Relapse of depression is associated with a criticising attitude of the patient's partner.

To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner.

A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner.

Drop-outs were 56.8 % from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments.

For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.

Recent research progress showing the benefits of cognitive therapy in schizophrenia leaves the general psychiatrist unsure whether to attempt to use such techniques.

To test whether cognitive–behavioural techniques are beneficial in the management of patients with schizophrenia in general psychiatric practice.

A randomised controlled study comparing the use of cognitive–behavioural techniques and befriending in schizophrenia.

Significant improvement in symptoms occurred in the group treated with cognitive–behavioural techniques but not in the befriending group. During the 6-month follow-up period the cognitive–behavioural group tended to have shorter periods in hospital.

General psychiatrists could help their patients with schizophrenia by using cognitive–behavioural techniques. Such techniques are well within the capability of general psychiatrists, but their application would involve more of the consultant's time spent in direct contact with patients with psychoses.

Factors underlying premature discontinuation of psychosocial in-patient treatment are still unclear.

Investigation of early discontinuation of specialised in-patient psychosocial treatment in a sample of people with personality disorder.

Out of 134 consecutive admissions to the Cassel Hospital, 42 early drop-outs and 92 patients who remained were compared on demographic and clinical variables. Early drop-outs were invited for in-depth interviews, to explore their hospital experiences.

The early drop-out group and the group which remained showed significant differences in occupational status, borderline personality disorder (BPD) and the treatment programme to which they were allocated. All three independent variables predicted early discontinuation of treatment. The qualitative analysis of interview transcripts identified significant problems in institutional dimensions.

Important subjects and process variables contributing to early drop-out in people with personality disorder were identified, with potential implications for clinical practice.

There is ample scope to devise forms of psychotherapy in consultation–liaison psychiatry, including the newly evolving area of psycho-oncology.

To highlight the development of psychotherapy in psycho-oncology, providing two illustrations.

We report on conceptual and clinical research in the context of oncology and palliative care, focusing on (a) an approach for families at risk of maladaptive bereavement; and (b) a group programme for women newly diagnosed with early-stage breast cancer.

We were able to introduce new forms of psychological treatment for specific clinical groups, and anecdotal evidence points to useful benefits for participants.

Psychotherapists should grasp the opportunity to bring their skills to the medical arena, but need to subject newly devised interventions to well-designed and methodologically rigorous research.

Polarisation of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism. Current knowledge of the interaction between biology and psychology makes it possible to consider a truly integrative approach to treatment.

The aim of this overview is to consider conceptual models of how psychotherapy may affect the brain.

The literature discussing the mutual influence of genes and environment is surveyed. Relevant data involving the influence of psychotherapy on the brain are also reviewed.

Research findings suggest that the brain responds to environmental influence through the alteration of gene expression; that psychotherapy has specific measurable effects on the brain; and that implicit memory may be modified by psychotherapeutic interventions.

Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning. These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy can be designed to target specific sites of brain functioning.

Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice.

To review the developments in measurement relevant to psychotherapy.

Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skilfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement.

Modern methods of measurement can support ‘evidence-based practice’ for psychological treatments. They also support ‘practice-based evidence’, a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs).

Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.

A clear distinction has been made between efficacy and effectiveness in relation to the methods of evaluation of new psychological treatments in psychiatry. Efficacy trials target patients with relatively pure conditions, who may not be representative of the patients who are usually referred for psychological treatment in a clinical setting. Few studies have explored the benefits of psychotherapy in patients with complex disorders and enduring symptoms.

To explore the rationale for the distinction between efficacy and effectiveness, particularly in relation to outcome studies of patients with complex and enduring disorders.

A narrative review with examples drawn from the literature, and an illustration of a recent naturalistic outcome study which combines features of both efficacy and effectiveness.

Studies of patients with complex and mixed disorders can be designed so that they retain internal validity, but also have external validity and are relevant to clinical practice.

Studies which evaluate psychological interventions should be carried out in populations of patients clinically representative of those who are likely to receive the intervention, should it be shown to be of benefit.

Psychiatrists have been criticised for failing to develop adequate treatment for personality disorder. Psychotherapeutic treatments are promising, but their effectiveness is uncertain.

To investigate the evidence for effectiveness of psychotherapeutic treatment for personality disorder.

Systematic literature review.

There is evidence for the effectiveness of psychotherapy for personality disorder. Problems of case identification, comorbidity, randomisation, specificity of treatment and outcome measurement are inadequately addressed. Authors mainly relied on cohort studies. Evidence neither suggests superiority of one type of therapy over another nor indicates which subgroups of patients should be offered psychotherapy as in-patient, day patient, or out-patient.

New research strategies are needed to show that personality change is both measurable and clinically meaningful. Effectiveness studies using randomised controlled designs are required. The literature suggests that effective treatment should be long-term, integrated, theoretically coherent and focused on compliance.

After exposure to traumatic stressors, a subgroup of survivors (20–30%) will develop post-traumatic stress disorder (PTSD).

