About 30% of people with depression do not respond to an antidepressant at the recommended dose and can be described as having treatment-refractory depression.

To summarise the findings from all randomised controlled trials (RCTs) that have assessed the efficacy of a pharmacological or psychological intervention for treatment-refractory depression.

We used a systematic search strategy to identify RCTs that included adults aged 18–75 years with a diagnosis of unipolar depression that had not responded to a 4-week course of a recommended dose of an antidepressant.

We identified 16 RCTs. None of the included trials assessed the efficacy of psychotherapy. All the trials were too small to detect an important clinical response. We found only two trials on lithium augmentation, which randomised 50 subjects in total.

There is little evidence to guide the management of depression that has not responded to a course of antidepressants. Treatment-refractory depression is an important public health problem and large pragmatic trials are needed to inform clinical practice.

Impaired intellectual performance is associated with an increased risk of schizophrenia.

To investigate whether this association is due to the influence of prenatal and early childhood exposures on both intellectual development and the risk of schizophrenia.

Cohort of 197 613 Swedish male conscripts with linked birth, census and hospital admission data together with five measures of verbal and non-verbal intellectual performance recorded at conscription. Results 109 643 subjects had complete data; over a mean 5-year follow-up, 60 developed schizophrenia and 92 developed other non-affective psychoses. Poor scores for each of the five tests were associated with 3-to 14-fold increased risk of psychosis, particularly schizophrenia. Controlling for birth-related exposures, including birth weight, and parental education did not attenuate these associations.

109 643 subjects had complete data; over amean 5-year follow-up,60 developed schizophrenia and 92 developed other non-affective psychoses. Poor scores for each of the five testswere associatedwith 3-to 14-foldincreasedrisk of psychosis, particularly schizophrenia. Controlling for birth-related exposures, including birthweight, and parental education didnot attenuate these associations.

Poor intellectual performance at 18 years of age is associated with early-onset psychotic disorder. Associations do not appear to be confounded by prenatal adversity or childhood circumstances, as indexed by parental education.

Comorbidity in epidemiological surveys of mental disorders is common and of uncertain importance.

To explore the correlates of current comorbidity.

Data from the Australian National Survey of Mental Health and Well-Being were used to evaluate the relationships between comorbidity, disability and service utilisation associated with particular mental disorders.

The number of current comorbid disorders predicted disability, distress, neuroticism score and service utilisation. Comorbidity is more frequent than expected, which might be due to the effect of one disorder on the symptom level of another, or to the action of common causes on both. The combination of affective and anxiety disorders was more predictive of disability and service utilisation than any other two or three group combinations. When people nominated their principal disorder as the set of symptoms that troubled them the most, the affective and anxiety disorders together were associated with four-fifths of the disability and service utilisation.

To make clinical interventions more practical, current comorbidity is best reduced to a principal disorder and subsidiary disorders.

Little is known about the effect of pharmacotherapy in the prevention of post-traumatic stress disorder (PTSD) relapse.

To assess the efficacy and tolerability of fluoxetine in preventing PTSD relapse.

This was a double-blind, randomised, placebo-controlled study. Following 12 weeks of acute treatment, patients who responded were re-randomised and continued in a 24-week relapse prevention phase with fluoxetine (n=69) or placebo (n=62). The primary efficacy assessment was the prevention of PTSD relapse, based on the time to relapse.

Patients in the fluoxetine/fluoxetine group were less likely to relapse than patients in the fluoxetine/placebo group (P=0.027). There were no clinically significant differences in treatment-emergent adverse events between treatment groups.

Fluoxetine is effective and well tolerated in the prevention of PTSD relapse for up to 6 months.

Specialised services should be developed to help people with schizophrenia and associated substance misuse. The extent of the problem therefore needs to be known.

To determine the use of drugs, alcohol and tobacco by people with schizophrenia drawn from rural, suburban and urban settings, and to compare use by general population control subjects.

People with schizophrenia (n=316) and general population controls of similar gender distribution, age and postcode area of residence (n=250) were identified in rural, urban and suburban areas of Scotland. Use of drugs and alcohol was assessed by the Schedules for Clinical Assessment in Neuropsychiatry, and use of tobacco by a questionnaire.

More patients than controls reported problem use of drugs in the past year (22 (7%) v. 5 (2%)) and at some time before then (50 (20%) v. 15 (6%)) and problem use of alcohol in the past year (42 (17%) v. 25 (10%)) but not at sometime previously (99 (40%) v. 84 (34%)). More patients were current smokers (162 (65%) v. 99(40%)).

Problem use of drugs and alcohol by people with schizophrenia is greater than in the general population, but absolute numbers are small. Tobacco use is the greatest problem.

Subtle formal thought disorders are difficult to quantify. Their relationship to florid thought disorder is unknown.

To assess the interrater reliability, sensitivity and factor structure of a new assessment instrument, the Thought and Language Index (TLI), and to determine if minor aberrations detectable in the speech of healthy individuals are related to the more severe formal thought disorders characteristic of schizophrenia.

Interrater reliability was evaluated by determining the intraclass correlation for the ratings by five assessors. Factor analysis of the TLI scores of 87 patients was performed, and TLI scores in matched patients and controls were compared.

The intraclass correlation was good for individual TLI items, and excellent for sub-scale scores. Factor analysis identified three groups of approximately orthogonal disorders. Mild speech aberrations were observed in healthy participants and in patients with schizophrenia. The prevalence of mild aberrations was correlated with the prevalence of definite formal thought disorders.

The TLI is reliable and capable of detecting subtle disorders. Some mild aberrations occurring in the speech of healthy individuals appear to be attenuated forms of the florid disorders characteristic of schizophrenia.

Few studies have investigated factors which predict inappropriate terminations (drop-out) of clinical contact with mental health services.

To identify patient and treatment characteristics associated with dropping out of contact with community-based psychiatric services (CPS).

A 3-month cohort of patients attending the CPS was followed up for 2 years, to identify drop-outs.

We identified 495 patients who had had at least one psychiatric contact of whom 261 had complete ratings for the Global Assessment of Functioning and the Verona Service Satisfaction Scale. In the year after the index contact, 70 terminated contact with the CPS; of these, 44 were rated as having inappropriate terminations (the ‘drop-out’ group) and 26 had appropriate terminations of contact. Drop-outs were younger, less likely to be married and their previous length of contact with services was shorter. No drop-outs had a diagnosis of schizophrenia. Multivariate analysis revealed predictors of dropping out.

In a CPS targeted to patients with severe mental illnesses, those who drop out of care are younger patients without psychoses who are generally satisfied with their treatment.

The prevalence of brain injury and its effects in populations exposed to war violence has not been studied in recent years.

To examine the association between traumatic brain injury events and psychiatric symptoms of major depression and post-traumatic stress disorder (PTSD) in Cambodian survivors of mass violence.

The population comprised a multi-stage random sample of Cambodian refugees livingin a Thai refugee camp. The main results analysed the relationship between six categories of trauma events and psychiatric symptoms of depression and PTSD during two time periods.

Almost 15 000 trauma events were reported (n=13481, Pol Pot period; n=1249, past year). Traumatic brain injury was most common in the highly educated and in individuals with the highest levels of cumulative trauma. Of all trauma categories, traumatic brain injury revealed the strongest association with symptoms of depression, and a weaker association with PTSD. Brain injury represented 4% of the total number of traumatic events for both time periods, contributing 20% of the total symptom score for depression and 8% of that for PTSD.

Clinical identification and treatment of traumatic brain injuries in highly traumatised populations must be maintained in order to develop a new public health model for their treatment.