Heroin-assisted treatment has been found to be effective for people with severe opioid dependence who are not interested in or do poorly on methadone maintenance.

To study heroin-assisted treatment in people on methadone who continue intravenous heroin and in those who are heroin dependent but currently not in treatment.

In an open-label multicentre randomised controlled trial, 1015 people with heroin dependence received a variable dose of injectable heroin (n=515) or oral methadone (n=500) for 12 months. Two response criteria, improvement of physical and/or mental health and decrease in illicit drug use, were evaluated in an intent-to-treat analysis.

Retention was higher in the heroin (67.2%) than in the methadone group (40.0%) and the heroin group showed a significantly greater response on both primary outcome measures. More serious adverse events were found in the heroin group, and were mainly associated with intravenous use.

Heroin-assisted treatment is more effective for people with opioid dependence who continue intravenous heroin while on methadone maintenance or who are not enrolled in treatment. Despite a higher risk, it should be considered for treatment resistance under medical supervision.

Severe mental illness is associated with increased risk of aggressive behaviour, crime and victimisation. Mental health policy does not acknowledge this evidence. The number of forensic beds has risen dramatically.

To examine the prevalence of aggressive behaviour, victimisation and criminality among people receiving in-patient treatment for severe mental illness in an inner-city area.

Self-reports of aggressive behaviour and victimisation and criminal records were collected for 205 in-patients with severe mental illness.

In the preceding 6 months 49% of the men and 39% of the women had engaged in aggressive behaviour and 57% of the men and 48% of the women had been victims of assault; 47% of the men and 17% of the women had been convicted of at least one violent crime.

Aggressive behaviour and victimisation are common among severely mentally ill people requiring hospitalisation in the inner city. Rates of violent crime are higher than in the general population.

Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy. However, the outcomes of RCTs often lackclinical utility and usually do not address real-world effectiveness

To review how traditional RCTs may be triangulatedwith other methodologies such as observational studies and pragmatic trials by highlighting recently reported studies, outcomes used and their respective merits

Literature review focusing on drug treatment

Recently reported observational and some pragmatic studies show a degree of consistency in reported results and use outcomes that have face validity for clinicians

No single experimental paradigm or outcome provides the necessary data to optimise treatment of mental illness in the clinical setting

Young people with anorexia nervosa are often admitted to hospital for treatment. As well as being disruptive to school, family and social life, in-patient treatment is expensive, yet cost-effectiveness evidence is lacking.

Cost-effectiveness analysis of three treatment strategies for adolescents with anorexia nervosa.

UK multicentre randomised, controlled trial comparing in-patient psychiatric treatment, specialist out-patient treatment and general out-patient treatment. Outcomes and costs assessed at baseline, 1 and 2 years.

There were 167 young people in the trial. There were no statistically significant differences in clinical outcome between the three groups at 2 years. The specialist out-patient group was less costly over the 2-year follow-up (mean total cost £26 738) than the in-patient (£34 531) and general out-patient treatment (£40 794) groups, but this result was not statistically significant. Exploration of the uncertainty associated with the costs and effects of the three treatments suggests that specialist out-patient treatment has the highest probability of being cost-effective.

On the basis of cost-effectiveness, these results support the provision of specialist out-patient services for adolescents with anorexia nervosa.

Although opioid receptor function in humans is clearly reduced during opioid dependence, what happens to the receptor in early abstinence is not understood.

This study sought to examine changes in opioid receptor availability in early abstinence from opioid dependence.

Ten people with opioid dependence who had completed inpatient detoxification and 20 healthy controls underwent [11C]-diprenorphine positron emission tomography. Clinical variables were assessed with structured questionnaires. Opioid receptor binding was characterised as the volume of distribution of [11C]-diprenorphine using a template of predefined brain volumes and an exploratory voxel-by-voxel analysis.

Compared with controls, participants with opioid dependence had increased [11C]-diprenorphine binding in the whole brain and in 15 of the 21 a priori regions studied.

This study suggests that opioid receptor binding is increased throughout the brain in early abstinence from dependent opioid use. These data complement the findings in cocaine and alcohol dependence.

There have been recent advances in the identification of people at high risk of psychosis and psychological treatments have shown promise for prevention

To compare the longitudinal course of psychotic experiences and emotional dysfunction in high-risk participants receiving cognitive therapy with those receiving treatment as usual

Data from a recent randomised controlled trial of cognitive therapy for people at risk of developing psychosis were utilised to examine three different statistical models that were based on 432 measurements of psychotic experiences and 421 of emotional dysfunction (anxiety–depression) contributed by 57 participants across the 13 measurement occasions (monthly monitoring for a year)

Psychotic experiences and emotional dysfunction were correlated and decreased significantly over the course of the study, with most improvement in the early months. The reduction in positive symptoms, but not emotional dysfunction, was enhanced by allocation to cognitive therapy

Psychotic experiences and emotional dysfunction appear to interact in people at risk of developing psychosis. There appears to be a specific benefit of cognitive therapy

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a new treatment option for depression. Previous studies were performed with low sample sizes in single centres and reported heterogeneous results.

