Studies of cognitive behavioural therapy delivered by computer (cCBT) show clinical efficacy for treating anxiety and depression, but have not focused on barriers to uptake. Potential barriers include adverse consequences, accessibility and acceptability.

An integrated systematic review was conducted of quantitative and qualitative studies and surveys from multiple electronic databases where computers delivered cCBT for anxiety or depression.

Substantial numbers of potential participants are lost prior to trials commencing with little explanation. Among trial participants, drop-outs may be higher in the cCBT groups (odds ratio 2.03, 95% confidence interval 0.81–5.09). Only a median of 56% completed a full course of cCBT and personal circumstance was a more common cause of drop-out than difficulties with the technology or social background. Risk was rarely assessed in the majority of programs. Significant staff time was needed to support clients. Therapists were more negative about cCBT than clients.

While cCBT is likely to be an effective and acceptable intervention for some people, there are barriers to its uptake that will substantially limit its impact if not addressed. These included investigating the outcome and attitudes of those who do not make it as far as cCBT trials and why so few finish a full course of cCBT.

Cognitive behaviour therapy (CBT) has been shown to reduce psychological morbidity in people with cancer, but no randomized controlled trial (RCT) exists in palliative care. We aimed to determine whether home care nurses could be taught to deliver basic cognitive behavioural techniques and so reduce symptoms of anxiety and depression.

Clinical nurse specialists (CNSs) at St Christopher's Hospice were randomly allocated to receive training in CBT or continue their usual practice. At the end of the trial, nurses were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Home care patients who scored as possible cases on the Hospital Anxiety and Depression Scale (HADS) entered the trial. Participants received home care nursing visits. Assessments were carried out at baseline, 6, 10 and 16 weeks.

Eight nurses received CBT training and seven continued practice as usual. The mean CTFARS scores were 35.9 for the CBT nurses and 19.0 for the controls (p=0.02). A total of 328 patients (54%) were possible cases and 80 entered the trial; most of those excluded were too ill to participate. There was an interaction between group and time: individuals receiving CBT had lower anxiety scores over time [coefficient −0.20, 95% confidence interval (CI) −0.35 to −0.05, p=0.01]. No effect of the training was found for depression.

It is possible to conduct a randomized trial of psychological interventions in palliative care but there is considerable attrition from physical morbidity and mortality. Nurses can learn to integrate basic CBT methods into their clinical practice. This training may be associated with better outcomes for symptoms of anxiety.

Neurocognitive impairment is a well-recognized feature of depression that has been reported in younger and older adults. Similar deficits occur with ageing and it is unclear whether the greater deficits in late-life depression are an ageing-related phenomenon or due to a difference in the nature of late-life depression itself. We hypothesized that ageing alone would not fully explain the increased neurocognitive impairment in late-life depression but that differences in the illness explain the greater decrements in memory and executive function.

Comparison of the neuropsychological performance of younger (<60 years) and older (⩾60 years) adults with major depressive disorder (MDD) and healthy comparison subjects. Scores for each depression group were normalized against their respective age-matched control group and the primary comparisons were on four neurocognitive domains: (i) attention and executive function; (ii) verbal learning and memory; (iii) visuospatial learning and memory; and (iv) motor speed.

We recruited 75 subjects with MDD [<60 years (n=44), ⩾60 years (n=31)] and 82 psychiatrically healthy comparison subjects [<60 years (n=42), ⩾60 years (n=40)]. The late-life depression group had greater impairment in verbal learning and memory and motor speed but not in executive function. The two depressed groups did not differ in depression severity, global cognitive function, intelligence or education.

Late-life depression is associated with more severe impairment in verbal learning and memory and motor speed than depression in earlier adult life and this is not due to ageing alone.

Previous surveys on depression in China focused on prevalence estimates without providing a detailed epidemiological profile.

Face-to-face household interviews were conducted with a multi-stage household probability sample of 2633 adults (age ⩾18 years) in Beijing and 2568 in Shanghai between November 2001 and February 2002. The World Health Organization Composite International Diagnostic Interview (CIDI) was used to assess major depressive episode (MDE) according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria.

