One year of antipsychotic treatment from symptom remission is recommended following a first episode of psychosis (FEP).

To investigate the effectiveness of commonly used antipsychotic medications in FEP.

A retrospective cohort study of naturalistic treatment of patients (N = 460) accepted by FEP services across seven UK sites. Treatment initiation to all-cause discontinuation determined from case files.

Risk of treatment discontinuation is greatest within 3 months of treatment initiation. Risperidone had longest median survival time. No significant differences were observed in time to discontinuation between commonly used antipsychotics on multivariable Cox regression analysis. Poor adherence and efficacy failure were the most common reasons for discontinuation.

Effectiveness differences appear not to be a current reason for antipsychotic choice in FEP. Adherence strategies and weighing up likely adverse effects should be the clinical focus.

Psychosis seminars enable service users, their carers and mental health professionals to meet outside of a formal care setting, increase understanding of mental illness and help establish a dialogue.

To explore feasibility of psychosis seminars in the UK and the experiences of participants.

Seven meetings attended by 25 people were held over a 3-month period. An open-ended questionnaire was returned by ten participants. Responses were subjected to content analysis.

Benefits experienced were having an open forum for talking freely about mental health issues in a neutral space, learning from others about psychosis and hearing different views. Suggested adjustments were clarifying expectations of participants at the beginning, strengthening facilitation and increasing attendance.

Psychosis seminars may help to establish a dialogue among users, carers and professionals and seem feasible in the UK, although adjustment to delivery can help their implementation.

Price's social competition hypothesis interprets the depressive state as an unconscious, involuntary losing strategy, which enables individuals to yield and accept defeat in competitive situations.

We investigated whether patients who suffer from major depressive disorder (MDD) would avoid competition more often than either patients suffering from borderline personality disorder (BPD) or healthy controls.

In a simple paper-folding task healthy participants and patiens with MDD and BPD were matched with two opponents, one with an unknown diagnosis and one who shared their clinical diagnosis, and they had to choose either a competitive or cooperative payment scheme for task completion.

When playing against an unknown opponent, but not the opponent with the same diagnosis, the patients with depression chose the competitive payment scheme statistically less often than healthy controls and patients diagnosed with BPD.

The competition avoidance against the unknown opponent is consistent with Price's social competition hypothesis.

Micronutrients containing vitamins are reported to reduce symptom levels in persons with attention-deficit hyperactivity disorder (ADHD), but data on vitamin levels in ADHD are sparse.

To examine the relationship between vitamin concentrations, ADHD diagnosis and psychiatric symptoms in young adult ADHD patients and controls.

Eight vitamins and the nicotine metabolite cotinine were analysed in serum samples from 133 ADHD patients and 131 controls aged between 18 and 40, who also reported ADHD symptoms and comorbid conditions.

Lower concentrations of vitamins B2, B6 and B9 were associated with the ADHD diagnosis, and B2 and B6 also with symptom severity. Smokers had lower levels of vitamins B2 and B9.

ADHD patients were overrepresented in the group with low levels of some vitamins, possibly indicative of inadequate dietary intake of these micronutrients in a subgroup of patients. It is important to identify these patients in dietary intervention trials of ADHD.

Challenging behaviour, especially in intellectual disability, covers a wide range that is in need of further evaluation.

To develop a short but comprehensive instrument for all aspects of challenging behaviour.

In the first part of a two-stage enquiry, a 28-item scale was constructed to examine the components of challenging behaviour. Following a simple factor analysis this was developed further to create a new short scale, the Problem Behaviour Checklist (PBCL). The scale was subsequently used in a randomised controlled trial and tested for interrater reliability. Scores were also compared with a standard scale, the Modified Overt Aggression Scale (MOAS).

Seven identified factors – personal violence, violence against property, self-harm, sexually inappropriate, contrary, demanding and disappearing behaviour – were scored on a 5-point scale. A subsequent factor analysis with the second population showed demanding, violent and contrary behaviour to account for most of the variance. Interrater reliability using weighted kappa showed good agreement (0.91; 95% CI 0.83–0.99). Good agreement was also shown with scores on the MOAS and a score of 1 on the PBCL showed high sensitivity (97%) and specificity (85%) for a threshold MOASscore of 4.

The PBCL appears to be a suitable and practical scale for assessing all aspects of challenging behaviour.

To combat the increasing rate of suicide, basic data on suicidal behaviours reflecting the uniqueness of the locality are needed in sub-Saharan Africa.

To assess the prevalence of suicidal ideation and associated factors.

Adults (n=11 246) from the five administrative divisions of Lagos State completed questionnaires detailing suicidal ideation, socio-demographic details, common mental disorders (depression, anxiety and somatic symptoms), alcohol and psychoactive substance use disorders and disability.

