Insight has recently re-emerged as an important aspect of psychopathology amenable to empirical study. We sought to examine the relationship between various aspects of insight into illness and clinical, sociodemographic and neuropsychological variables.

From an inner-London catchment area population, 150 in-patients with recent onset of psychosis were assessed on a variety of measures, including the Present State Examination (PSE). Subjects were followed up for a mean of four years and reassessed.

High IQ was associated with better insight as rated on the PSE, while gender, ethnicity and a diagnosis of schizophrenia appeared to be unrelated. At follow-up, similar associations were found, as well as correlations with attitudes to treatment and a more elaborate measure of insight. Cerebral ventricular enlargement and tests of frontal lobe function did not correlate with insight, but there was a curious, strong association with left-handedness at both assessment points. Initial insight correlated significantly but weakly with insight at follow-up.

The assessment of insight in psychosis has concurrent validity and is a distinct aspect of psychotic phenomenology. It may, in part, have a neuropsychological basis.

PET studies of verbal fluency in schizophrenia report a failure of ‘deactivation’ of left superior temporal gyrus (STG) in the presence of activation of left dorsolateral prefrontal cortex (DLPFC), which deficit has been attributed to underlying ‘functional disconnectivity’.

To test whether these findings provide trait-markers for schizophrenia.

We used H215O PET to examine verbal fluency in 10 obligate carriers of the predisposition to schizophrenia, 10 stable patients and 10 normal controls.

We found no evidence of a failure of left STG deactivation in carriers or patients. Instead, patients failed to deactivate the precuneus relative to other groups. We found no differences in functional connectivity between left DLPFC and left STG but patients exhibited significant disconnectivity between left DLPFC and anterior cingulate cortex.

Failure of left STG ‘deactivation’ and left fronto-temporal disconnectivity are not consistent findings in schizophrenia; neither are they trait-markers for genetic risk. Prefrontal functional disconnectivity here may characterise the schizophrenic phenotype.

This study explored the prevalence of social phobia (SP) in general health care, sociodemographic characteristics of patients with SP, the age at onset and severity of SP, its comorbidity with other psychiatric disorders, and the recognition by general practitioners.

The study was conducted in Paris as part of the WHO study on Psychological Problems in General Health Care. Among 2096 consecutive primary care patients, 405 were interviewed using the CIDI. DSM–III–R diagnoses, severity and disability were assessed.

The one-month prevalence of SP is high (4.9) in primary care, although underdiagnosed by GPs. It has an early onset and leads to substantial disability. Patients with SP are at risk of developing further depression, alcoholism or suicidal behaviour.

SP appears to be a true and frequently severe pathological condition. The awareness of GPs and the general population should be improved.

Computerised cognitive–behavioural therapy (CCBT) might offer a solution to the current undertreatment of depression.

To determine the clinical effectiveness of online, unsupported CCBT for depression in primary care.

Three hundred and three people with depression were randomly allocated to one of three groups: Colour Your Life; treatment as usual (TAU) by a general practitioner; or Colour Your Life and TAU combined. Colour Your Life is an online, multimedia, interactive CCBT programme. No assistance was offered. We had a 6-month follow-up period.

No significant differences in outcome between the three interventions were found in the intention-to-treat and per protocol analyses.

Online, unsupported CCBT did not outperform usual care, and the combination of both did not have additional effects. Decrease in depressive symptoms in people with moderate to severe depression was moderate in all three interventions. Online CCBT without support is not beneficial for all individuals with depression.

To make informed choices, patients need information about negative as well as positive effects of treatments. There is little information about negative effects of psychological interventions.

To determine the prevalence of and risk factors for perceived negative effects of psychological treatment for common mental disorders.

Cross-sectional survey of people receiving psychological treatment from 184 services in England and Wales. Respondents were asked whether they had experienced lasting bad effects from the treatment they received.

Of 14 587 respondents, 763 (5.2%) reported experiencing lasting bad effects. People aged over 65 were less likely to report such effects and sexual and ethnic minorities were more likely to report them. People who were unsure what type of therapy they received were more likely to report negative effects (odds ratio (OR) = 1.51, 95% CI 1.22–1.87), and those that stated that they were given enough information about therapy before it started were less likely to report them (OR = 0.65, 95% CI 0.54–0.79).

One in 20 people responding to this survey reported lasting bad effects from psychological treatment. Clinicians should discuss the potential for both the positive and negative effects of therapy before it starts.