The lifetime prevalence and 1-year prevalence estimates of DSM-IV/CIDI MDE were 3.6% [95% confidence interval (CI) 2.8–4.4%] and 1.8% (95% CI 1.2–2.4%) respectively. No significant gender difference was found in these estimates. Respondents born in 1967 or later were at elevated lifetime risk compared with respondents born in earlier cohorts. The mean age of onset was 30.3 years. Among those reporting 1-year MDE, 15.7, 51.8, 25.3 and 6.4% reported mild, moderate, severe and very severe symptoms respectively; 4.8, 2.6 and 3.2% reported suicidal ideation, plans, and recent attempts in the same year respectively. Respondents with 1-year MDE reported a mean of 27.5 days out of role owing to their depression in the year before interview. Significant co-morbidity was found between MDE and other mental disorders [odds ratio (OR) 22.0] and chronic physical disorders (OR 3.2). Only 22.7% of respondents with 1-year MDE sought treatment.

The low prevalence and insignificant gender difference, but not patterns of onset, course, co-morbidity, and impairment, distinguish the epidemiological profile of MDE in metropolitan China from those in other countries.

We investigated whether depressive disorder and Type D personality refer to different forms of distress in the Myocardial INfarction and Depression – Intervention Trial (MIND-IT).

A total of 1205 myocardial infarction (MI) patients were screened at 3, 6, 9 and 12 months post-MI; those with a Beck Depression Inventory (BDI) score ⩾10 underwent the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Patients completed the DS14 measure of Type D personality at 12 months and were stratified to one of four subgroups: depressed/Type D, depressed/non-Type D, non-depressed/Type D, or non-distressed.

Two hundred and six (17%) patients were diagnosed with depression and 224 (19%) with Type D. Only 7% (n=90) had both forms of distress, and 60% of Type D patients were free of depression in the first year post-MI. Type D moderated the relationship between depressive and cardiac disorder. Depressed patients without Type D had the worst clinical status (left ventricular dysfunction, heart failure, Killip class ⩾2) as compared to other patients, whereas depressed patients with a Type D personality did not differ in clinical status from non-distressed patients. Contrasting ‘pure’ Type D and depression subgroups showed that Type D patients without depression were less likely to have left ventricular dysfunction [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.35–0.65, p<0.0001] than depressed patients without Type D.

Depression and Type D refer to different forms of distress in post-MI patients; most Type D patients display non-psychiatric levels of distress and Type D moderates the relationship between depressive and cardiac disorder. Different depression/Type D subgroups may be involved in the prediction of cardiac prognosis.

Memory deficits are common in depressed patients and may persist after recovery. The aim of the present study was to determine whether memory impairments were present in young women at increased familial risk of depression and whether memory performance was related either to cortisol secretion or to allelic variation in the promoter region of the serotonin transporter gene (5-HTT).

Young women (n=35, age range 16–21 years) with no personal history of depression but with a depressed parent (FH+) carried out the Rey Auditory Verbal Learning Test (RAVLT). They also provided samples for the measurement of waking salivary cortisol and for 5-HTT genotyping. An age-matched control group of women (n=31) with no family history of depression were similarly studied.

The FH+ participants had decreased immediate recall and recognition memory compared to controls. The impairment in recall, but not recognition, correlated negatively with increased cortisol secretion in FH+ subjects. There was no significant effect of 5-HTT allelic status on either memory or waking cortisol secretion.

Impairments in declarative memory are present in young women at increased genetic risk of depression and may be partly related to increased cortisol secretion. Further studies are needed to explore the neural mechanisms underlying the memory impairments and whether they predict the development of clinical illness.

Suicide is a leading cause of death and has been strongly associated with affective disorders. The influence of affective disorder polarity on subsequent suicide attempts or completions and any differential effect of suicide risk factors by polarity were assessed in a prospective cohort.

Participants with major affective disorders in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) were followed prospectively for up to 25 years. A total of 909 participants meeting prospective diagnostic criteria for major depressive and bipolar disorders were followed through 4204 mood cycles. Suicidal behavior was defined as suicide attempts or completions. Mixed-effects, grouped-time survival analysis assessed risk of suicidal behavior and differential effects of risk factors for suicidal behavior by polarity. In addition to polarity, the main effects of age, gender, hopelessness, married status, prior suicide attempts and active substance abuse were modeled, with mood cycle as the unit of analysis.

After controlling for age of onset, there were no differences in prior suicide attempts by polarity although bipolar participants had more prior severe attempts. During follow-up, 40 cycles ended in suicide and 384 cycles contained at least one suicide attempt. Age, hopelessness and active substance abuse but not polarity predicted suicidal behavior. The effects of risk factors did not differ by polarity.