To investigate the efficacy of rTMS as augmentative treatment in depression.

In a randomised, double-blind, sham-controlled multicentre trial 127 patients with moderate to severe depressive episodes were randomly assigned to real or sham stimulation for 3 weeks in addition to simultaneously initiated antidepressant medication.

We found no difference in the responder rates of the real and the sham treatment groups (31% in each) or in the decrease of the scores on the depression rating scales.

The data do not support previous reports from smaller samples indicating an augmenting or accelerating antidepressant effect of rTMS. Further exploration of the possible efficacy of other stimulation protocols or within selected sub-populations of patients is necessary.

Therapeutic alliance between clinicians and their patients is important in community mental healthcare. It is unclear whether providing effective interventions influences therapeutic alliance.

To assess the impact of meeting previously unmet mental health needs on the therapeutic alliance between patients and clinicians.

Secondary analysis of data from a longitudinal study assessing 101 patients and paired staff.

Patient-rated unmet need was negatively associated with patient-rated and staff-rated therapeutic alliance. Staff-rated unmet need was positively associated with patient-rated therapeutic alliance only. Reducing patient-rated unmet need increased patient-rated but not staff-rated therapeutic alliance, even when controlling for other variables. Reducing staff-rated unmet need increased staff-rated but not patient-rated therapeutic alliance, but the effect became insignificant when controlling for other variables.

Patient-rated therapeutic alliance will be maximised by focusing assessment and interventions on patient-rated rather than staff-rated unmet need.

Self-help for social phobia has not received controlled empirical evaluation.

To evaluate the efficacy of pure self-help through written materials for severe social phobia and self-help augmented by five group sessions with a therapist. These conditions were compared with a waiting-list control and standard, therapist-led group therapy.

Participants with severe generalised social phobia (n=224) were randomised to one of four conditions. Assessment included diagnoses, symptoms and life interference at pretreatment, 12 weeks and at 24 weeks.

A larger percentage of patients no longer had a diagnosis of social phobia at post-intervention in the pure self-help group than in the waiting-list group, although this percentage decreased slightly over the next 3 months. Symptoms of social anxiety and life interference did not differ significantly between these groups. Augmented self-help was better than waiting list on all measures and did not differ significantly from group treatment.

Self-help augmented by therapist assistance shows promise as a less resource-intensive method for the management of social phobia. Pure self-help shows limited efficacy for this disorder.

Depression is prevalent, costly and often undertreated.

To test the hypothesis that people with low socio-economic status are least likely to receive and adhere to evidence-based treatments for depression, after controlling for clinical need.

Individuals with an ICD-10 depressive episode in the past 12 months (n = 866) were recruited from 7271 attendees in 36 general practices in England and Wales. Depressive episodes were identified using the 12-month Composite International Diagnostic Interview. Treatment receipt and adherence were assessed by structured interview, and rated using evidence-based criteria.

We identified 332 individuals (38.3%) who received and adhered to evidence-based treatment. There were few socio-economic differences in treatment allocation. Although those without educational qualifications were least likely to receive psychological treatments (OR = 0.55, 95% CI 0.34–0.89, P = 0.02), this association was not statistically significant after adjusting for depression severity.

We found no evidence of inverse care in the treatment of moderate and severe depression in primary care in England and Wales.

People in a putatively late prodromal state not only have an enhanced risk for psychosis but already suffer from mental and functional disturbances

To evaluate the acute effects of a combined supportive and antipsychotic treatment on prodromal symptoms

Putatively prodromal individuals were randomly assigned to a needs-focused intervention without (n=59) or with amisulpride (n=65). Outcome measures at 12-weeks effects were prodromal symptoms, global functioning and extrapyramidal side-effects

Amisulpride plus the needs-focused intervention produced superior effects on attenuated and full-blown psychotic symptoms, basic, depressive and negative symptoms, and global functioning. Main side-effects were prolactin associated

Coadministration of amisulpride yielded a marked symptomatic benefit. Effects require confirmation by a placebo-controlled study

Repetition of self-poisoning is common.

To report the 24-month outcomes of a non-obligatory postcard intervention (plus treatment as usual) compared with treatment as usual.

