Electroconvulsive therapy (ECT) is the most effective acute treatment for severe depression, but widely held concerns about memory problems may limit its use.

To find out whether repeated or maintenance courses of ECT cause cumulative cognitive deterioration.

Analysis of the results of 10 years of cognitive performance data collection from patients who have received ECT. The 199 patients had a total of 498 assessments, undertaken after a mean of 15.3 ECT sessions (range 0–186). A linear mixed-effect regression model was used, testing whether an increasing number of ECT sessions leads to deterioration in performance.

The total number of previous ECT sessions had no effect on cognitive performance. The major factors affecting performance were age, followed by the severity of depression at the time of testing and the number of days since the last ECT session.

Repeated courses of ECT do not lead to cumulative cognitive deficits. This message is reassuring for patients, carers and prescribers who are concerned about memory problems and confusion during ECT.

Gambling disorder is a relatively common psychiatric disorder recently re-classified within the DSM-5 under the category of ‘substance-related and addictive disorders'.

To compare white matter integrity in patients with gambling disorder with healthy controls; to explore relationships between white matter integrity and disease severity in gambling disorder.

In total, 16 participants with treatment-resistant gambling disorder and 15 healthy controls underwent magnetic resonance imaging (MRI). White matter integrity was analysed using tract-based spatial statistics.

Gambling disorder was associated with reduced fractional anisotropy in the corpus callosum and superior longitudinal fasciculus. Fractional anisotropy in distributed white matter tracts elsewhere correlated positively with disease severity.

Reduced corpus callosum fractional anisotropy is suggestive of disorganised/damaged tracts in patients with gambling disorder, and this may represent a trait/vulnerability marker for the disorder. Future research should explore these measures in a larger sample, ideally incorporating a range of imaging markers (for example functional MRI) and enrolling unaffected first-degree relatives of patients.

Placebo-controlled clinical trials have led to concern over possible increased risk of suicide-related events in some populations exposed to antidepressants.

To evaluate the risk of suicide attempts by antidepressant drug class and the presence or absence of depression.

A retrospective propensity-matched new-user cohort study was used to compare participants with incident depression classified by antidepressant treatment with each other and with the general population.

Among the treated group, the suicide attempt rate peaked in the month prior to diagnosis then decreased steadily over the next 6 months. Among the pharmacologically untreated group, the highest rate was seen in the second month after diagnosis. Cohorts with depression had significantly higher suicide attempt risk than the general population, but the treated group did not differ significantly from the untreated group.

Patients on antidepressants did not have significantly higher risk compared with untreated patients. No significant differences were observed for patients treated with individual serotonin–noradrenaline reuptake inhibitors (SNRIs) or selective serotonin reuptake inhibitors (SSRIs) or by class (SSRI v. SNRI cohorts).

Controversy exists over antidepressant use in bipolar II depression.

To compare the safety and effectiveness of antidepressant v. mood stabiliser monotherapy for bipolar type II major depressive episodes.

Randomised, double-blind, parallel-group, 12-week comparison of venlafaxine (n = 65) v. lithium (n = 64) monotherapy in adult out-patients (trial registration number NCT00602537).

Primary outcome – venlafaxine produced a greater response rate (67.7%) v. lithium (34.4%, P<0.001). Secondary outcomes – venlafaxine produced a greater remission rate (58.5% v. 28.1%, P<0.001); greater decline in depression symptom scores over time (β=–5.32, s.e. = 1.16, χ2 = 21.19, P<0.001); greater reduction in global severity scores over time (β=–1.05, s.e. = 0.22, χ2 = 22.33, P<0.001); and greater improvement in global change scores (β=–1.31, s.e. = 0.32, χ2 = 16.95, P<0.001) relative to lithium. No statistically significant or clinically meaningful differences in hypomanic symptoms were observed between treatments.

These findings suggest that short-term venlafaxine monotherapy may provide effective antidepressant treatment for bipolar II depression without a statistically significant increase in hypomanic symptoms relative to lithium.