Bipolarity does not independently influence risk of suicidal behavior or alter the influence of well-established suicide risk factors within affective disorders. Suicide risk assessment strategies may continue to appraise these common risk factors without regard to mood polarity.

There are few theoretical proposals that attempt to account for the variation in affective processing across different affective states of bipolar disorder (BD). The Interacting Cognitive Subsystems (ICS) framework has been recently extended to account for manic states. Within the framework, positive mood state is hypothesized to tap into an implicational level of processing, which is proposed to be more extreme in states of mania.

Thirty individuals with BD and 30 individuals with no history of affective disorder were tested in euthymic mood state and then in induced positive mood state using the Question–Answer task to examine the mode of processing of schemas. The task was designed to test whether individuals would detect discrepancies within the prevailing schemas of the sentences.

Although the present study did not support the hypothesis that the groups differ in their ability to detect discrepancies within schemas, we did find that the BD group was significantly more likely than the control group to answer questions that were consistent with the prevailing schemas, both before and after mood induction.

These results may reflect a general cognitive bias, that individuals with BD have a tendency to operate at a more abstract level of representation. This may leave an individual prone to affective disturbance, although further research is required to replicate this finding.

Many studies have used negative mood induction techniques to investigate the effect of emotional state on cognitive performance but positive mood induction paradigms have been used less frequently. The objective of this study was to investigate the effect of positive mood induction on emotional processing in euthymic individuals with bipolar disorder (BD) and controls.

Previously, we reported that positive mood induction using a novel technique based on feedback produced a longer-lasting effect in euthymic individuals with BD than controls (Farmer et al. 2006). Here we report the effect of mood induction on two tests of emotional processing, the Affective Go/No-go test (AGNG) and the Cambridge Gamble task (CGT), on which BD patients in the manic phase differ in their performance from controls.

Following positive mood induction, bipolar cases exhibited a positive emotional bias on the AGNG and performed more slowly than controls on the CGT, particularly when making more difficult decisions.

These data confirm that positive mood induction is more effective in individuals with BD than controls. They also suggest that alterations in decision making and attentional biases occur even with transient and subtle changes in mood in bipolar disorder.

We and others have reported that patients experiencing their first episode of psychosis already have significant structural brain abnormalities. Antipsychotics seem to reverse subcortical volume deficits after months of treatment. However, the early impact of medication on brain morphology is not known.

Forty-eight individuals in their first episode of psychosis underwent magnetic resonance imaging (MRI) brain scanning. Twenty-six were antipsychotic naive and 22 were newly treated with antipsychotic medication for a median period of 3 weeks. In each group, 80% of subjects received a diagnosis of schizophrenia. The two groups were balanced for age, sex, handedness, ethnicity, height, years of education, paternal socio-economic status (SES) and Positive and Negative Syndrome Scale (PANSS) score. Group differences in whole-brain grey matter were compared voxel by voxel, using Brain Activation and Morphological Mapping (BAMM) software. We also conducted testing of group differences with region-of-interest (ROI) measurements of the caudate nucleus.

Relative to the untreated group, those receiving antipsychotic medication for 3–4 weeks had significantly greater grey-matter volumes in the bilateral caudate and cingulate gyri, extending to the left medial frontal gyrus. ROI analysis confirmed that, in treated patients, the right and left caudate nuclei were significantly larger by 10% (p<0.039, two-tailed) and 9% (p<0.048, two-tailed) respectively.

Early striatal grey-matter enlargement may occur within the first 3–4 weeks of antipsychotic treatment. Possible reasons for putative striatal hypertrophy and its implications are discussed.

The literature suggests an association between obesity and schizophrenia but fat mass and fat-free mass, which have been shown to be more predictive of all-cause mortality than only waist circumference and obesity [body mass index (BMI) ⩾30 kg/m2], have not been reported in psychotic disorders. We examined the detailed body composition of people with different psychotic disorders in a large population-based sample.

We used a nationally representative sample of 8082 adult Finns aged ⩾30 years with measured anthropometrics (height, weight, waist circumference, fat percentage, fat-free mass and segmental muscle mass). Psychiatric diagnoses were based on a consensus procedure utilizing the Structured Clinical Interview for DSM-IV (SCID)-interview, case-notes and comprehensive register data.

