequency and severity of adverse effects remains unclear. We are collecting data that should inform future practice.

Modern neurosurgery can offer clinically meaningful symptom relief and improved function for ‘untreatable’ patients with chronic, severe depression and obsessive-compulsive disorder. However, follow-up studies of greater rigour are required. The potential role of non-ablative alternatives remains unclear.

Despite a growing use of selective serotonin reuptake inhibitors in older people, only one trial has examined their prophylactic efficacy in people aged 65 years and over.

To examine the efficacy of sertraline in preventing the recurrence of depression in older people living in the community.

Participants were openly treated with sertraline and then randomised into a double-blind, placebo-controlled continuation/maintenance study of about 2 years duration. Drug dosage was maintained at levels that achieved remission.

No significant difference between the sertraline and placebo groups was found in the proportion of recurrences (–7.9%; 95% CI –28.06 to 12.23). Increased age and minor residual symptoms during the continuation phase were associated with recurrence.

Sertraline at therapeutic dosage does not provide significant protection against recurrence.

Administration of a complex tyrosine-free amino acid drink acutely decreases manic symptoms. Although a nutrient-based approach to illness management is attractive, complex amino acid drinks are too unpalatable for repeated administration.

To assess whether a simple, branched-chain amino acid (BCAA) drink diminishes manic symptoms acutely and following repeated administration.

Twenty-five patients with mania were randomly and blindly allocated to treatment with BCAA (60 g) or placebo daily for 7 days.

Relative to placebo, the BCAA drink lowered mania ratings acutely over the first 6 h of treatment. In protocol completers there was a persistent advantage to the BCAA group 1 week after the end of treatment.

A nutritional intervention that decreases tyrosine availability to the brain acutely ameliorates manic symptoms. Further studies are required to assess whether this approach has longer-term efficacy.

Mental disorder is more prevalent among people in prison than in the general population. Prisoners who require transfer to psychiatric hospitals for treatment face long delays. Doctors working in prisons regularly face ethical and legal dilemmas posed by prisoners with mental illness.

To develop a policy for providing treatment under the common law to prisoners with mental disorders who lack treatment decision-making capacity while arrangements are made to transfer them to hospital.

The policy was developed through literature review and consultation with the Faculty of Law at Southampton University and health care staff at Winchester prison in the UK.

The policy provides guidelines for establishing decision-making capacity standards for documentation, and guidelines for implementation based on the Mental Health Act Code of Practice, other best-practice guidelines and case law.

It can be argued that case law allows more-extensive treatment to be provided in the best interests of the incompetent prisoner, beyond emergency situations. The policy has ethical implications and its use should be carefully monitored.

Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition.

To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive–behavioural therapy (CBT).

A 3-month randomised, controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care.

Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% v. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibility in general practice.

Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

An increased rate of premorbid impairment has been reported in both child- and adolescent-onset schizophrenic and affective psychoses.

To examine the evidence for a specific association between premorbid impairment and child- and adolescent-onset schizophrenia, and whether specific continuities exist between premorbid impairments and psychotic symptom dimensions.

Retrospective case note study of 110 first-episode child- and adolescent-onset psychoses (age 10–17 years). DSM–III–R diagnoses derived from the OPCRIT algorithm showed 61 with schizophrenia (mean age 14.1 years) and 49 with other non-schizophrenic psychoses (mean age 14.7 years).

Premorbid social impairment was more common in early-onset schizophrenia than in other early-onset psychoses (OR 1.9, P=0.03). Overall, impaired premorbid development, enuresis and incontinence during psychosis were specifically associated with the negative psychotic symptom dimension.

Premorbid social impairments are more marked in child- and adolescent-onset schizophrenia than in other psychoses. There appears to be developmental continuity from premorbid impairment to negative symptoms.

Psychological interventions for postnatal depression can be beneficial in the short term but their longer-term impact is unknown.

To evaluate the long-term effect on maternal mood of three psychological treatments in relation to routine primary care.