Since the incidence and prevalence rates for PTSD in the community are significant, it is important that general practitioners and psychiatrists be familiar with possible therapeutic options. In this review we shall look at the published evidence about the effectiveness of psychological treatments for PTSD.

The psychopathological mechanisms involved in PTSD are discussed. Studies of the effectiveness of different psychological therapies are reviewed.

The review suggests that persistent fear or shame reactions are key aspects of PTSD. Evidence from systematic reviews suggests that psychotherapeutic treatments are effective in the therapy of reactions based on fear, and may increase the effectiveness of pharmacological therapy. There is less systematic evidence for the efficacy of interventions for symptoms based on shame.

Although a proportion of patients with complex or chronic PTSD may require specialist interventions, most patients can be treated effectively by a general psychiatric service which can offer both pharmacological and psychological interventions.

There is little consistency in how severe mental illness (SMI) is defined in practice, and no operational definitions.

To test two operationalised definitions, based on the National Institute of Mental Health (1987) definition: the first uses three criteria (diagnosis of psychosis; duration of service contact ≥ 2 years; GAF score ≤ 50), the second only the last two.

Annual prevalence rates of SMI in two European catchment areas for each criterion and the criteria combined were calculated.

The first definition produced rates of 2.55 and 1.34/1000 in London and Verona, respectively; the second permitted an additional 0.98/1000 non-psychotic disorders to be included in Verona.

The three-dimensional definition selects a small group of patients with SMI who have psychotic disorders. The two-dimensional approach allows estimates of SMI prevalence rates which include all forms of mental disorder.

Information on survival and cause of death in pre-senile dementia is scarce and the organisation of services controversial.

To study survival, place of death and death certification in pre-senile dementia.

Patients aged 45–64 were identified from hospital and community sources in the Northern health region (1985–89) and classified as having pre-senile dementia of Alzheimer type (PDAT) or pre-senile vascular dementia (PVD) by applying an algorithm to case notes. Deaths were ascertained from the National Health Service Central Registry (NHSCR) to 31 December 1998. Survival analysis was performed using the SPSS/PC program, and expected survival calculated from life tables.

Median survival time from diagnosis was 6.08 years and did not differ significantly in PDAT and PVD, or by age or gender; 19.3% of deaths occurred at home, 24.5% in nursing or residential homes and 56.3% in hospital; 72.4% of the death certificates mentioned dementia or Alzheimer's disease; 15.4% were still alive.

Pre-senile dementia has a variable but usually chronic course, requiring appropriate planning and services.

Patients with depression are often not prescribed antidepressants for an adequate period of time.

The impact of antidepressant prescribing patterns on the risk of relapse or recurrence of depression is examined.

The Medi Plus UK Primary Care Database was used to identify patients treated for depression with a selective serotonin reuptake inhibitor (SSRI). Records were used to construct hierarchical prescription patterns (less than 120 days, switching/augmentation, upward titration, or stable use) as indicators for the occurrence of relapse or recurrence of depression.

Patients with stable use experienced the lowest risk of relapse or recurrence. Factors significantly associated with increased risk include prior use of anxiolytic medications, more comorbid conditions and younger age.

The SSRI prescription pattern most consistent with recommended depression treatment guidelines was associated with the lowest risk of relapse or recurrence.

Neuroimaging studies of major depressive disorder (MDD) indicate interhemispheric differences in prefrontal cortical activity (right greater than left).

To investigate whether there are any interhemispheric differences of motor cortical excitability in MDD.

Eight patients with treatment-refractory MDD off medication were assessed for the severity of their depression, and transcranial magnetic stimulation studies (bilateral motor threshold and paired-pulse studies) were conducted. Eight normal controls were also studied.

MDD patients showed significant interhemispheric differences in motor threshold and paired-pulse curves, both of which showed lower excitability on the left hemisphere. Such differences were absent in controls.

Our findings may aid the further understanding of the neurophysiology underlying MDD.

Although millions of people with schizophrenia live in betel chewing regions, the effects of betel chewing on their symptoms are unknown. Betel nut alkaloids include potent muscarinic cholinomimetics: recent research suggests that these agents may be therapeutic in schizophrenia.

To compare the primary and extrapyramidal symptom profiles and substance-using habits of betel chewing v. non-chewing people with schizophrenia.

A cross-sectional study of 70 people with schizophrenia. Symptom ratings measured by the Positive and Negative Syndrome Scale (PANSS) and Extrapyramidal Symptom Rating Scale (ESRS), and demographic and substance-use data, were compared for 40 chewers and 30 non-chewers of betel nut.

Betel chewers with schizophrenia scored significantly lower on the positive (P=0.001) and negative (P=0.002) sub-scales of the PANSS than did non-chewers. There were no significant differences in extrapyramidal symptoms or tardive dyskinesia.

Betel chewing is associated with milder symptomatology and avoidance of more harmful recreational drugs. These initial results indicate that longitudinal research is merited.