Schizophrenia (including schizo-affective disorder) was associated with obesity [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.5–3.6], abdominal obesity (waist circumference ⩾88 cm for women, ⩾102 cm for men) (OR 2.2, 95% CI 1.3–3.6) and with higher fat percentage (mean difference 3.8%, 95% CI 2.0–5.7%), adjusted for age and gender, than in the remaining sample. The associations between schizophrenia and low fat-free mass and decreased muscle mass on trunk and upper limbs became statistically significant after adjusting for BMI. After further adjusting for current antipsychotic medication, education, diet and smoking, schizophrenia remained associated with obesity (OR 1.9, 95% CI 1.1–3.6) and abdominal obesity (OR 3.8, 95% CI 1.5–9.4). Participants with affective psychoses did not differ from the general population.

Individuals with schizophrenia have metabolically unfavorable body composition, comprising abdominal obesity, high fat percentage and low muscle mass. This leads to increased risk of metabolic and cardiovascular diseases.

This study was designed to investigate potential temperament endophenotypes for clinically significant importance of shape and weight.

Seven temperament risk factors for eating disorders and the Eating Disorder Examination were assessed in 699 female twins aged 12–15 years. Each variable was evaluated against the following endophenotype criteria: associated with illness in the general population; found in non-affected family members at a higher rate than in the general population; and, heritable.

All seven variables were significantly associated with clinically significant importance of shape and weight, while thin-ideal internalization, ineffectiveness, body dissatisfaction and sensitivity to punishment were found at significantly elevated levels in non-affected twins, when controlling for sister's temperament score. These four variables had genetic correlations with importance of shape and weight, ranging from 0.48 to 0.95.

Future research should evaluate the stability of the identified endophenotypes and their utility for predicting significant growth in importance of shape and weight, and also whether different endophenotypes emerge when the importance of weight and shape reaches its peak in adolescents, around 15 to 16 years of age.

Little is known about the epidemiology of bulimia nervosa outside clinical settings. We report the incidence, prevalence and outcomes of bulimia nervosa using for the first time a nationwide study design.

To assess the incidence and natural course and outcomes of DSM-IV bulimia nervosa among women from the general population, women (n=2881) from the 1975–79 birth cohorts of Finnish twins were screened for lifetime eating disorders using a two-stage procedure consisting of a questionnaire screen and the Structured Clinical Interview for DSM-IV (SCID). Clinical recovery was defined as 1-year abstinence from bingeing and purging combined with a body mass index (BMI) ⩾19 kg/m2.

The lifetime prevalence of DSM-IV bulimia nervosa was 2.3%; 76% of the women suffered from its purging subtype and 24% from the non-purging subtype. The incidence rate of bulimia nervosa was 300/100000 person-years at the peak age of incidence, 16–20 years, and 150/100000 at 10–24 years. The 5-year clinical recovery rate was 55.0%. Less than a third of the cases had been detected by health-care professionals; detection did not influence outcome. After clinical recovery from bulimia nervosa, the mean levels of residual psychological symptoms gradually decreased over time but many women continued to experience significantly more body image problems and psychosomatic symptoms than never-ill women.

Few women with bulimia nervosa are recognized in health-care settings. Symptoms of bulimia are relatively long-standing, and recovery is gradual. Many clinically recovered women experience residual psychological symptoms after attaining abstinence from bingeing and purging.

DSM-IV cites <85% of expected body weight (EBW) as a guideline for the diagnosis of anorexia nervosa (AN) but does not require a specific method for calculating EBW. The purpose of the present study was to determine the degree to which weight cut-off calculations vary across studies, and to evaluate whether differential cut-offs lead to discrepancies in the prevalence of individuals who are eligible for the AN diagnosis.

Two coders independently recorded the EBW calculation methods from 99 studies that either (a) compared individuals with AN to those with subclinical eating disorders or (b) conducted AN treatment trials. Each weight cut-off was applied to a nationally representative (n=12001) and treatment-seeking (n=189) sample to determine the impact of EBW calculation on the proportion who met the AN weight criterion.

Coders identified 10 different EBW methods, each of which produced different weight cut-offs for the diagnosis of AN. Although only 0.23% of the national sample met the lowest cut-off, this number increased 43-fold to 10.10% under the highest cut-off. Similarly, only 48.1% of treatment seekers met the lowest cut-off, whereas 89.4% met the highest.

