Brief screening instruments appear to be a viable way of detecting post-traumatic stress disorder (PTSD) but none has yet been adequately validated.

To test and cross-validate a brief instrumentthat is simple to administer and score.

Forty-one survivors of a rai l crash were administered a questionnaire, followed by a structured clinical interview 1 week later.

Excellent prediction of a PTSD diagnosis was provided by respondents endorsing at least six re-experiencing or arousal symptoms, in any combination. The findings were replicated on data from a previous study of 157 crime victims.

Performance of the new measure was equivalent to agreement achieved between two full clinical interviews.

Previous research suggests that various types of childhood maltreatment frequently co-occur and confer risk for multiple psychiatric diagnoses. This non-specific pattern of risk may mean that childhood maltreatment increases vulnerability to numerous specific psychiatric disorders through diverse, specific mechanisms or that childhood maltreatment engenders a generalised liability to dimensions of psychopathology. Although these competing explanations have different implications for intervention, they have never been evaluated empirically.

We used a latent variable approach to estimate the associations of childhood maltreatment with underlying dimensions of internalising and externalising psychopathology and with specific disorders after accounting for the latent dimensions. We also examined gender differences in these associations.

Data were drawn from a nationally representative survey of 34 653 US adults. Lifetime DSM-IV psychiatric disorders were assessed using the AUDADIS-IV. Physical, sexual and emotional abuse and neglect were assessed using validated measures. Analyses controlled for other childhood adversities and sociodemographics.

The effects were fully mediated through the latent liability dimensions, with an impact on underlying liability levels to internalising and externalising psychopathology rather than specific psychiatric disorders. Important gender differences emerged with physical abuse associated only with externalising liability in men, and only with internalising liability in women. Neglect was not significantly associated with latent liability levels.

The association between childhood maltreatment and common psychiatric disorders operates through latent liabilities to experience internalising and externalising psychopathology, indicating that the prevention of maltreatment may have a wide range of benefits in reducing the prevalence of many common mental disorders. Different forms of abuse have gender-specific consequences for the expression of internalising and externalising psychopathology, suggesting gender-specific aetiological pathways between maltreatment and psychopathology.

Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother–child relationship and child outcome.

To evaluate the effect of three psychological treatments on the mother–child relationship and child outcome.

Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive–behavioural therapy or psychodynamic therapy. The women and their children were assessed at 4.5, 18 and 60 months post-partum.

Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants; counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother–infant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infant–mother attachment, infant cognitive development or any child outcome at 5 years.

Early intervention was of short-term benefit to the mother–child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

Following the development of a child and adolescent version of the Health of the Nation Outcome Scales (HoNOSCA), field trials were conducted to assess their feasibility and acceptability in routine outcome measurement.

To evaluate the reliability, validity and acceptability of HoNOSCA in routine outcome measurement.

Following training, 36 field sites provided ratings on 1276 cases at one time point and outcome data on 906. Acceptability was assessed by way of written feedback and at a debriefing meeting.

HoNOSCA demonstrated satisfactory reliability and validity characteristics. It was sensitive to change and its ability to measure change accorded with the clinicians' independent rating. HoNOSCA was reasonably acceptable to clinicians' from a range of disciplines and services.

Provided that training needs can be met, HoNOSCA represents a satisfactory brief outcome measure which could be used routinely in child and adolescent mental health services.

Treatment coverage for mental disorders is poor in most developed countries.

To explore some reasons for the poor treatment coverage for mental disorders in developed countries.

Data were taken from Australian national surveys and from the World Health Report.

Only one-third of people with a mental disorder consulted. Probability of consulting varied by diagnosis: 90% for schizophrenia, which is accounted for by external factors; 60% for depression; and 15% for substance use and personality disorders. The probability of consulting varied by gender, age, marital status and disability, from 73% among women aged 25–54 years, disabled and once married to 9% among males without these risk factors. Those who did not consult but were disabled or comorbid said that they “preferred to manage themselves”. Data from five countries showed no evidence that overall health expenditure, out-of-pocket cost or responsiveness of the health system affected the overall consulting rates.

Societal, attitudinal and diagnostic variables account for the variation. Funding does not. Public education about the recognition and treatment of mental disorders and the provision of effective treatment by providers might remedy the shortfall.

There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.

To provide an evidence base for this debate, and present a stepped care model.

Cochrane systematic reviews and other reviews were summarised.

The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.

Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.

Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies.

To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder.

A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability.

Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness.

The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Pharmacological treatment is widely used for post-traumatic stress disorder (PTSD) despite questions over its efficacy.

To determine the efficacy of all types of pharmacotherapy, as monotherapy, in reducing symptoms of PTSD, and to assess acceptability.

A systematic review and meta-analysis of randomised controlled trials was undertaken; 51 studies were included.

Selective serotonin reuptake inhibitors were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference −0.23, 95% CI −0.33 to −0.12). For individual pharmacological agents compared with placebo in two or more trials, we found small statistically significant evidence of efficacy for fluoxetine, paroxetine and venlafaxine.

Some drugs have a small positive impact on PTSD symptoms and are acceptable. Fluoxetine, paroxetine and venlafaxine may be considered as potential treatments for the disorder. For most drugs there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more research in this area.

Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.

To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.

Cross-sectional prevalence survey in four urban UK centres.

Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-931) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.

Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

The dose – effect relationships of cumulative trauma to the psychiatric symptoms of major depression and post-traumatic stress disorder (PTSD) in a community study of Cambodian survivors of mass violence were evaluated.

In 1990, a survey of 1000 households was conducted in aThai refugee camp (Site 2) using a multi-stage random sampling design. Trauma history and psychiatric symptoms were assessed for two time periods. Analysis used linear dose – response regression modelling.

993 Cambodian adults reported a mean of 14 Pol Pot era trauma events and 1.3 trauma events during the past year. Symptom categories of depression, PTSD, dissociative and culturally dependent symptoms exhibited strong dose – effect responses with the exception of avoidance. All symptom categories, except avoidant symptoms, were highly correlated.

Cumulative trauma continued to affect psychiatric symptom levels a decade after the original trauma events. The diagnostic validity of PTSD criteria, with the notable exception of avoidance, was supported. Inclusion of dissociative and culturally dependent symptoms increased the cultural sensitivity of PTSD.

About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive–behavioural therapy (CBT).

To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression.

Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150).

Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination.

This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.