The weighted prevalence of current suicidal ideation was 7.28% (s.e. 0.27). Independently associated factors were older age, being female, not married, low occupational group, depression, anxiety, somatic symptoms and disability.

Despite the validity of cross-national surveys, there is need for individual countries to generate complementary local data to explain variability in rates and risk factors in order to plan for suicide prevention or develop timely and effective response.

Symptoms of anxiety and depression are prevalent in older adults.

To compare clinician-guided and self-guided versions of a transdiagnostic internet-delivered cognitive–behavioural therapy (iCBT) intervention for adults aged 60 years and above.

Adults (n=433) with symptoms of anxiety and depression were randomly allocated to: (1) clinician-guided treatment (n=153); (2) initial clinician interview followed by self-guided treatment (n=140); or (3) self-guided treatment without interview (n=140).

Large reductions (d ≥1.00) in symptoms of depression and anxiety were observed across groups, and sustained at follow-up. No differences were observed in clinical outcomes or satisfaction ratings. Age did not affect outcomes.

Carefully developed iCBT interventions may significantly reduce symptoms of anxiety and depression in older adults when delivered in either clinician-guided or self-guided formats.

Maternal vitamin D deficiency may increase risk of autism spectrum disorder (ASD), but direct evidence is lacking.

To clarify the relationship between maternal vitamin D deficiency and offspring risk of ASD with and without intellectual disability.

Using a register-based total population study (N=509 639), we calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIS) of ASD with and without intellectual disability in relation to lifetime diagnoses of maternal vitamin D deficiency. Although rare, such deficiency was associated with offspring risk of ASD with, but not without, intellectual disability (aORs 2.51, 95% CI 1.22–5.16 and 1.28, 0.68–2.42). Relationships were stronger in non-immigrant children.

If reflecting associations for prenatal hypovitaminosis, these findings imply gestational vitamin D substitution as a means of ASD prevention.

There is currently limited experience in the initiation and maintenance of clozapine for treatment-resistant psychosis in adults with established structural heart disease. These complex patients require close supervision and liaison between colleagues. Here we present the successful experience of treating one such patient within our service and describe a monitoring plan to ensure that these treatments can be provided both safely and effectively.

A 36-year-old man with treatment-resistant schizophrenia and known hypertrophic cardiomyopathy (HCM) was admitted to a specialist unit for a trial of clozapine. His psychiatric illness was characterised by multimodal hallucinations and delusions combined with low mood and poor motivation. The diagnosis of HCM was made 3 years previously following a routine electrocardiogram (ECG), and he had remained asymptomatic throughout this time; there were concerns about the risk of initiating clozapine given his pre-existing cardiac condition. Baseline investigations were performed as per local guidelines prior to commencing clozapine; these were within normal limits other than a mildly raised troponin level of 54 ng/L (normal <16 ng/L), which was attributed to the HCM. In addition, baseline transthoracic echocardiography (TTE) was performed which showed no change in the structural heart disease in comparison with previous TTEs.

Clozapine was started at 12.5 mg daily and up-titrated to 150 mg twice daily over 14 days as per our institute's guidelines. The patient was monitored with regular testing of troponins, inflammatory markers and ECG. On day 18, the troponin level increased to 1371 ng/L. Creatine kinase and inflammatory markers remained stable. No changes in ECG or TTE were noted and the patient remained clinically asymptomatic. Cardiology opinion was sought and reported that the finding of an isolated elevated troponin was likely to reflect a ‘troponin leak’ in the context of increased cardiac muscle mass associated with HCM. In the absence of any clinical compromise, it was not felt to be of concern. Clozapine was continued with good effect on mental state. Troponin levels gradually reduced and the patient remained well.

While multiple cases of clozapine-induced cardiotoxicity have been reported in the literature, its implications for pre-existing structural disease are unclear. This case report suggests that clozapine can be safely introduced in pre-existing HCM, explores strategies for monitoring and highlights the importance of liaising with experienced cardiologists.

Recovery-oriented language has been widely adopted in mental health policy; however, little is known about how recovery practices are implemented within individual services, such as psychosocial clubhouses.

To explore how recovery practices are implemented in a psychosocial clubhouse.

Qualitative case study design informed by self-determination theory was utilised. This included 120 h of participant observation, interviews with 12 clubhouse members and 6 staff members. Field notes and interview transcripts were subject to theoretical thematic analysis.

Two overarching themes were identified, each comprising three sub-themes. In this paper, the overarching theme of ‘social environment’ is discussed. It was characterised by the sub-themes, ‘community and consistency’, ‘participation and opportunity’ and ‘respect and autonomy’.

