Late-life depression may differ from early-life depression in its phenomenology.

To investigate the effect of age on the phenomenology of major depression.

A systematic search was conducted in PubMed, Embase and PsycINFO for all studies examining the relation between age and phenomenology of major depression according to RDC, DSM and ICD criteria. Studies were included only if the age groups were compared at the single-item level using the 17-, 21- or 24-item versions of the Hamilton Rating Scale for Depression; a meta-analysis was done for each item of the 17-item scale.

Eleven papers met the inclusion criteria. Older depressed adults, compared with younger depressed adults, demonstrated more agitation, hypochondriasis and general as well as gastrointestinal somatic symptoms, but less guilt and loss of sexual interest.

The phenomenology of late-life depression differs only in part from that of early-life depression. Major depression in older people may have a more somatic presentation, whereas feelings of guilt and loss of sexual function may be more prevalent in younger people.

Stigma affects not only people with mental illnesses, but their families as well. Understanding how stigma affects family members in terms of both their psychological response to the ill person and their contacts with psychiatric services will improve interactions with the family.

To investigate factors of psychological significance related to stigma of the relatives.

In a Swedish multi-centre study, 162 relatives of patients in acute psychiatric wards following both voluntary and compulsory admissions were interviewed concerning psychological factors related to stigma.

A majority of relatives experienced psychological factors of stigma by association. Eighteen per cent of the relatives had at times thought that the patient would be better off dead, and 10% had experienced suicidal thoughts. Stigma by association was greater in relatives experiencing mental health problems of their own, and was unaffected by patient background characteristics.

Interventions are needed to reduce the negative effects of psychological factors related to stigma by association in relatives of people with mental illness.

Post-traumatic stress disorder (PTSD) is the only psychiatric condition that requires a specific event to have occurred for its diagnosis.

To gather evidence from the adult general population on whether life events (e. g. divorce, unemployment) generate as many symptoms of post-traumatic stress as traumatic events (e. g. accidents, abuse).

Data on demographic characteristics and history of stressful events were collected through a written questionnaire sent to a random sample of 2997 adults. Respondents also filled out a PTSD symptom checklist, keeping in mind their worst event. Mean PTSD scores were compared, controlling for differences between the two groups. Differences in item scores and in the distribution of the total PTSD scores were analysed.

Of the 1498 respondents, 832 were eligible for inclusion in our analysis. For events from the past 30 years the PTSD scores were higher after life events than after traumatic events; for earlier events the scores were the same for both types of events. These findings could not be explained by differences in demographics, history of stressful events, individual item scores, or the distribution of the total PTSD scores.

Life events can generate at least as many PTSD symptoms as traumatic events. Our findings call for further studies on the specificity of traumatic events as a cause of PTSD.

Antidepressant drugs are usually prescribed at low doses, possibly to avoid adverse reactions. No comprehensive review has addressed the issue of dose, clinical response and tolerability in a quantitative way.

To determine whether high doses of antidepressants are more effective than lowdoses, and how safety is affected by dose.

Trials comparing two or more doses of the same antidepressant were located, and all antidepressants administered were converted to the equivalent dose of imipramine. Generalised estimating equations were used to analyse percentage improvement and adverse event rate according to dose level.

Thirty-three studies were identified. The dose level 100-200 mg imipramine equivalents showed an average improvement of 53% by ‘intention-to-treat’. Higher doses were not accompanied by increased efficacy, while lower doses showed reduction in efficacy. Adverse events significantly increased with dose.

With a low dose of antidepressants, clinicians trade off a slightly reduced chance of improvement for a higher chance of avoiding adverse reactions.

In the UK and The Netherlands, people with high rates of psychosis are chronically exposed to discrimination.

To test whether perceived discrimination is associated longitudinally with onset of psychosis.

A 3-year prospective study of cohorts with no history of psychosis and differential rates of reported discrimination on the basis of age, gender, disability, appearance, skin colour or ethnicity and sexual orientation was conducted in the Dutch general population (n=4076). The main outcome was onset of psychotic symptoms (delusions and hallucinations).