Although the incidence of suicide among women who have given birth during the past 12 months is lower than that of women who have not given birth, suicide remains one of the most common causes of death during the year following delivery in high-income countries, such as Sweden.

To characterise women who died by suicide during pregnancy and postpartum from a maternal care perspective.

We traced deaths (n = 103) through linkage of the Swedish Cause of Death Register with the Medical Birth and National Patient Registers. We analysed register data and obstetric medical records.

The maternal suicide ratio was 3.7 per 100 000 live births for the period 1980–2007, with small magnitude variation over time. The suicide ratio was higher in women born in low-income countries (odds ratio 3.1 (95% CI 1.3–7.7)). Violent suicide methods were common, especially during the first 6 months postpartum. In all, 77 women had received psychiatric care at some point, but 26 women had no documented psychiatric care. Antenatal documentation of psychiatric history was inconsistent. At postpartum discharge, only 20 women had a plan for psychiatric follow-up.

Suicide prevention calls for increased clinical awareness and cross-disciplinary maternal care approaches to identify and support women at risk.

Excoriation (skin-picking) disorder (SPD) is a relatively common psychiatric condition whose neurobiological basis is unknown.

To probe the function of fronto-striatal circuitry in SPD.

Eighteen participants with SPD and 15 matched healthy controls undertook an executive planning task (Tower of London) during functional magnetic resonance imaging (fMRI). Activation during planning was compared between groups using region of interest and whole-brain permutation cluster approaches.

The SPD group exhibited significant functional underactivation in a cluster encompassing bilateral dorsal striatum (maximal in right caudate), bilateral anterior cingulate and right medial frontal regions. These abnormalities were, for the most part, outside the dorsal planning network typically activated by executive planning tasks.

Abnormalities of neural regions involved in habit formation, action monitoring and inhibition appear involved in the pathophysiology of SPD. Implications exist for understanding the basis of excessive grooming and the relationship of SPD with putative obsessive–compulsive spectrum disorders.

Clinical and aetiological heterogeneity have impeded our understanding of depression.

To evaluate differences in psychiatric and somatic course between people with depression subtypes that differed clinically (severity) and aetiologically (melancholic v. atypical).

Data from baseline, 2-, 4- and 6-year follow-up of The Netherlands Study of Depression and Anxiety were used, and included 600 controls and 648 people with major depressive disorder (subtypes: severe melancholic n = 308; severe atypical n = 167; moderate n = 173, established using latent class analysis).

Those with the moderate subtype had a significantly better psychiatric clinical course than the severe melancholic and atypical subtype groups. Suicidal thoughts and anxiety persisted longer in those with the melancholic subtype. The atypical subtype group continued to have the highest body mass index and highest prevalence of metabolic syndrome during follow-up, although differences between groups became less pronounced over time.

Course trajectories of depressive subtypes mostly ran parallel to each other, with baseline severity being the most important differentiator in course between groups.

Depression is a highly prevalent disorder, causing a large burden of disease and substantial economic costs. Web-based self-help interventions seem promising in promoting mental health.

To compare the efficacy of a guided web-based intervention based on acceptance and commitment therapy (ACT) with an active control (expressive writing) and a waiting-list control condition (Netherlands Trial Register NTR1296).

Adults with depressive symptoms from the general population were randomised to ACT (n = 82), expressive writing (n = 67) or waiting-list control (n = 87). The main outcome was reduction in depressive symptoms assessed with the Center for Epidemiological Studies – Depression scale.

Significant reductions in depressive symptoms were found following the ACT intervention, compared with the control group (Cohen's d = 0.56) and the expressive writing intervention (d = 0.36). The effects were sustained at 6-month and 12-month follow-up.

Acceptance and commitment therapy as a web-based public mental health intervention for adults with depressive symptoms can be effective and applicable.

Somatic severity of a self-poisoning episode varies widely between patients.