Depression is a common condition that has been frequently treated with psychotropics.

To review systematically the evidence of efficacy and acceptability of antidepressant and benzodiazepine treatments for patients with minor depression.

A systematic review and meta-analysis of double-blind randomised controlled trials comparing antidepressants or benzodiazepines v. placebo in adults with minor depression. Data were obtained from MEDLINE, CINAHL, EMBASE, PsycInfo, Cochrane Controlled Trials Register and pharmaceutical company websites. Risk of bias was assessed for the generation of the allocation sequence, allocation concealment, masking, incomplete outcome data, and sponsorship bias.

Six studies met inclusion criteria. Three studies compared paroxetine with placebo; fluoxetine, amitriptyline and isocarboxazid were studied in one study each. No studies compared benzodiazepines with placebo. In terms of failures to respond to treatment (6 studies, 234 patients treated with antidepressants and 234 with placebo) no significant difference between antidepressants and placebo was found (relative risk (RR) 0.94, 95% CI 0.81–1.08). In terms of acceptability, data extracted from two studies (93 patients treated with antidepressants and 93 with placebo) showed no statistically significant difference between antidepressants and placebo (RR = 1.06, 95% CI 0.65–1.73). There was no statistically significant between-study heterogeneity for any of the reported analyses.

There is evidence showing there is unlikely to be a clinically important advantage for antidepressants over placebo in individuals with minor depression. For benzodiazepines, no evidence is available, and thus it is not possible to determine their potential therapeutic role in this condition.

Despite considerable research investigating the relationship between a long duration of untreated psychosis (DUP) and outcomes, there has been much less considering predictors of a long DUP.

To investigate the clinical and social determinants of DUP in a large sample of patients with a first episode of psychosis.

All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined catchment areas in London and Nottingham, UK were included in the ÆSOP study Data relating to clinical and social variables and to DUP were collected from patients, relatives and case notes.

An insidious mode of onset was associated with a substantially longer DUP compared with an acute onset, independent of other factors. Unemployment had a similar, if less strong, effect. Conversely family involvement in help-seeking was independently associated with a shorter duration. There was weak evidence that durations were longer in London than in Nottingham.

These findings suggest that DUP is influenced both by aspects of the early clinical course and by the social context.

Outcome measures for mental health services need to adopt a service-user recovery focus.

To develop and validate a 10- and 20-item self-report recovery-focused quality of life outcome measure named Recovering Quality of Life (ReQoL).

Qualitative methods for item development and initial testing, and quantitative methods for item reduction and scale construction were used. Data from >6500 service users were factor analysed and item response theory models employed to inform item selection. The measures were tested for reliability, validity and responsiveness.

ReQoL-10 and ReQoL-20 contain positively and negatively worded items covering seven themes: activity, hope, belonging and relationships, self-perception, well-being, autonomy, and physical health. Both versions achieved acceptable internal consistency, test–retest reliability (>0.85), known-group differences, convergence with related measures, and were responsive over time (standardised response mean (SRM) > 0.4). They performed marginally better than the Short Warwick-Edinburgh Mental Well-being Scale and markedly better than the EQ-5D.

Both versions are appropriate for measuring service-user recovery-focused quality of life outcomes.

M.B. and J.Co. were members of the research group that developed the Clinical Outcomes in Routine Evaluation (CORE) outcome measures.

Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important.

To assess the relative toxicity of specific tricyclic antidepressants (TCAs), a serotonin and noradrenaline reuptake inhibitor (SNRI), a noradrenergic and specific serotonergic antidepressant (NaSSA), and selective serotonin reuptake inhibitors (SSRIs).

Observational study of prescriptions (UK), poisoning deaths involving single antidepressants receiving coroners' verdicts of suicide or undetermined intent (England and Wales) and non-fatal self-poisoning episodes presenting to six general hospitals (in Oxford, Manchester and Derby) between 2000 and 2006. Calculation of fatal toxicity index based on ratio of rates of deaths to prescriptions, and case fatality based on ratio of rates of deaths to non-fatal self-poisonings.

Fatal toxicity and case fatality indices provided very similar results (rho for relative ranking of indices 0.99). Case fatality rate ratios showed greater toxicity for TCAs (13.8, 95% CI 13.0–14.7) than the SNRI venlafaxine (2.5, 95% CI 2.0–3.1) and the NaSSA mirtazapine (1.9, 95% CI 1.1–2.9), both of which had greater toxicity than the SSRIs (0.5, 95% CI 0.4–0.7). Within the TCAs, compared with amitriptyline both dosulepin (relative toxicity index 2.7) and doxepin (2.6) were more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs (1.1, 95% CI 0.8–1.4 v. 0.3, 95% CI 0.2–0.4).

There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, and to regulatory policy.

Patients with psychosis have activation of the hypothalamic-pituitary-adrenal (HPA) axis during the acute phase of the psychosis. Whether this has any morphological consequences for the pituitary gland is currently unknown.

To examine pituitary volume variation in people at different stages of psychotic disorder.

Pituitary volume was measured using 1.5 mm, coronal magnetic resonance images in 24 people with first-episode psychosis, 51 with established schizophrenia and 59 healthy controls.

Compared with the control group, the people with first-episode psychosis had pituitary volumes that were 10% larger, whereas those with established schizophrenia had pituitary volumes that were 17% smaller. In both of the groups with psychosis, there was no difference in pituitary volume between those receiving typical antipsychotic drugs and those receiving atypical antipsychotics.

The first episode of a psychosis is associated with a larger pituitary volume, which we suggest is due to activation of the HPA axis. The smaller pituitary volume in the group with established schizophrenia could be the consequence of repeated episodes of HPA axis hyperactivity.

This study examined the ability of commonly used questionnaires and a structured clinical interview to predict PTSD in recent trauma survivors.

Horowitz's Impact of Event Scale (IES), Speilberger's State Anxiety (SANX) and the Peri Traumatic Dissociation Questionnaire (PDEQ) were administered one week post-trauma to 239 traumatised individuals recruited from a general hospital emergency room. The IES, the SANX, the civilian version of the Mississippi Scale for Combat Related PTSD (MISS), and the Clinician Administered PTSD Scale (CAPS) were administered one month and four months post-trauma. Receiver operator characteristic (ROC) analysiswas used with these data.

All questionnaires were better than chance at predicting PTSD. The so called PTSD questionnaires (IES and MISS) were not better than the more general ones. No difference in predictive value was found when questionnaires were carried outone week or one month after a trauma. Recovery was better predicted than PTSD, and the CAPS was better than the questionnaires.

The use of psychometrics and clinical interviews to predict PTSD should be guided by clinical relevance and by the availability of resources.

Severe mania is life-threatening, carries an increased risk of suicide and has a serious impact on patients and their families. Efficient and rapid control of episodes of acute mania is needed.

To evaluate the safety and efficacy of risperidone monotherapy for acute mania.

In a 3-week, randomised, double-blind trial, 290 in-patients with bipolar l disorder with current manic or mixed episode and a baseline Young Mania Rating Scale (YMRS) score of 20 or more received flexible doses of risperidone (1–6 mg per day) or placebo.

Risperidone was received by 146 patients and placebo by 144. Their mean baselineYMRS score was 37. 2 (s. e. =0. 5). Significantly greater improvements were observed with risperidone than with placebo at weeks l and 2 and at end-point (total YMRS: P<0. 01). Extrapyramidal symptoms were the most frequently reported adverse events in the risperidone group.

In patients with severe manic symptoms, risperidone produced significant improvements in YMRS scores as early as week 1 and substantial changes at end-point. Treatment was well tolerated.

Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.

To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).

We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).

A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1–9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9–11.3%) compared with LMICs (4.3%, 95% CI 2.6–6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).

Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Cognitive models propose that faulty appraisal of anomalous experiences is critical in developing psychosis, particularly delusions. A data gathering bias may be fundamental to abnormal appraisal

To examine whether there is a data gathering bias in people at high risk of developing psychosis

Individuals with an at-risk mental state (n=35) were compared with a matched group of healthy volunteers (n=23). Participants were tested using a modified version of the ‘beads’ reasoning task with different levels of task difficulty

When task demands were high, the at-risk group made judgements on the basis of less information than the control group (P < 0.05). Within both groups, jumping to conclusions was directly correlated with the severity of abnormal beliefs and intolerance of uncertainty (P<0.05). In the at-risk group it was also associated with impaired working memory (P<0.05), whereas in the control group poor working memory was associated with a more conservative response style (P<0.05)

People with an at-risk mental state display a jumping to conclusions reasoning style, associated with impaired working memory and intolerance of uncertainty. This may underlie a tendency to develop abnormal beliefs and a vulnerability to psychosis