Attachment theory argues that psychological development and functioning are affected by our earliest attachments to care-givers. Failed or pathological attachment in childhood may give rise to repetition of maladaptive attachment patterns in adulthood.

Analysis of therapeutic relationships in the light of attachment theory.

Relationships between patients and both psychiatric care-givers and institutions may resemble attachment relationships.

An attachment perspective may be useful for understanding common behavioural disturbances in general psychiatric settings, and support the use of clinical strategies which focus on containment of arousal and the management of anxiety states.

Consensus has been achieved about how depression should be treated in primary care, and guidelines have been issued by the Royal Colleges of General Practitioners and Psychiatrists, and by the British Association for Psychopharmacology. One of the principal recommendations is to prescribe antidepressant medicine at effective doses. This study was established to investigate how current prescribing practices in primary care compared with these guidelines.

Information on prescribing of antidepressant medicines was obtained using three independent data sources: Prescribing Analysis and Cost (PACT) data; medical notes; and a large, computerised patient record database.

Data were obtained on populations in excess of 1.5 million people, and over 80 000 prescriptions were reviewed. All three data sources showed very similar patterns of prescribing, in particular that as many as 88% of prescriptions for older tricyclic antidepressants are prescribed by GPs at doses below those recommended by the consensus guidelines. Newer antidepressants – lofepramine and the SSRIs – are prescribed comparatively well.

Prescribing of antidepressants by GPs is not in line with the consensus recommendations on dosage. This may have major educational implications for GPs. A pragmatic approach to improve prescribing in the short term may be to advocate the use of lofepramine or the SSRIs as first line treatment for depression. This study validates the use of PACT data as a useful audit tool in this area of clinical practice.

Social adversity may be a risk factor for depression, by increasing Cortisol secretion, which impairs serotonin (5-HT) neurotransmission.

To examine this causal pathway in a community setting.

Women who were currently ICD–10 depressed (n=94), vulnerable to depression but not depressed (n=166) and non-vulnerable controls (n=177) were recruited. We assessed social adversity and vulnerability (Life Eventsand Difficulties Schedule; Self Evaluation and Social Support Scales) and psychiatric state (Schedules for Clinical Assessment in Neuropsychiatry). Salivary cortisol concentrations were measured at 09.00 and 23.00 h. Serotonin function was assessed using prolactin responses to dexfenfluramine.

Cortisol concentrations were not increased in the depressed or vulnerable. Morning salivary and serum cortisol were reduced in depression. Evening cortisol was increased after recent life events. Life events and depression were associated with increased prolactin responses.

The hypothalamic–pituitary–adrenal axis is sensitive to social stress but does not mediate vulnerability to depression. Exaggerated 5-HT2 receptor responsiveness to stress may play a role in the evolution of depression.

An epidemiological study of anorexia nervosa and bulimia nervosa in primary care was performed using the General Practice Research Database (GPRD).

The GPRD was screened between 1988 and 1994 for newly diagnosed cases of anorexia nervosa and bulimia nervosa. The validity of the computer diagnosis was established by obtaining clinical details from a random sample of the general practitioners (GPs).

Incidence rates for detection of cases by GPs in 1993 was 4.2 per 100 000 population for anorexia nervosa and 12.2 per 100 000 for bulimia nervosa The relative risks of females to males was 40:1 for anorexia nervosa and 47:1 for bulimia nervosa A threefold increase in the recording of bulimia nervosa was found from 1988 to 1993. Eighty per cent of anorexia nervosa cases and 60% of bulimia nervosa cases were referred to secondary care.

There is a continuing expansion of service need for bulimia nervosa The majority of cases of eating disorders are referred to secondary services. There is scope for more effective management of bulimia nervosa in primary care.

Schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial.

To assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder.

Costs were assessed by interview. Health-related quality of life was measured using EQ-5D. Outcomes were costs per recovered patient (recovery assessed with the Borderline Personality Disorder Severity Index) and costs per quality-adjusted life-year (QALY).

Mean 4-year bootstrapped costs were $37826 for SFT and $46 795 for TFP (95% uncertainty interval for difference −21 775 to 3546); QALYs were 2.15 for SFT and 2.27 for TFP (95% UI −0.51 to 0.28). The percentages of patients who recovered were 52% and 29% respectively. The SFT intervention was less costly and more effective than TFP (dominant), for recovery; it saved $90457 for one QALY loss.

Despite the initial slight disadvantage in QALYs, there is a high probability that compared with TFP, SFT is a cost-effective treatment for borderline personality disorder.

Little is known about the long-term outcome of anorexia nervosa.

To study the 30-year outcome of adolescent-onset anorexia nervosa.

All 4291 individuals born in 1970 and attending eighth grade in 1985 in Gothenburg, Sweden were screened for anorexia nervosa. A total of 24 individuals (age cohort for anorexia nervosa) were pooled with 27 individuals with anorexia nervosa (identified through community screening) who were born in 1969 and 1971–1974. The 51 individuals with anorexia nervosa and 51 school- and gender-matched controls were followed prospectively and examined at mean ages of 16, 21, 24, 32 and 44. Psychiatric disorders, health-related quality of life and general outcome were assessed.

At the 30-year follow-up 96% of participants agreed to participate. There was no mortality. Of the participants, 19% had an eating disorder diagnosis (6% anorexia nervosa, 2% binge-eating disorder, 11% other specified feeding or eating disorder); 38% had other psychiatric diagnoses; and 64% had full eating disorder symptom recovery, i.e. free of all eating disorder criteria for 6 consecutive months. During the elapsed 30 years, participants had an eating disorder for 10 years, on average, and 23% did not receive psychiatric treatment. Good outcome was predicted by later age at onset among individuals with adolescent-onset anorexia nervosa and premorbid perfectionism.

This long-term follow-up study reflects the course of adolescent-onset anorexia nervosa and has shown a favourable outcome regarding mortality and full symptom recovery. However, one in five had a chronic eating disorder.

There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

Social cognition has been implicated in the relationship between cognition and social functioning.

To test the hypothesis that social cognition mediates the relationship between cognitive and social functioning.

This was a 1-year longitudinal cohort study comparing three groups: 50 people with first-episode psychosis, 53 people with multi-episode schizophrenia and 55 people without psychiatric disorder as controls. Participants were assessed on social perception, social knowledge, interpersonal problem-solving, cognition and social functioning.

There were significant associations between social cognition, cognition and social functioning in all three groups. Deficits in social cognition were stable over time. In the first two groups, controlling for social cognition reduced the relationship between cognitive and social functioning.

This study provides some evidence that social cognition mediates the relationship between cognitive and social functioning.

Knowledge of when and how to implement treatments to prevent criminal offending among people with schizophrenia is urgently needed.

To identify opportunities for interventions to prevent offending among men with schizophrenic disorders by tracking their histories of offending and admissions to hospital.

We examined 232 men with schizophrenic disorders discharged from forensic and general psychiatric hospitals. Data were collected from participants, family members and official records.

More than three-quarters (77.8%) of the forensic patients had previously been admitted to general psychiatric services; 24.3% of the general psychiatric patients had a criminal record. Offences had been committed by 39.8% of the forensic patients and 10.8% of the general psychiatric patients before their first admission to general psychiatry, and after their first admission these 59 patients committed 195 non-violent and 59 violent offences. Subsequently, 49 of them committed serious violent offences that led to forensic hospital admission. The offenders were distinguished by a pervasive and stable pattern of antisocial behaviour evident from at least mid-adolescence.

General psychiatry requires resources in order to prevent criminal offending among a subgroup of patients with schizophrenic disorders.

It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders.

To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications.

A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years.

At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05).

Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

Attention-deficit hyperactivity disorder (ADHD) is a common childhood condition, and is more prevalent in boys. The adult outcome of girls with ADHD has never been studied.

To identify predictors for adult psychiatric outcome of children with ADHD, including gender and comorbidity.

Children aged 4–15 years, referred for hyperactivity/inattention and treated with stimulants were included (n=208). The Psychiatric Case Register provided follow-up data on psychiatric admissions in adulthood until a mean age of 31 years.

A total of 47 cases (22.6%) had a psychiatric admission in adulthood. Conduct problems in childhood were predictive (hazard ratio HR=2.3; 95% CI 1.22–4.33). Girls had a higher risk compared with boys (HR=2.4; 95% CI 1.1–5.6).

Girls with ADHD had a higher risk of adult psychiatric admission than boys. Conduct problems were also associated with a higher risk. Girls with ADHD with conduct problems had a very high risk of a psychiatric admission in adulthood.