To determine the correlates (psychiatric profiles, long-term outcome) of mechanical ventilation used as a proxy to define somatic severity during a self-poisoning.

All patients who required mechanical ventilation were pair-matched with ones who did not for age, gender and presence of psychiatric history. One year after the self-poisoning episode, patients were interviewed using the Hospital Anxiety and Depression Scale (HADS) and a quality-of-life assessment questionnaire (Short-Form 12 Health Survey).

The ventilation group (n = 99) more frequently had mood disorders and less frequently had adjustment disorders (P = 0.007), with a higher depression score on the HADS (P = 0.01) than those in the non-ventilation group (n = 97). Survival curves showed lower survival in the ventilation group (P = 0.03).

Requirement for mechanical ventilation following self-poisoning is associated with a high prevalence of mood disorders and poor long-term outcome.

Implementation intentions link triggers for self-harm with coping skills and appear to create an automatic tendency to invoke coping responses when faced with a triggering situation.

To test the effectiveness of implementation intentions in reducing suicidal ideation and behaviour in a high-risk group.

Two hundred and twenty-six patients who had self-harmed were randomised to: (a) forming implementation intentions with a ‘volitional help sheet’; (b) self-generating implementation intentions without help; or (c) thinking about triggers and coping, but not forming implementation intentions. We measured self-reported suicidal ideation and behaviour, threats of suicide and likelihood of future suicide attempt at baseline and then again at the 3-month follow-up.

All suicide-related outcome measures were significantly lower at follow-up among patients forming implementation intentions compared with those in the control condition (ds>0.35). The volitional help sheet resulted in fewer suicide threats (d = 0.59) and lowered the likelihood of future suicide attempts (d = 0.29) compared with patients who self-generated implementation intentions.

Implementation intention-based interventions, particularly when supported by a volitional help sheet, show promise in reducing future suicidal ideation and behaviour.

Higher daytime cortisol levels because of a hyperactive hypothalamic–pituitary–adrenal axis have been reported in patients with major depressive disorder (MDD). The elevated glucocorticoids inhibit the proliferation of the oligodendrocytes that are responsible for myelinating the axons of white matter fibre tracts.

To evaluate the relationship between white matter integrity and serum cortisol levels during a first depressive episode in drug-naive patients with MDD (MDD group) using a tract-based spatial statistics (TBSS) method.

The MDD group (n = 29) and a healthy control group (n = 47) underwent diffusion tensor imaging (DTI) scans and an analysis was conducted using TBSS. Morning blood samples were obtained from both groups for cortisol measurement.

Compared with the controls, the MDD group had significantly reduced fractional anisotropy values (P<0.05, family-wise error (FWE)-corrected) in the inferior fronto-occipital fasciculus, uncinate fasciculus and anterior thalamic radiation. The fractional anisotropy values of the inferior fronto-occipital fasciculus, uncinate fasciculus and anterior thalamic radiation had significantly negative correlations with the serum cortisol levels in the MDD group (P<0.05, FWE-corrected).

Our findings indicate that the elevated cortisol levels in the MDD group may injure the white matter integrity in the frontal–subcortical and frontal–limbic circuits.

Randomised studies examining the effect on patients of training professionals in adherence to suicide guidelines are scarce.

To assess whether patients benefited from the training of professionals in adherence to suicide guidelines.

In total 45 psychiatric departments were randomised (Dutch trial register: NTR3092). In the intervention condition, all staff in the departments were trained with an e-learning supported train-the-trainer programme. After the intervention, patients were assessed at admission and at 3-month follow-up. Primary outcome was change in suicide ideation, assessed with the Beck Scale for Suicide Ideation.

For the total group of 566 patients with a positive score on the Beck Scale for Suicide Ideation at baseline, intention-to-treat analysis showed no effects of the intervention on patient outcomes at 3-month follow-up. Patients who were suicidal with a DSM-IV diagnosis of depression (n = 154) showed a significant decrease in suicide ideation when treated in the intervention group. Patients in the intervention group more often reported that suicidality was discussed during treatment.

