Depression therapies: mindfulness, email reminders and behavioural activation
Mindfulness-based approaches have been proposed as a treatment for a range of psychological difficulties. A highly topical editorial by Williams & Kuyken (pp. ) reviews the theoretical background and evidence for the efficacy of mindfulness-based cognitive therapy in preventing relapse of depressive illness. It clarifies the distinction between seeking to change the content of negative thoughts during conventional cognitive therapy, and developing an observational style to one's own thoughts and feelings which allows them to coexist without routinely precipitating patterns of rumination or worry during mindfulness therapy. The success of this approach is demonstrated by the uptake of this approach by three UK-based training programmes and the development of an increasing quantity of high-quality self-help material. An Australian study has used automated emails to disseminate information promoting effective self-help behaviours for alleviating subthreshold depression. Morgan and colleagues (pp. ) report that these automated Mood Memo emails reduced depressive symptoms in adults with subthreshold depression, relative to a control condition providing education about depression. The authors suggest that this is a cost-effective approach which could also usefully be tested in treating clinical depression. An editorial by Kanter et al (pp. ) reviews the development of behavioural activation in the treatment of depressive illness. It describes the background to this approach, including the seminal finding that treatment with the isolated behavioural activation part was as effective as the full cognitive–behavioural therapy package. The authors review evidence demonstrating behavioural activation to be as effective as treatment with a selective serotonin reuptake inhibitor, in the treatment of moderate to severe depression, and highlight the advantages of an approach that does not rely on highly trained therapists, but offers an ease of implementation and acceptability across a wide spectrum of settings and conditions.
Self-harm: in older adults and in Taiwan
The relationship between episodes of self-harm and a subsequent increased suicide risk is well established; however, how this changes with increasing age is less clear. In some countries, older age is associated with higher rates of suicide, whereas in the UK the rates are highest in younger age groups, although the ratio of episodes of self-harm to completed suicide is highest in older adults. Murphy and colleagues (pp. ) examined self-harm across three centres in the UK and found that 1.5% of older adults presenting with self-harm completed suicide over the subsequent 12 months, representing a 67-fold increase compared with the general population. The relative risk of suicide in older adults was almost 3 times higher than in younger adults presenting with self-harm. The authors suggest that older adults presenting with self-harm require a thorough assessment by experienced personnel. An accompanying editorial reiterates the need for adherence to existing guidelines concerning specialist assessment following self-harm in older adults. Dennis & Owens (pp. ) also emphasise the need for adequate longer-term management of older adults with depressive illness, especially those with a history of self-harm; they suggest a potential role for the development of modern communication technology to aid this process. Kuo and colleagues (pp. ) carried out a prospective cohort study in Taiwan following up individuals after self-harming. They found that suicide risk was over 100 times greater in the subsequent year; and highest in older adults and in males. They also found that the most lethal methods of self-harm – hanging, pesticide ingestion and charcoal burning – were associated with higher suicide rates and were more likely to be used during subsequent suicides. They suggest that the relationships between self-harm and elevated prospective risk of suicide is common to both Western and Asian countries.
Autoimmune processes in OCD and psychosis
There is an increasingly close relationship between abnormalities of basal ganglia integrity and connectivity and the symptoms of obsessive–compulsive disorder (OCD). High rates of symptoms have been observed in disorders characterised by the presence of anti-basal ganglia antibodies, considered to be part of a post-streptococcal autoimmune reaction. Nicholson et al (pp. ) found that 20% of patients with OCD were positive for anti-basal ganglia antibodies, compared with 4% of controls. They suggest that although this does not confirm a causal relationship, it appears that such bacterial exposure could be a factor in the vulnerability to develop OCD. Chen et al (pp. ) examined the association between schizophrenia and autoimmune disorders, reporting an overrepresentation of a range of autoimmune disorders in patients with schizophrenia. The one notable exception was a negative association of schizophrenia with rheumatoid arthritis. The authors suggest that there are many similarities between schizophrenia and autoimmune disorders, including complex relationships between genetic and environmental contributory factors, and further investigations may lead to clues to a shared aetiology. An accompanying editorial by Davison (pp. ) provides a valuable overview of the contemporary autoimmune findings associated with various psychiatric disorders and highlights the increasing importance of this to clinical practice.
Trends in prescribing and side-effects of antipsychotics
There has been a suggestion that rates of prescribing of psychoactive medication have increased over the past 20 years. Ilyas & Moncrieff (pp. ) analyse data from the National Health Service community prescriptions database to demonstrate an increased number of prescriptions for antipsychotic and anti-depressant medications over time. They discuss possible reasons for these changes, including increased off-label usage, and speculate about the lack of any corresponding decrease in the use of hypnotic or anxiolytic medication. They suggest that further research into prescribing patterns, particularly unlicensed use, would benefit current discussions around containing costs and ensuring rational use of medication. A secondary analysis of the Cost Utility of the Latest Antipsychotics in Schizophrenia Study demonstrated that first-generation antipsychotic medication did not cause a greater level of extrapyramidal side-effects (EPS) than second-generation antipsychotics. Peluso and colleagues (pp. ) suggest that the reason for this counterintuitive finding is the use of higher doses of haloperidol (with relatively high EPS liability) as a comparator in most of the earlier second-generation studies, thus favouring the second-generation antipsychotics. The authors suggest that there is value in psychiatrists reacquainting themselves with first-generation antipsychotic drugs, which may avoid some of the obesity and metabolic consequences of second-generation antipsychotic use, without necessarily causing increased extrapyramidal side-effects.
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