The rate of delusional ideation was 0.5% (n=19) in those who did not report discrimination, 0.9% (n=4) in those who reported discrimination in one domain, and 2.7% (n=3) in those who reported discrimination in more than one domain (exact P=0.027). This association remained after adjustment for possible confounders. No association was found between baseline discrimination and onset of hallucinatory experiences.

Perceived discrimination may induce delusional ideation and thus contribute to the high observed rates of psychotic disorder in exposed minority populations.

No national data on the prevalence of mental disorders are available in Iran. Such information may be a prerequisite for efficient national mental health intervention.

To determine the mental health status of a population sample aged 15 years and over.

Through random cluster sampling, 35 014 individuals were selected and evaluated using the 28-item version of the General Health Questionnaire. A complementary semi-structured clinical interview was also undertaken to detect learning disability (‘mental retardation’), epilepsy and psychosis.

About a fifth of the people in the study (25.9% of the women and 14.9% of the men) were detected as likely cases. The prevalence of mental disorders was 21.33% in rural areas and 20.9% in urban areas. Depression and anxiety symptoms were more prevalent than somatisation and social dysfunction. The interview of families by general practitioners revealed that the rates of learning disability epilepsy and psychosis were 1.4%, 1.2% and 0.6%, respectively Prevalence increased with age and was higher in the married, widowed, divorced, unemployed and retired people.

Prevalence rates are comparable with international studies. There is a wide regional difference in the country, and women are at greater risk.

Depressive symptoms are associated with cognitive decline in elderly people, but the nature of their temporal relationship remains equivocal.

To test whether depressive symptoms predict cognitive decline in elderly people with normal cognition.

The Center for Epidemiologic Study depression scale (CES – D) and the Mini-Mental State Examination (MMSE) were used to evaluate depressive symptomatology and cognitive functioning, respectively. A sample of 1003 persons aged 59–71 years and with a MMSE score of 26 or over was selected. Cognitive decline was defined as a drop of at least 3 points on the MMSE at 4-year follow-up.

Baseline high levels of depressive symptoms predicted a higher risk of cognitive decline at 4-year follow-up. The MMSE score of participants with depression was more likely to fall below 26 at 2-year follow-up and to remain below at 4-year follow-up than the MMSE score of those without depressive symptoms. Persistent but not episodic depressive episodes were associated with cognitive decline.

High levels of depressive symptoms, when persistent, are associated with cognitive decline in a sample of elderly people.

International evidence on the cost and effects of interventions for reducing the global burden of depression remain scarce.

To estimate the population-level cost-effectiveness of evidence-based depression interventions and their contribution towards reducing current burden.

Primary-care-based depression interventions were modelled at the level of whole populations in 14 epidemiological subregions of the world. Total population-level costs (in international dollars or I) and effectiveness (disability adjusted life years (DALYs) averted) were combined to form average and incremental cost-effectiveness ratios.

Evaluated interventions have the potential to reduce the current burden of depression by 10–30%. Pharmacotherapy with older antidepressant drugs, with or without proactive collaborative care, are currently more cost-effective strategies than those using newer antidepressants, particularly in lower-income subregions.

Even in resource-poor regions, each DALYaverted by efficient depression treatments in primary care costs less than 1 year of average per capita income, making such interventions a cost-effective use of health resources. However, current levels of burden can only be reduced significantly if there is a substantial increase in treatment coverage.

Relapse is one of the most costly aspects of schizophrenia.

To compare costs, clinical outcomes and quality of life for patients who experienced relapse in schizophrenia with a control group who did not relapse.

Patients were randomly selected from current psychiatric case-loads drawn from urban and suburban areas of Leicester. Differences in costs and outcomes by relapse status in the previous 6 months were examined using parametric and non-parametric tests, and multivariate analysis was used to examine factors associated with relapse and costs.

Costs for the patients who relapsed were over four times higher than those for the non-relapse group. There were few statistically significant differences in clinical and quality of life measures by relapse status. Multivariate analyses suggested some significant correlates of relapse and costs.