Women with post-partum depression (n=193) were assigned randomly to one of four conditions: routine primary care, non-directive counselling, cognitive–behavioural therapy or psychodynamic therapy. They were assessed immediately after the treatment phase (at 4.5 months) and at 9, 18 and 60 months post-partum.

Compared with the control, all three treatments had a significant impact at 4.5 months on maternal mood (Edinburgh Postnatal Depression Scale, EPDS). Only psychodynamic therapy produced a rate of reduction in depression (Structured Clinical Interview for DSM–III–R) significantly superior to that of the control. The benefit of treatment was no longer apparent by 9 months post-partum. Treatment did not reduce subsequent episodes of post-partum depression.

Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.

Although neurocognitive impairment has been widely reported in major depressive disorder (MDD), confounding factors, such as the effects of psychotropic medication, have rarely been controlled for.

To examine neurocognitive function in medication-free patients with MDD and healthy controls.

Forty-four patients meeting DSM–IV criteria for MDD, all psychotropic-medication-free for at least 6 weeks, and 44 demographically matched, healthy comparison subjects completed a comprehensive neurocognitive battery.

Patients with depression were impaired significantly in a range of cognitive domains, including attention and executive function and visuospatial learning and memory, compared with controls. Motor and psychomotor functions were intact. Severity of depression correlated with learning and memory performance, but not executive function.

Pronounced neurocognitive impairment was found in this sample of young adult out-patients with MDD. This is not attributable to the confounding effects of psychotropic medication and could therefore provide an objective marker of brain dysfunction in depression.

The impact of comorbid personality disorder on the occurrence of violence in psychosis has not been fully explored.

To examine the association between comorbid personality disorder and violence in community-dwelling patients with psychosis.

A total of 670 patients with established psychotic illness were screened for comorbid personality disorder. Physical assault was measured from multiple data sources over the subsequent 2 years. Logistic regression was used to assess whether the presence of comorbid personality disorder predicted violence in the sample.

A total of 186 patients (28%) were rated as having a comorbid personality disorder. Patients with comorbid personality disorder were significantly more likely to behave violently over the 2-year period of the trial (adjusted odds ratio = 1.71, 95% CI 1.05–2.79).

Comorbid personality disorder is independently associated with an increased risk of violent behaviour in psychosis.

Evidence for the efficacy of cognitive–behavioural therapy for schizophrenia is promising but evidence for clinical effectiveness is limited.

To test the effectiveness of cognitive–behavioural therapy delivered by clinical nurse specialists in routine practice.

Of 274 referrals, 66 were allocated randomly to 9 months of treatment as usual (TAU), cognitive–behavioural therapy plus TAU (CBT) or supportive psychotherapy plus TAU (SPT) and followed up for 3 months.

Treatment effects were modest but the CBT condition gave significantly greater improvement in overall symptom severity than the SPT or TAU conditions combined (F (1,53)=4.14; P=0.05). Both the CBT and SPT conditions combined gave significantly greater improvement in severity of delusions than did the TAU condition (F (1,53)=4.83; P=0.03). Clinically significant improvements were achieved by 7/21 in the CBT condition (33%), 3/19 in the SPT condition (16%) and 2/17 in the TAU condition (12%).

Cognitive–behavioural therapy delivered by clinical nurse specialists is a helpful adjunct to routine care for some people with chronic psychosis.

There has been much debate about changes in the incidence of schizophrenia.

To identify any changes in incidence of schizophrenia in Camber well, south-east London, between 1965 and 1997.

Research Diagnostic Criteria and DSM–III–R diagnoses were generated for all first contacts by the OPCRIT computer program, and incidence rates of schizophrenia in seven time periods were measured. Indirect standardisation and Poisson models were used to measure the effect of time period and to examine interactions with age and gender.

There was a continuous and statistically significant increase in the incidence of schizophrenia, which was greatest in people under 35 years of age and was not gender-specific.

The incidence of schizophrenia has doubled in south-east London over the past three decades.

Maintenance of treatment effect is important for the choice of treatment for social phobia.