Social environment was used to facilitate recovery-oriented practice within the clubhouse. Whether recovery is experienced by clubhouse members in wider society, may well depend on supports and opportunities outside the clubhouse.

For treatment of patients diagnosed with schizophrenia, comparative long-term effectiveness of antipsychotic drugs to reduce relapses when minimising adverse effects is of clinical interest, hence prompting this review.

To evaluate the comparative long-term effectiveness of antipsychotic drugs.

We systematically searched electronic databases for reports of randomised controlled trials (RCTs) of antipsychotic monotherapy aimed at reducing relapse risks in schizophrenia. We conducted network meta-analysis of 18 antipsychotics and placebo.

Studies of 10 177 patients in 56 reports were included; treatment duration averaged 48 weeks (range 4–156). Olanzapine was significantly more effective than chlorpromazine (odds ratio (OR) 0.35, 95% CI 0.14–0.88) or haloperidol (OR=0.50, 95% CI 0.30–0.82); and fluphenazine decanoate was more effective than chlorpromazine (OR=0.31, 95% CI 0.11–0.88) in relapse reduction. Fluphenazine decanoate, haloperidol, haloperidol decanoate and trifluoperazine produced more extrapyramidal adverse effects than olanzapine or quetiapine; and olanzapine was associated with more weight gain than other agents.

Except for apparent superiority of olanzapine and fluphenazine decanoate over chlorpromazine, most agents showed intermediate efficacy for relapse prevention and differences among them were minor. Typical antipsychotics yielded adverse neurological effects, and olanzapine was associated with weight gain. The findings may contribute to evidence-based treatment selection for patients with chronic psychotic disorders.

Individuals with personality disorders often have extensive involvement with healthcare services including frequent utilisation of emergency departments.

The aim of this study was to identify factors associated with emergency department presentations by individuals with personality disorders.

A 12-month retrospective data analysis of all mental-health-related emergency department visits was performed. Age, gender, time and season of presentation, length of stay, mode of arrival and discharge arrangements for individuals with personality disorders were compared to individuals with other psychiatric diagnoses.

There were 336 visits by individuals with personality disorders and 5290 visits by individuals with other psychiatric diagnoses.

Individuals with personality disorders were significantly more likely to be female, young adults, brought in by police, arrive in the evening, discharged home and have a longer median length of stay.

Knowing what factors are associated with emergency department presentations by individuals with personality disorders can help ensure that appropriately trained support staff are available.

There is a growing interest in using cognitive–behavioural therapy (CBT) with people who have Asperger syndrome and comorbid mental health problems.

To examine whether modified group CBT for clinically significant anxiety in an Asperger syndrome population is feasible and likely to be efficacious.

Using a randomised assessor-blind trial, 52 individuals with Asperger syndrome were randomised into a treatment arm or a waiting-list control arm. After 24 weeks, those in the waiting-list control arm received treatment, while those initially randomised to treatment were followed up for 24 weeks.

The conversion rate for this trial was high (1.6:1), while attrition was 13%. After 24 weeks, there was no significant difference between those randomised to the treatment arm compared with those randomised to the waiting-list control arm on the primary outcome measure, the Hamilton Rating Scale for Anxiety.

Trials of psychological therapies with this population are feasible. Larger definitive trials are now needed.

Community-based screening for mental health problems may increase service use through feedback to individuals about their severity of symptoms and provision of contacts for appropriate services.

The effect of symptom feedback on service use was assessed. Secondary outcomes included symptom change and study attrition.

Using online recruitment, 2773 participants completed a comprehensive survey including screening for depression (n=1366) or social anxiety (n=1407). Across these two versions, approximately half (n=1342) of the participants were then randomly allocated to receive tailored feedback. Participants were reassessed after 3 months (Australian New Zealand Clinical Trials Registry ANZCTR12614000324617).

A negative effect of providing social anxiety feedback to individuals was observed, with significant reductions in professional service use. Greater attrition and lower intentions to seek help were also observed after feedback.

Online mental health screening with feedback is not effective for promoting professional service use. Alternative models of online screening require further investigation.

Self-criticism is a ubiquitous feature of psychopathology and can be combatted by increasing levels of self-compassion. However, some patients are resistant to self-compassion.

To investigate whether the effects of self-identification with virtual bodies within immersive virtual reality could be exploited to increase self-compassion in patients with depression.

We developed an 8-minute scenario in which 15 patients practised delivering compassion in one virtual body and then experienced receiving it from themselves in another virtual body.

In an open trial, three repetitions of this scenario led to significant reductions in depression severity and self-criticism, as well as to a significant increase in self-compassion, from baseline to 4-week follow-up. Four patients showed clinically significant improvement.

The results indicate that interventions using immersive virtual reality may have considerable clinical potential and that further development of these methods preparatory to a controlled trial is now warranted.