The higher costs associated with relapse will be of interest to policy-makers who face difficult choices concerning new but more expensive treatments for patients with schizophrenia.

Quality of life is the subject of growing interest and investigation.

To develop and validate a short, self-report quality of life questionnaire (the Schizophrenia Quality of Life Scale, SQLS).

People with schizophrenia in Liverpool were recruited via the NHS. Items, generated from in-depth interviews, were developed into an 80-item self-report questionnaire. Data were factor analysed, and a shorter form measure was tested for reliability and validity. This measure was administered together with other self-report measures – SF–36, GHQ–12 and HADS – to assess validity.

Data were analysed to produce a final 30-item questionnaire, comprising three scales (‘psychosocial’, ‘motivation and energy’, and ‘symptoms and side-effects’) addressing different SQLS dimensions. Internal consistency reliability of the scale was found to be satisfactory. There was a high level of association with relevant SF–36, GHQ–12 and HADS scores.

The SQLS was completed within 5–10 minutes. It possesses internal reliability and construct validity, and promises to be a useful tool for the evaluation of new treatment regimes for people with schizophrenia.

The nosology of the psychosis high-risk state is controversial. Traditionally conceived as an ‘at risk’ state for the development of psychotic disorders, it is also conceptualised as a clinical syndrome associated with functional impairment.

To investigate meta-analytically the functional status of patients at high clinical risk for psychosis and its association with longitudinal outcomes.

Three meta-analyses compared level of functioning (n = 3012) and quality of life (QoL) (n = 945) between a high-risk group, a healthy control group and group with psychosis, and baseline functioning in people in the high-risk group who did or did not have a transition to psychosis at follow-up (n = 654).

People at high risk had a large impairment in functioning (P<0.001) and worse QoL (P = 0.001) than the healthy control group, but only small to moderately better functioning (P = 0.012) and similar QoL (P = 0.958) compared with the psychosis group. Among the high-risk group, those who did not develop psychosis reported better functioning (P = 0.001) than those who did.

Our results indicate that the high-risk state is characterised by consistent and large impairments of functioning and reduction in QoL similar to those in other coded psychiatric disorders.

Repetitive transcranial magnetic stimulation (rTMS) may be useful in the treatment of depression but results from trials have been inconclusive to date.

To assess the efficacy of rTMS in treating depression.

We conducted a systematic review of randomised controlled trials that compared rTMS with sham in patients with depression. We assessed the quality of design of all studies and conducted a metaanalysis of data from trials with similar rTMS delivery.

We included a total of 14 trials. The quality of the included studies was low. Pooled analysis using the Hamilton Rating Scale for Depression showed an effect in favour of rTMS compared with sham after 2 weeks of treatment (standardised mean difference=–0.35; 95% CI –0.66 to –0.04), but this was not significant at the 2-week follow-up (standardised mean difference= — 0.33; 95% CI —0.84 to 0.17).

Current trials are of low quality and provide insufficient evidence to support the use of rTMS in the treatment of depression.

Family intervention reduces relapse rates in psychosis. Cognitive-behavioural therapy (CBT) improves positive symptoms but effects on relapse rates are not established.

To test the effectiveness of CBT and family intervention in reducing relapse, and in improving symptoms and functioning in patients who had recently relapsed with non-affective psychosis.

A multicentre randomised controlled trial (ISRCTN83557988) with two pathways: those without carers were allocated to treatment as usual or CBT plus treatment as usual, those with carers to treatment as usual, CBT plus treatment as usual or family intervention plus treatment as usual. The CBT and family intervention were focused on relapse prevention for 20 sessions over 9 months.

A total of 301 patients and 83 carers participated. Primary outcome data were available on 96% of the total sample. The CBT and family intervention had no effects on rates of remission and relapse or on days in hospital at 12 or 24 months. For secondary outcomes, CBT showed a beneficial effect on depression at 24 months and there were no effects for family intervention. In people with carers, CBT significantly improved delusional distress and social functioning. Therapy did not change key psychological processes.

Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers.