Concerns have been expressed that staff burnout may make community mental health care difficult to sustain. This study compares stress and job satisfaction between community and hospital-based staff.

The GHQ-12, the Maslach Burnout Inventory and a job satisfaction measure were used to study 160 Inner London staff.

Community staff scored significantly higher on the GHQ-12 and the ‘emotional exhaustion’ component of the Maslach Burnout Inventory than hospital-based in-patient, day care or out-patient staff. Satisfaction did not vary significantly between settings.

These results may be explained in several ways. Community work may be inherently more stressful than hospital work, or may currently be stressful because of inadequate resources, training or supervision. The results may also reflect widespread recent changes in community services or the specific effects of working in a deprived area.

Persistent drug-resistant psychotic symptoms are a pervasive problem in the treatment of schizophrenia.

To evaluate the durability of the treatment effects of cognitive–behavioural therapy for chronic schizophrenia one year after treatment termination.

A comparison of clinical outcomes was made at one-year follow-up from a randomised trial of cognitive–behavioural therapy, supportive counselling and routine care alone in the treatment of chronic schizophrenia.

Seventy out of the 72 patients (97%) who completed treatment were assessed at follow-up. There were significant differences between the three groups when positive and negative symptoms were analysed by means of ANCOVAs. Between-group comparisons indicated significant differences between cognitive–behavioural therapy and routine care at follow-up for positive symptoms. There was a trend towards significance for both cognitive–behavioural therapy and supportive counselling to be superior to routine care alone on negative symptoms.

At 12-month follow-up the significant advantage of cognitive– behavioural therapy compared to routine care alone remained.

Early worsening of anxiety, agitation and irritability are thought to be common among people commencing antidepressants, especially for anxiety disorders. This phenomenon, which may be termed jitteriness/anxiety syndrome, is cited as an explanation for early treatment failure and caution in using selective serotonin reuptake inhibitors (SSRIs). However, we believe that it is inconsistently defined and that robust evidence to support the phenomenon is lacking.

To review systematically all evidence relating to jitteriness/ anxiety syndrome to identify: constituent symptoms; medications implicated; disorders in which it was reported; incidence; time course; management strategies; relationship of this syndrome to therapeutic response; distinction between syndrome and akathisia; relationship between syndrome and suicide; and genetic predispositions.

A systematic search identified articles and these were included in the review if they addressed one of the above aspects of jitteriness/anxiety syndrome.

Of 245 articles identified, 107 articles were included for review. No validated rating scales for jitteriness/anxiety syndrome were identified. There was no robust evidence that the incidence differed between SSRIs and tricyclic antidepressants, or that there was a higher incidence in anxiety disorders. Published incidence rates varied widely from 4 to 65% of people commencing antidepressant treatment. Common treatment strategies for this syndrome included a slower titration of antidepressant and the addition of benzodiazepines. Conclusive evidence for the efficacy of these strategies is lacking. There was conflicting and inconclusive evidence as to whether the emergence of this syndrome had a predictive value on the response to treatment. It appears to be a separate syndrome from akathisia, but evidence for this assertion was limited. The effect of jitteriness/anxiety syndrome on suicide rates has not been evaluated. Three studies examined genetic variations and side-effects from treatment, but none was specifically designed to assess jitteriness/anxiety syndrome.

Jitteriness/anxiety syndrome remains poorly characterised. Despite this, clinicians' perception of this syndrome influences prescribing and it is cited to support postulated mechanisms of drug action. We recommend systematised evaluation of side-effects at earlier time points in antidepressant trials to further elucidate this clinically important syndrome.

There is some evidence that natural levels of lithium in drinking water may have a protective effect on suicide mortality.

To evaluate the association between local lithium levels in drinking water and suicide mortality at district level in Austria.

A nationwide sample of 6460 lithium measurements was examined for association with suicide rates per 100 000 population and suicide standardised mortality ratios across all 99 Austrian districts. Multivariate regression models were adjusted for well-known socioeconomic factors known to influence suicide mortality in Austria (population density, per capita income, proportion of Roman Catholics, as well as the availability of mental health service providers). Sensitivity analyses and weighted least squares regression were used to challenge the robustness of the results.

The overall suicide rate (R2 = 0.15, β =–0.39, t =–4.14, P = 0.000073) as well as the suicide mortality ratio (R2 = 0.17, β =–0.41, t =–4.38, P = 0.000030) were inversely associated with lithium levels in drinking water and remained significant after sensitivity analyses and adjustment for socioeconomic factors.

In replicating and extending previous results, this study provides strong evidence that geographic regions with higher natural lithium concentrations in drinking water are associated with lower suicide mortality rates.

Lack of social interaction, which is characteristically seen in people with autistic-spectrum disorder, may be caused by malfunctioning of the frontostriatal reward systems. However, no reported in vivo brain imaging studies have investigated reward mechanisms in autistic-spectrum disorder.

To investigate functional brain activation during reward feedback in people with autistic-spectrum disorder and control individuals.

We used event-related functional magnetic resonance imaging to examine the neural substrates of monetary reward in individuals with autistic-spectrum disorder and matched controls.

When rewarded, individuals with autism compared with control individuals showed significantly greater brain activation in the left anterior cingulate gyrus. In addition, activation of this region was negatively correlated with social interaction as measured by the Autism Diagnostic Interview.

In people with autistic-spectrum disorder, achieving reward is associated with significant differences in the activation of areas known to be responsible for attention and arousal, and this may partially underpin some deficits in social behaviour.

People with major depressive disorder who fail to respond to adequate trials of antidepressant treatment may harbour hidden bipolar disorder.

We aimed to compare the rates of a change in diagnosis to bipolar disorder among people with major depressive disorder with stratified responses to antidepressants during an 8-year follow-up period.

Information on individuals with major depressive disorder identified during 2000 (cohort 2000, n = 1485) and 2003 (cohort 2003, n = 2459) were collected from a nationally representative cohort of 1 000 000 health service users in Taiwan. Participants responding well to antidepressants were compared with those showing poor responses to adequate trials of antidepressants.

In 7.6–12.1% of those with a diagnosis of unipolar major depressive disorder this diagnosis was subsequently changed to bipolar disorder, with a mean time to change of 1.89–2.98 years. Difficult-to-treat participants presented higher rates of change to a bipolar diagnosis (25.6% in cohort 2000; 26.6% in cohort 2003) than easy-to-treat participants (8.8–8.9% in cohort 2000; 6.8–8.6% in cohort 2003; P<0.0001). Regression analysis showed that the variable most strongly associated with the change in diagnosis was antidepressant use history. The difficult-to-treat participants were associated most with diagnostic changing (cohort 2000: odds ratio (OR) = 1.88 (95% CI 1.12–3.16); cohort 2003: OR = 4.94 (95% CI 2.81–8.68)).

This is the first large-scale study to report an association between antidepressant response history and subsequent change in diagnosis from major depressive disorder to bipolar disorder. Our findings support the view that a history of poor response to antidepressants in unipolar depression could be a useful predictor for bipolar diathesis.

Population studies indicate that subjective memory complaints by elderly people are correlated with cognitive performance. These complaints have some predictive power regarding the development of dementia. The present study attempted to replicate this finding, and investigated which variables determine subjective memory complaints.

Participants in the Amsterdam Study of the Elderly (n=2114; 65–84 years of age), who were not demented and had a normal MMSE score (> 23) at baseline, were re-examined after four years. Subjective complaints were measured using a previously developed scale. Dementia and depression were measured using the Geriatric Mental State Schedule (GMS). Premorbid intelligence was measured by the Dutch Adult Reading Test (DART)

Memory complaints at baseline contributed a small but significant amount of diagnostic information with respect to the prediction of future dementia. Depressive symptoms at baseline had no predictive value when these memory complaints were accounted for. Subjective memory complaints were associated with depression, baseline MMSE score, and premorbid intelligence.

Subjective memory complaints are not just secondary to depression, but in part reflect realistic self-observations of cognitive decline.

Exposure to childhood adversity may explain why only a minority of combatants exposed to trauma develop psychological problems.

To examine the association between self-reported childhood vulnerability and later health outcomes in a large randomly selected male military cohort.

Data are derived from the first stage of a cohort study comparing Iraq veterans and non-deployed UK military personnel. We describe data collected by questionnaire from males in the regular UK armed forces (n=7937).

Pre-enlistment vulnerability is associated with being single, of lower rank, having low educational attainment and serving in the Army. Pre-enlistment vulnerability is associated with a variety of negative health outcomes. Two main factors emerge as important predictors of ill health: a ‘family relationships’ factor reflecting the home environment and an ‘externalising behaviour’ factor reflecting behavioural disturbance.

Pre-enlistment vulnerability is an important individual risk factor for ill health in military men. Awareness of such factors is important in understanding post-combat psychiatric disorder.

Avoidance coping (e.g. sealing over) is common in people recovering from psychosis, but it is not understood why some individuals ‘seal over’.

We examined the hypothesis that individuals who ‘seal over’ do not have the personal resilience to withstand this major life event.

Fifty participants were interviewed during an acute episode of psychosis and reassessed at 3-month and 6-month follow-up. Measures included psychotic symptoms, recovery style, service engagement, parental and adult attachment and self-evaluative beliefs.

Sealing-over recovery styles are associated with negative early childhood experience, insecure adult attachment, negative self-evaluative beliefs and insecure identity. Insecure adult attachment was associated with less engagement with services.

Sealing over was associated with multiple signs of low personal resilience in adapting to psychosis.

Dietary variations are known to predict the prevalence of physical illnesses such as diabetes and heart disease but the possible influence of diet on mental health has been neglected.

To explore dietary predictors of the outcome of schizophrenia and the prevalence of depression.

Ecological analysis of national dietary patterns in relation to international variations in outcome of schizophrenia and prevalence of depression.

A higher national dietary intake of refined sugar and dairy products predicted a worse 2-year outcome of schizophrenia. A high national prevalence of depression was predicted by a low dietary intake of fish and seafood.

The dietary predictors of outcome of schizophrenia and prevalence of depression are similar to those that predict illnesses such as coronary heart disease and diabetes, which are more common in people with mental health problems and in which nutritional approaches are widely recommended. Dietary intervention studies are indicated in schizophrenia and depression.

Patient-rated unmet need is cross-sectionally associated with quality of life. Its longitudinal relationship has not been established.

To test the hypotheses that: (a) higher patient-rated unmet need is associated with lower individual quality of life assessments by apatientover time; and (b) reduction in patient-rated unmet need precedes improvement in quality of life.

One hundred and one individuals using adult mental health services were asked to complete 6-monthly questionnaires, comprising quality of life (Manchester Short Assessment of Quality of Life, MANSA) and unmet need (Camberwell Assessment of Need Short Appraisal Schedule, CANSAS) assessments.

Seventy-three participants provided 240 separate pairs of consecutive assessments. Random effects regression models indicated an impact on current quality of life for both average level of unmet need (B= −0.23, 95% CI −0.29 to −0.17) and change in unmet need over the past month (B= −0.04, 95% CI −0.02).

Changes in patient-rated unmet needs may cause changes in quality of life.

Late-life depression has become an important public health problem. Available evidence suggests that late-life depression is associated with all-cause and cardiovascular mortality among older adults living in the community, although the associations have not been comprehensively reviewed and quantified.

To estimate the pooled association of late-life depression with all-cause and cardiovascular mortality among community-dwelling older adults.

We conducted a systematic review and meta-analysis of prospective cohort studies that examine the associations of late-life depression with all-cause and cardiovascular mortality in community settings.

A total of 61 prospective cohort studies from 53 cohorts with 198 589 participants were included in the systematic review and meta-analysis. A total of 49 cohorts reported all-cause mortality and 15 cohorts reported cardiovascular mortality. Late-life depression was associated with increased risk of all-cause (risk ratio 1.34; 95% CI 1.27, 1.42) and cardiovascular mortality (risk ratio 1.31; 95% CI 1.20, 1.43). There was heterogeneity in results across studies and the magnitude of associations differed by age, gender, study location, follow-up duration and methods used to assess depression. The associations existed in different subgroups by age, gender, regions of studies, follow-up periods and assessment methods of late-life depression.

Late-life depression is associated with higher risk of both all-cause and cardiovascular mortality among community-dwelling elderly people. Future studies need to test the effectiveness of preventing depression among older adults as a way of reducing mortality in this population. Optimal treatment of late-life depression and its impact on mortality require further investigation.

None.

3,4-methylenedioxymethamphetamine (MDMA or ‘Ecstasy’) has become one of the most widely used illicit substances in the UK. Little is known of the psychiatric morbidity which may be associated with its use. We have examined this association by collecting a series of psychiatric cases in which MDMA use was a prominent feature.

Patients presenting between 1990 and 1992 with psychiatric symptoms which developed in the context of MDMA use (n = 13) were interviewed, and their psychiatric, medical and drug history, sociodemographic background and mental state were examined in detail. The psychopathology of cases with psychosis (n = 8) was assessed with the Present State Examination and compared with that of substance-naïve psychotic controls (n = 40).

Eight patients presented with psychotic syndromes, two experienced visual illusions, hallucinations and palinopsia, one had panic attacks, one suffered from depression, and one described chronic depersonalisation and derealisation. The psychopathology of the patients with psychoses was very similar to that of controls.

Use of MDMA may be associated with a broader spectrum of psychiatric morbidity than heretofore suspected. Cases with psychosis may be clinically similar to psychotic patients with no history of substance use.