To examine the effect of exposure therapy and sertraline 28 weeks after cessation of medical treatment.

In this study 375 patients with social phobia were randomised to treatment with sertraline or placebo for 24 weeks, with or without the addition of exposure therapy Fifty-two weeks after inclusion, 328 patients were evaluated by the same psychometric tests as at baseline and the end of treatment (24 weeks).

The exposure therapy group and the placebo group had a further improvement in scores on social phobia during follow-up: mean change in the Clinical Global Impression – Social Phobia overall severity score was 0.45 (95% CI 016–0.65, P < 0.01) for the exposure group, and 0.25 (95% CI 0.00–0.48, P < 0.05) for the placebo group. At week 52 the sertraline plus exposure group and the sertraline-alone group had a significant deterioration on the 36-item Short Form Health Survey compared with exposure alone.

Exposure therapy alone yielded a further improvement during follow-up, whereas exposure therapy combined with sertraline and sertraline alone showed a tendency towards deterioration after the completion of treatment.

There is a lack of data on the cost-effectiveness of relapse prevention in depression.

A total of 158 subjects with partially remitted major depression despite adequate clinical treatment were randomly allocated to cognitive therapy in addition to antidepressants and clinical management v. antidepressants and clinical management alone. Relapse rates and health care resource utilisation were measured prospectively over 17 months.

Cumulative relapse rates in the cognitive therapy group were significantly lower than in the control group (29% v. 47%). The incremental cost incurred in subjects receiving cognitive therapy over 17 months (£779; 95% CI £387–£1170) was significantly lower than the overall mean costs of cognitive therapy (£1164; 95% CI £1084–£1244). The incremental cost-effectiveness ratio ranged from £4328 to £5027 per additional relapse prevented.

In individuals with depressive symptoms that are resistant to standard treatment, adjunctive cognitive therapy is more costly but more effective than intensive clinical treatment alone.

Schizophrenia is a major cause of suicide, and symptoms characteristic of treatment-resistant disease are strong risk factors. Clozapine reduces symptoms in 60% of such patients and significantly decreases the risk of suicide.

To model the impact of increased clozapine prescribing on lives saved and resource utilisation.

A model was built to compare current levels of clozapine prescribing with a scenario in which all suitable patients with treatment-resistant schizophrenia received clozapine.

It was estimated that an average of 53 lives could be saved in the UK each year. If clozapine is cost-neutral, the cost per life-year saved is $.5108. If clozapine achieves a 10% reduction in annual support costs, the net saving is $8.7 million per annum. An average of 167 acute beds would be freed each year.

The use of clozapine in treatment-resistant schizophrenia saves lives, frees resources and is cost-effective.

Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother–child relationship and child outcome.

To evaluate the effect of three psychological treatments on the mother–child relationship and child outcome.

Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive–behavioural therapy or psychodynamic therapy. The women and their children were assessed at 4.5, 18 and 60 months post-partum.

Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants; counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother–infant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infant–mother attachment, infant cognitive development or any child outcome at 5 years.

Early intervention was of short-term benefit to the mother–child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

Dialectical behaviour therapy (DBT) is widely considered to be a promising treatment for borderline personality disorder (BPD). However, the evidence for its efficacy published thus far should be regarded as preliminary.

To compare the effectiveness of DBT with treatment as usual for patients with BPD and to examine the impact of baseline severity on effectiveness.

Fifty-eight women with BPD were randomly assigned to either 12 months of DBT or usual treatment in a randomised controlled study. Participants were recruited through clinical referrals from both addiction treatment and psychiatric services. Outcome measures included treatment retention and the course of suicidal, self-mutilating and self-damaging impulsive behaviours.

Dialectical behaviour therapy resulted in better retention rates and greater reductions of self-mutilating and self-damaging impulsive behaviours compared with usual treatment, especially among those with a history of frequent self-mutilation.

Dialectical behaviour therapy is superior to usual treatment in reducing high-risk behaviours in patients with BPD.