Many people with substance use disorders are vulnerable to other psychiatric disorders and present to addiction treatment services with comorbid psychiatric symptoms.

To describe the prevalence of recent psychiatric treatment and current psychiatric symptoms and explore links between substance misuse, personal/social functioning and symptom severity.

Subjects were 1075 adults recruited to the National Treatment Outcome Research Study (NTORS), of whom 90% were opiate-dependent. Psychiatric symptoms at intake were recorded using sub-scales from the Brief Symptom Inventory.

Recent psychiatric treatment was reported by one in five subjects. Psychiatric symptom levels were high and females had elevated scores on all scales. Symptoms were elevated among opiate users who were also frequent users of benzodiazepines, alcohol and, in particular, stimulants. Gender, physical health, drug dependence and personal relationship problems were more powerful predictors of psychiatric symptoms than substance use.

Addictions service providers should be vigilant to psychiatric problems among their clients at intake to treatment. Psychiatric symptoms are more closely linked to polydrug use than to opiate use in this population.

The number of elderly prisoners has increased significantly in Western countries over the past decade. Little is known about the psychiatric morbidity of this population.

To determine the prevalence of psychiatric morbidity in elderly sentenced prisoners.

A stratified sample of 203 male sentenced prisoners aged over 59 years, from 15 prisons in England and Wales, representing one in five men in this age group, was interviewed using semi-structured standardised instruments for psychiatric illness and personality disorder.

More than half of the elderly prisoners had a psychiatric diagnosis. The most common diagnoses were personality disorder and depressive illness.

The prevalence of depressive illness was five times greater than that found in other studies of younger adult prisoners and elderly people in the community. Underdetected, undertreated depressive illness in elderly prisoners is an increasing public health problem.

Secure hospitals are a high-cost, low-volume service consuming around a fifth of the overall mental health budget in England and Wales.

A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy.

We searched for primary studies that followed patients discharged from a secure hospital, and reported mortality, readmissions or reconvictions. We determined crude rates for all adverse outcomes.

In total, 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders. The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175–1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235– 415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916–8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679–5287), with lower rates in more recent studies.

There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.

Treatment within medium secure forensic psychiatry services is expected to reduce risk to the public.

To measure the period prevalence and incidence of offending following discharge and identify associated risk factors.

Follow-up of patients from 7 of 14 regional services in England and Wales who spent time at risk (n=1344) for a mean of 6.2 years. Outcome was obtained from offenders index, hospital case-files and the central register of deaths.

One in 8 men and 1 in 16 women were convicted of grave offences. Incidence rates indicated low density and most patients were not subsequently convicted. Offence predictors included gender, younger age, early-onset offending, previous convictions and a comorbid or primary diagnosis of personality disorder. Longer in-patient stay and restriction on discharge were protective.

Risks of reoffending remain for a subgroup of discharged patients. Future research should aim to improve their identification and risk management following discharge.

Evidence from cross-sectional studies suggests a link between cerebral age-related white matter changes and depressive symptoms in older people, although the temporal association remains unclear.

To investigate age-related white matter changes on magnetic resonance imaging (MRI) as an independent predictor of depressive symptoms at 1 year after controlling for known confounders.

In a pan-European multicentre study of 639 older adults without significant disability, MRI white matter changes and demographic and clinical variables, including cognitive scores, quality of life, disability and depressive symptoms, were assessed at baseline. Clinical assessments were repeated at 1 year.

Using logistic regression analysis, severity of white matter changes was shown to independently and significantly predict depressive symptoms at 1 year after controlling for baseline depressive symptoms, quality of life and worsening disability (P<0.01).

White matter changes pre-date and are associated with the development of depressive symptoms. This has implications for treatment and prevention of depression in later life.

The prevalence of psychotic phenomena in confirmed Alzheimer's disease (AD) and their potential neuropathological correlates have rarely been the subject of prospective investigation.

Psychopathological disturbances were recorded prospectively according to the Geriatric Mental State Schedule and the CAMDEX. The frequency of these phenomena and neuropathological changes were examined in 56 patients with definite AD.

Hallucinations had been documented in 13 patients, paranoid delusions in 9 and delusional misidentification (e.g. the Capgras-type and the ‘phantom boarder’ symptoms) in 14 patients. Misidentifications were associated with lower neurone counts in the area CA1 of the hippocampus. Delusions and hallucinations were observed in patients with less severe cell loss in the parahippocampal gyrus and with lower cell counts in the dorsal raphe nucleus. A decrease of neurones in the locus coeruleus in a subset of depressed patients with AD had been reported earlier. Delusions and delusional misidentification were common in 5 patients with basal ganglia mineralisation, but there was no statistically significant association of these symptoms with the presence of Lewy bodies in the brainstem and neocortex of our patient sample.

These findings are compatible with the view that morphological changes in certain brain areas may promote the development of psychotic phenomena in AD. AD may offer a model for the understanding of pathomechanisms underlying the development of psychopathological disturbances in other psychoses with more discrete neuropathological changes.

This study was designed to establish whether (as suggested in a number of open and relatively small controlled trials) lithium augmentation is more effective than continued antidepressant alone, where response to a standard course of antidepressant treatment has been absent or partial.

Lithium or placebo was added on a double-blind basis for six weeks to the drug regime of 62 patients with major depressive illness (in both hospital and primary care settings) who had failed to respond to a controlled trial of fluoxetine or lofepramine. Response was defined as a final Hamilton Depression Rating Scale (HDRS) score of < 10.