In a randomised-controlled trial (Zelen design) conducted in Newcastle, Australia, eight postcards were sent to participants over a 12-month period. The principal outcomes were the proportion of participants with one or more repeat episodes of self-poisoning and the number of repeat episodes per person.

No significant reduction was observed in the proportion of people repeating self-poisoning in the intervention group (21.2%, 95% CI 17.0–25.3) compared with the control group (22.8%, 95% CI 18.7–27.0; χ2=0.32, d.f. = 1, P= 0.57); the difference between groups was −1.7% (95% CI −7.5 to 4.2). There was a significant reduction in the rate of repetition, with an incidence risk ratio of 0.49 (95% CI 0.33–0.73).

A postcard intervention maintained the halving of the rate of repetition of hospital-treated self-poisoning events over a 2-year period, although it did not significantly reduce the proportion of individuals who repeated self-poisoning.

The availability of firearms in homes and at aggregate levels is a risk factor for suicide and homicide. One method of reducing access to suicidal means is the restriction of firearm availability through more stringent legislation.

To evaluate the impact of firearm legislation reform on firearm suicides and homicides as well as on the availability of firearms in Austria.

Official statistics on suicides, firearm homicides and firearm licences issued from 1985 to 2005 were examined. To assess the effect of the new firearm law, enacted in 1997, linear regression and Poisson regressions were performed using data from before and after the law reform.

The rate of firearm suicides among some age groups, percentage of firearm suicides, as well as the rate of firearm homicides and the rate of firearm licences, significantly decreased after a more stringent firearm law had been implemented.

Our findings provide evidence that the introduction of restrictive firearm legislation effectively reduced the rates of firearm suicide and homicide. The decline in firearm-related deaths seems to have been mediated by the legal restriction of firearm availability. Restrictive firearm legislation should be an integral part of national suicide prevention programmes in countries with high firearm suicide rates.

There are few long-term follow-up studies of patients discharged from medium secure units in the UK, even though these units were introduced over 20 years ago.

To describe mortality, rates of reconviction at different time periods; violent behaviour (not leading to conviction), readmission and employment, after discharge from a medium secure unit.

Of 595 first admissions over a 20-year period, 550 discharged cases were followed-up. Multiple data sources were used.

Fifty-seven (10%) patients had died, of whom 18 (32%) died by suicide, and the risk of death was six times greater than in the general population. Almost half (49%) of those discharged were reconvicted and almost two-fifths (38%) of patients were readmitted to secure care.

Community psychiatric services need to be aware that those discharged from medium secure care are a highly vulnerable group requiring careful follow-up if excess mortality high levels of psychiatric morbidity and further offending are to be prevented.

Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care.

To survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders.

Structured interviews were conducted with each facility's head psychiatrist in all Italian regions, with the exception of Sicily.

Overall, Italy (except Sicily) has atotal of 4108 public in-patient beds in 319 facilities, with 0.78 beds for every 10 000 inhabitants, and 4862 beds in 54 private in-patient facilities, with 0.94 beds per 10 000 inhabitants. In 2001 the rates of psychiatric admissions and admitted patients per 10 000 inhabitants were 26.7 and 17.8 respectively. In the same year the percentage of involuntary admissions was 12.9%, for atotal of 114 570 hospital days. Many in-patient facilities showed significant limitations in terms of architectural and logistic characteristics. Staffing showed a great variability among facilities.

The overall number of acute beds per 10 000 inhabitants is one of the lowest in Europe. The survey has provided evidence of two parallel systems of in-patient care, a public one and a private one, which are not fully interchangeable.

Screening instruments for autistic-spectrum disorders have not been compared in the same sample.

To compare the Social Communication Questionnaire (SCQ), the Social Responsiveness Scale (SRS) and the Children's Communication Checklist (CCC).

Screen and diagnostic assessments on 119 children between 9 and 13 years of age with special educational needs with and without autistic-spectrum disorders were weighted to estimate screen characteristics for a realistic target population.

The SCQ performed best (area under receiver operating characteristic curve (AUC)=0.90; sensitivity 0.86; specificity 0.78). The SRS had a lower AUC (0.77) with high sensitivity (0.78) and moderate specificity (0.67). The CCC had a high sensitivity but lower specificity (AUC=0.79; sensitivity 0.93; specificity 0.46). The AUC of the SRS and CCC was lower for children with IQ < 70. Behaviour problems reduced specificity for all three instruments.

The SCQ, SRS and CCC showed strong to moderate ability to identify autistic-spectrum disorder in this at-risk sample of school-age children with special educational needs.