There is considerable variance across studies in the determination of the AN weight cut-off. Discrepancies substantially affect the proportion of individuals who are eligible for diagnosis, treatment and insurance reimbursement. However, differences may not be fully appreciated because the ubiquitous citation of the 85% criterion creates a sense of false consensus.

It has been demonstrated that the mechanism of cognitive memory control in humans is sustained by the hippocampus and prefrontal cortices, which have been found to be structurally and functionally abnormal in borderline personality disorder (BPD). We investigated whether the memory control mechanism is affected in BPD.

Nineteen Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV BPD patients and 19 matched healthy controls (HC) performed a specific think/no-think paradigm exploring the capacity of remembering and suppressing pair of words previously learned. After the think–no think phase, the second member of each word pair has to be remembered either when subjects are presented with the cue word showed at the beginning of the test (Same Probe Test; SPT) or when they are presented with an extra-list categorical word (Independent Probe Test; IPT). We evaluated the effect of suppression and of retrieval activity on later retention of words.

Both on the SPT and on the IPT, HC showed the expected improvement of memory retrieval on to-be-remembered words, unlike BPD patients. On the SPT, HC, but not BPD patients, correctly recalled significantly more words among remembered words (RW) than among suppressed words (SW). Similarly to HC, subjects with BPD without a history of childhood abuse showed a significantly higher percentage of correctly recalled words among RW than among SW.

The mechanism of active retrieval of memories and of improvement through repetition is impaired in BPD, particularly in those who experienced traumatic experiences. This impairment might play an important role, possibly resulting in the emergence of unwanted memories and dissociative symptoms.

The ability to decode emotional information from facial expressions is crucial for successful social interaction. Borderline personality disorder (BPD) is characterized by serious problems in interpersonal relationships and emotional functioning. Empirical research on facial emotion recognition in BPD has been sparsely published and results are inconsistent. To specify emotion recognition deficits in BPD more closely, the present study implemented two emotion recognition tasks differing in response format.

Nineteen patients with BPD and 19 healthy subjects were asked to evaluate the emotional content of visually presented stimuli (emotional and neutral faces). The first task, the Fear Anger Neutral (FAN) Test, required a rapid discrimination between negative or neutral facial expressions whereas in the second task, the Emotion Recognition (ER) Test, a precise decision regarding default emotions (sadness, happiness, anger, fear and neutral) had to be achieved without a time limit.

In comparison to healthy subjects, BPD patients showed a deficit in emotion recognition only in the fast discrimination of negative and neutral facial expressions (FAN Test). Consistent with earlier findings, patients demonstrated a negative bias in the evaluation of neutral facial expressions. When processing time was unlimited (ER Test), BPD patients performed as well as healthy subjects in the recognition of specific emotions. In addition, an association between performance in the fast discrimination task (FAN Test) and post-traumatic stress disorder (PTSD) co-morbidity was indicated.

Our data suggest a selective deficit of BPD patients in rapid and direct discrimination of negative and neutral emotional expressions that may underlie difficulties in social interactions.

Evidence regarding the long-term separate and combined impact of adolescent psychiatric disorder and personality disorder (PD) on physical health is absent.

A total of 736 people randomly selected in childhood were contacted for home or telephone interviews four times over 20 years. DSM Axis I disorders and Axis II PDs were assessed at mean age 13.7 years in 1983 and physical health was assessed in 1985–1986, 1991–1994 and 2001–2004.

Comparisons were made between 506 adolescents without Axis I disorder or PD and adolescents with Axis I disorder or PD or both. Adolescents with an Axis I disorder (n=150) had significantly higher odds of pain and physical illness and poorer physical health. Adolescents with a PD (n=149) had higher odds of pain and physical illness and poorer physical health and a more rapid decline in physical health. In addition, the 81 participants with an Axis I disorder without co-morbid PD had poorer physical health, but this effect did not reach statistical significance, whereas the 80 participants with a PD but no Axis I disorder reported significantly more pain and more rapid decline in physical health. However, the 69 participants with co-morbid Axis I disorder and PD had the highest rates of pain and physical illness and the worst physical health.

Co-morbid PD accounted for many of the associations of adolescent Axis I disorder with physical health over the ensuing two decades. Co-morbid adolescent Axis I disorder and PD represent a particularly high risk for physical health.