Response was seen more frequently in patients taking lithium (15/29) than in those remaining on antidepressant alone (8/32; P < 0.05). Rapid response to lithium augmentation (LA) was not consistently observed in this cohort. Mean HDRS scores after six weeks were significantly lower (P < 0.01) in the lithium group after excluding those who had not achieved significant exposure to lithium (arbitrarily defined as two or more lithium levels ≥ 0.4 mmol/1). No differences in the efficacy of LA were apparent between fluoxetine and lofepramine.

Our results confirm that LA is a useful strategy in the treatment of antidepressant-resistant depression. Partial response was, however, frequently observed with continued antidepressant treatment alone, and the superiority of LA appears to depend on achieving adequate serum lithium levels.

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

Studies examining the impact of childhood disaster exposure on the development of adult psychopathology report increased rates of post-traumatic stress disorder (PTSD) and other psychopathology.

To examine the rates of PTSD and other lifetime DSM–IV disorders in adults exposed to an Australian bushfire disaster as children in 1983 using a matched control sample recruited at the time of the original study.

A total of 1011 adults recruited from an original sample of 1531 were assessed 20 years following the fires using the Composite International Diagnostic Interview (CIDI–2.1).

Results showed only a small direct impact of the fires on adult psychiatric morbidity. A higher proportion of bushfire survivors met criteria for ‘any DSM–IV disorder’ and ‘any anxiety’.

Findings suggest that the long-term impact of a prominent trauma in childhood should be assessed in the context of other lifetime trauma in order to provide a more accurate account of PTSD prevalence rates.

This study employed an alternative method for assessing serotonergic function to further evaluate our finding that cerebrospinal fluid (CSF) 5-hydroxyindole acetic acid (5-HIAA) in depressed suicide attempters with a lifetime history of higher lethality suicide attempts is significantly lower compared to depressed patients who have a history of low lethality suicide attempts.

We used dl-fenfluramine (60 mg) as a neuroendocrine probe to examine the serotonin system in 41 in-patients with a DSM–III–R major depressive episode, divided into two groups on the basis of a lifetime history of high or low lethality suicide attempts. Fenfluramine challenge test outcome was defined as the maximum prolactin response in the five hours following fenfluramine.

Patients with a history of a higher lethality suicide attempt had a significantly lower prolactin response to fenfluramine, even when controlling for cortisol, age, sex, weight, comorbid cluster B personality disorder, pharmacokinetic and menstrual cycle effects.

The data provide further support for the hypothesis that serotonin dysfunction is associated with more lethal suicide attempts, and suggests that higher lethality suicide attempters or failed suicides resemble completed suicides both behaviourally and biochemically.

There have been few detailed longitudinal symptom studies of bipolar disorder.

To describe the course of bipolar disorder over 18 months in 204 patients receiving mental healthcare.

Patients were interviewed every 8 weeks, with weekly ratings of depression, mania and overall severity.

Participants were symptomatic 53% of the time, with sub-syndromal symptoms present for twice as long as major disorder, and depressive symptoms three times more than manic symptoms. Individuals who were experiencing an episode at baseline spent 33% of the 18 months with substantial sub-syndromal symptoms, 17% with major disorder and 28% symptom free. Those not experiencing a baseline episode spent twice as long symptom free and half as long at disorder levels. Changes in symptom level were frequent. Predictors of sub-syndromal symptoms were similar to those of major disorder.

Sub-syndromal residual symptoms are an important problem in recurrent bipolar disorder and require therapeutic intervention.

Various problems are associated with schizophrenia which may theoretically lead to impaired educability about treatment.

The Understanding of Medication Questionnaire, designed to measure knowledge about treatment in schizophrenia, is described and presented. An educational programme based on a specially designed information booklet was developed. Sixty-four patients with DSM–III–R diagnosis schizophrenia were randomly allocated to groups receiving none (control), one session or three sessions of education.

Pre-intervention low levels of knowledge about illness and treatment increased significantly immediately after a standard education session. Three education sessions led to significantly greater knowledge gain than one session. There was no significant change in the control group. Only the PANSS negative syndrome score independently and consistently explained a significant proportion of the education effect. The influence on educability of attitudes to education, impaired insight, cognitive impairment and other variables were considered. Three sessions of education led to significantly increased insight, but no change in compliance.

Techniques appropriate for educating schizophrenic patients were discussed, and the value of involving patients in education emphasised. A series of patient education sessions is needed to consolidate learning, rather than a single informing process. The strong association between impaired learning and more severe negative schizophrenic syndrome emphasises the need for responsible prescribing of antipsychotic treatment in schizophrenia.

Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice.

To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK.

Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later.

Thirty-two services participated, submitting data for 3942 patients at baseline and 3271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required (‘p.r.n.’) prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions.

The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.

The association between depression and increased mortality risk in older persons may depend on the severity of the depressive disorder and gender.

To investigate the association between major and mild depressive syndromes and excess mortality in community-living elderly men and women.

Depression (Geriatric Mental State AGECAT) was assessed in 4051 older persons, with a 6-year follow-up of community death registers. The mortality risk of neurotic and psychotic depression was calculated after adjustment for demographic variables, physical illness, cognitive decline and functional disabilities.

A total of 75% of men and 41% of women with psychotic depression had died at follow-up. Psychotic depression was associated with significant excess mortality in both men and women. Neurotic depression was associated with a 1.67-fold higher mortality risk in men only.

In the elderly, major depressive syndromes increase the risk of death in both men and women, but mild depression increases the risk of death only in men.

There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers.

To verify combat exposure history for a relevant sample through objective historical data.

Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined.

Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam ‘combat’ and ‘no combat’ groups on relevant clinical variables.

A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.