PSYCHOSIS: INSIGHT, OUTCOME AND PHYSICAL ANOMALIES
Impaired insight is common in psychosis, and is related to poor adherence to treatment regimens. Aleman and colleagues (pp. ) have used meta-analytic techniques to demonstrate that certain cognitive deficits, particularly of executive functions, may be linked with insight. However, these have relatively small effect sizes and the authors highlight the need for research into metacognitive functions. The correlation of duration of untreated psychosis with outcome, albeit mostly in the short term, has reinforced the need for specialised first-onset psychosis services. Clarke et al (pp. ) confirm that longer duration of untreated psychosis was associated with poorer outcome over a 4-year follow-up; this supports the results of shorter-term outcome studies and emphasises the potential benefits of early intervention. Substance misuse is relatively common in psychotic illness, especially by younger adults. Wade and colleagues (pp. ) report that substance misuse was associated with increased risk of admission and shorter time to recurrence of positive symptoms in a prospective study of first-episode psychosis. They emphasise the importance of investigating further interventions for comorbid psychosis and substance misuse. Minor physical anomalies are found more often in patients with psychosis and support a neurodevelopmental aetiology for psychotic disorders. Dean et al (pp. ) examined the magnetic resonance imaging scans of patients with first-onset psychosis and correlated them with the degree of minor physical anomalies. They found minor physical anomalies to correlate with changes in regional gray matter, including prefrontal cortex and basal ganglia. They suggest that alterations in these regions may occur before birth, and may have a role in the development of psychosis.
DEPRESSION: AETIOLOGY, OUTCOME AND TREATMENT
Depressive illness is associated with significant disability, mortality and service use in high-income countries; low- and middle-income countries lack the resources to offer treatment to most sufferers. Mogga and colleagues (pp. ) describe the outcome of major depression in Ethiopia and find a low (1.2%) baseline prevalence, with 26% of these still fulfilling the diagnosis at 2- to 4-year follow-up. Morbidity and mortality in the depressed group were higher than in the comparator group, with the large majority not having any contact with service providers. They conclude that depression was associated with significant disability, which normalised with remission of the illness. Depression is also very common in people with dementia, with some support for the risk of depression being related to vascular disease. Purandare et al (pp. ) show that the presence of spontaneous cerebral emboli was associated with depressive symptoms in dementia, lending further support to the vascular depression hypothesis. Chronic fatigue is the main illness-related cause of absence from school, but depression is a common comorbid condition. Fowler et al (pp. ) used twin data to demonstrate that although fatigue in children has a heritable component, this heritability is different from that of the depression. Treatment-resistant depression is associated with significant functional impairment and can be problematic to treat; Corcoran et al (pp. ) report that vagus nerve stimulation may benefit some patients but had significant side-effects which require careful consideration.
ANXIETY, THE INTERNET AND PSYCHOPATHY
Generalised anxiety disorder is relatively common and both cognitive-behavioural treatments and selective serotonin reuptake inhibitors have been demonstrated to be effective treatments. Baldwin and colleagues (pp. ) report that escitalopram is an effective treatment for generalised anxiety disorder, with no significant difference between the 10 mg and 20 mg doses, and appears more efficacious than paroxetine 20 mg. They suggest starting with 10 mg escitalopram and increasing to 20 mg if there is no response after 4 weeks. The internet is becoming more popular and it is no surprise that it is being used to find information on health issues. Powell & Clarke (pp. ) show that 18% of users surveyed had used the internet to find information related to mental health; this figure was greater in users with a history of psychiatric disorder. Reassuringly, users had a healthy scepticism about the quality of the available information and only 12% reported that it was an accurate source of information. The authors suggest that more attention needs to be paid to the quality of information available on the internet, especially in mental health, where illness-related stigma may be more likely to inhibit consultation via more traditional routes. Recognition of fear has been shown to be deficient in psychopathy and in patients with damage to the amygdala. Dadds et al (pp. ) report that the impairment in recognition of fearful faces is associated with psychopathic traits in children, but that this can be rectified if the children are instructed to attend to the eyes. They speculate that emotion recognition difficulties in psychopathy may be overcome by directing a person's attention to significant aspects of the environment, and suggest that this could play a role in interventions with high-risk individuals.
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