Overall, no effect of our intervention on patients was found. However, we did find a beneficial effect of the training of professionals on patients with depression.

Cognitive–behavioural therapy is efficacious in the treatment of major depressive disorder but response rates are still far from satisfactory.

To better understand brain responses to individualised emotional stimuli and their association with outcome, to enhance treatment.

Functional magnetic resonance imaging data were collected prior to individual psychotherapy. Differences in brain activity during passive viewing of individualised self-critical material in 23 unmedicated out-patients with depression and 28 healthy controls were assessed. The associations between brain activity, cognitive and emotional change, and outcome were analysed in 21 patients.

Patients showed enhanced activity in the amygdala and ventral striatum compared with the control group. Non-response to therapy was associated with enhanced activity in the right amygdala compared with those who responded, and activity in this region was negatively associated with outcome. Emotional but not cognitive changes mediated this association.

Amygdala hyperactivity may lessen symptom improvement in psychotherapy for depression through attenuating emotional skill acquisition.

Adjunctive antidepressant therapy is commonly used to treat acute bipolar depression but few studies have examined this strategy.

To examine the efficacy of agomelatine v. placebo as adjuncts to lithium or valproate in bipolar depression.

Patients who were currently depressed despite taking lithium or valproate for at least 6 weeks were randomised to treatment with agomelatine (n = 172) or placebo (n = 172) for 8 weeks of acute therapy and 44 weeks of continuation therapy (trial registration: ISRCTN28588282).

No significant differences in improvement of depressive symptoms were observed between the two groups either at 8 weeks or 52 weeks on the primary efficacy measure of change in Montgomery–Åsberg Depression Rating Scale scores from baseline to end-point. Adverse events including switches into mania/hypomania were low and similar in both groups.

Agomelatine adjunctive therapy was not superior to placebo adjunctive therapy for acute bipolar depression.

Presentation at an accident and emergency (A&E) department is a key opportunity to engage with a young person who self-harms. The needs of this vulnerable group and their fears about presenting to healthcare services, including A&E, are poorly understood.

To examine young people's perceptions of A&E treatment following self-harm and their views on what constitutes a positive clinical encounter.

Secondary analysis of qualitative data from an experimental online discussion forum. Threads selected for secondary analysis represent the views of 31 young people aged 16–25 with experience of self-harm.

Participants reported avoiding A&E whenever possible, based on their own and others' previous poor experiences. When forced to seek emergency care, they did so with feelings of shame and unworthiness. These feelings were reinforced when they received what they perceived as punitive treatment from A&E staff, perpetuating a cycle of shame, avoidance and further self-harm. Positive encounters were those in which they received ‘treatment as usual’, i.e. non-discriminatory care, delivered with kindness, which had the potential to challenge negative self-evaluation and break the cycle.

The clinical needs of young people who self-harm continue to demand urgent attention. Further hypothesis testing and trials of different models of care delivery for this vulnerable group are warranted.

Mindfulness-based cognitive therapy (MBCT) and maintenance antidepressant medication (mADM) both reduce the risk of relapse in recurrent depression, but their combination has not been studied.

To investigate whether MBCT with discontinuation of mADM is non-inferior to MBCT+mADM.

A multicentre randomised controlled non-inferiority trial (ClinicalTrials.gov: NCT00928980). Adults with recurrent depression in remission, using mADM for 6 months or longer (n = 249), were randomly allocated to either discontinue (n = 128) or continue (n = 121) mADM after MBCT. The primary outcome was depressive relapse/recurrence within 15 months. A confidence interval approach with a margin of 25% was used to test non-inferiority. Key secondary outcomes were time to relapse/recurrence and depression severity.

The difference in relapse/recurrence rates exceeded the non-inferiority margin and time to relapse/recurrence was significantly shorter after discontinuation of mADM. There were only minor differences in depression severity.

Our findings suggest an increased risk of relapse/recurrence in patients withdrawing from mADM after MBCT.