Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched.

To explore short-term outcomes and costs of admission to alternative and standard services.

Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services.

All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12–2.86), TAG (difference 1.40, 95% CI 0.39–2.51) and GAF functioning (difference 4.15, 95% CI 1.08–7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK£3832 v. £9850). Standard services cost an additional £2939 per unit HoNOS improvement.

The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.

Law 180 eliminated psychiatric hospitals for the care of people with chronic psychosis in Italy. After 30 years, we review the consequences for the practice of psychiatry in Italy and parallels for England and Wales. We argue that the substitution of legal/political direction for clinical leadership means psychiatrists may cease to merit the privileges and responsibilities of being doctors.

Research findings have fuelled debate on the construct validity of post-traumatic stress disorder (PTSD). Accompanying these issues are competing suggestions to redefine PTSD's criteria, including a recent proposal by DSM–V committee members. We review various approaches to revising the PTSD diagnosis and conclude that proposed changes should be placed in the appendix that the DSM has used for experimental criteria sets.

Fatigue and common psychiatric symptoms – depression in particular – have consistently been found to be strongly associated. All have a negative impact on functional status, but evidence suggests that functional impairment is especially marked when they co-occur. Therefore, it is pertinent to understand the relationship between fatigue and depression.

Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions.

To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services.

Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission.

After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services.

Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

The National Institute for Health and Clinical Excellence (NICE) recently updated its guidance on managing depression, adding specific guidance for depression in people with physical illness. The guidance should help improve the targeting of treatments, although implementation of the guidance on depression in physical illness is challenging in the National Health Service (NHS) context of separate primary and secondary care services.

Two major approaches can be used for the up-coming revisions of DSM–V and ICD–10: an ‘iterative model’ in which incremental changes are made or a ‘paradigm shift model’ in which the existing approach is jettisoned in favour of a new nosological model. We explore each of these two approaches and conclude that although they both have strengths and limitations, our field is not currently ready for a paradigm shift.

The use of antipsychotics for the treatment of behavioural and psychological symptoms of dementia (BPSD) is controversial. Antipsychotics cause harm and evidence-based guidelines advise against their use. We argue that antipsychotics may be justified using a palliative model: by reducing severe distress in those whose life expectancy is short.

Meta-analyses on psychological treatment for depression in individuals with a somatic disease are limited to specific underlying somatic diseases, thereby neglecting the generalisability of the interventions.

To examine the effectiveness of cognitive–behavioural therapy (CBT) for depression in people with a diversity of somatic diseases.

Meta-analysis of randomised controlled trials evaluating CBT for depression in people with a somatic disease. Severity of depressive symptoms was pooled using the standardised mean difference (SMD).

Twenty-nine papers met inclusion criteria. Cognitive–behavioural therapy was superior to control conditions with larger effects in studies restricted to participants with depressive disorder (SMD =–0.83, 95% CI –1.36 to –0.31, P<0.001) than in studies of participants with depressive symptoms (SMD =–0.16, 95% CI –0.27 to –0.06, P = 0.001). Subgroup analyses showed that CBT was not superior to other psychotherapies.

Cognitive–behavioural therapy significantly reduces depressive symptoms in people with a somatic disease, especially in those who meet the criteria for a depressive disorder.

Treatment with antipsychotics seems to increase the risk of developing diabetes but the association is poorly characterised in clinical practice.

To investigate and characterise the incidence of diabetes for people treated with antipsychotic medication in clinical practice.

The study used the linkage of registers of all prescribed antipsychotics, antidiabetics and diagnoses of diabetes in Denmark during a period from 1996 to 2005 and identified all people treated with antipsychotics in Denmark and a random sample of about 30% of the total Danish population.

In total, 345 937 patients who purchased antipsychotics and 1 426 488 unexposed individuals were included in the study. Among the total population, 50 379 individuals subsequently developed incident diabetes. Compared with unexposed individuals, treatment with first- (rate ratio, RR = 1.53, 95% CI 1.49–1.56) as well as second-generation (RR = 1.32, 95% CI 1.22–1.42) antipsychotics was associated with increased risk of subsequent incident diabetes. The rate of incident diabetes varied substantially between individual second-generation antipsychotic drugs (olanzapine, risperidone clozapine compared with unexposed individuals: low to moderate rate ratio between 1.17 and 1.57; ziprasidone and sertindol: two or more times increased rate ratio; amisulpride, quetiapine and aripiprazole: no significantly increased rate ratio). For both first- and second-generation antipsychotics, the incidence of diabetes increased with the number of prescriptions. Additionally, the incidence of diabetes increased with the number of combined antipsychotic drugs.

In clinical practice, treatment with first- and second-generation antipsychotics is associated with an increased risk of developing incident diabetes with large differences between individual drugs. The risk increases with the duration of treatment and with polypharmacy of antipsychotic drugs.

Little is known about the preferences and experiences of people with mental illness in relation to residential alternatives to hospital.

To explore patients' subjective experiences of traditional hospital services and residential alternatives to hospital.

In-depth interviews were conducted with 40 purposively selected patients in residential alternative services who had previously experienced hospital in-patient stays. Transcripts were coded and analysed for thematic content.

Patients reported an overall preference for residential alternatives. These were identified as treating patients with lower levels of disturbance, being safer, having more freedom and decreased coercion, and having less paternalistic staff compared with traditional in-patient services. However, patients identified no substantial difference between their relationships with staff overall and the care provided between the two types of services.

For patients who have acute mental illness but lower levels of disturbance, residential alternatives offer a preferable environment to traditional hospital services: they minimise coercion and maximise freedom, safety and opportunities for peer support.

The EQ–5D is a widely used questionnaire for calculating quality-adjusted life-years (QALYs) for assessing cost-effectiveness in healthcare. It reflects the impact of common mental health conditions such as mild to moderate depression but seems to be more problematic for use in people with psychotic and severe and complex nonpsychotic disorders.