Individuals in lower socio-economic groups have an increased prevalence of common mental disorders.

To investigate the longitudinal association between socio-economic position and common mental disorders in a general population sample in the UK.

Participants (n=2406) were assessed at two time points 18 months apart with the Revised Clinical Interview Schedule. The sample was stratified into two cohorts according to mental health status at baseline.

None of the socio-economic indicators studied was significantly associated with an episode of common mental disorder at follow-up after adjusting for baseline psychiatric morbidity. The analysis of separate diagnostic categories showed that subjective financial difficulties at baseline were independently associated with depression at follow-up in both cohorts.

These findings support the view that apart from objective measures of socio-economic position, more subjective measures might be equally important from an aetiological or clinical perspective.

A higher risk of suicide has been associated with low birth weight in one study, but not yet replicated. Higher birth order has been associated with self-harm, but not with suicide.

To examine the relationship between perinatal circumstances and subsequent young adult suicide in Scotland.

Using linked data from the Scottish Morbidity Record and Scottish death records, a birth cohort of 1 061 830 people was followed-up for a mean of 25.1 years. Data were analysed using Cox regression.

Higher maternal parity, younger maternal age (<25 years), non-professional parental occupations and low birth weight (<2500 g) were independently associated with higher suicide risk of offspring as young adults. There was no independent association with gestational age.

Our findings provide support for the influence of maternal circumstance and foetal experience on subsequent mental health.

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.

Routine use of standardised outcome measures is not universal.

To evaluate the effectiveness of standardised outcome assessment.

A randomised controlled trial, involving 160 representative adult mental health patients and paired staff (ISRCTN16971059). The intervention group (n=101) (a) completed monthly postal questionnaires assessing needs, quality of life, mental health problem severity and therapeutic alliance, and (b) received 3-monthly feedback. The control group (n=59) received treatment as usual.

The intervention did not improve primary outcomes of patient-rated unmet need and of quality of life. Other subjective secondary outcome measures were also not improved. The intervention reduced psychiatric inpatient days (3.5 v. 16.4 mean days, bootstrapped 95% CI 1.6-25.7), and hence service use costs were £2586 (95% CI 102-5391) less for intervention-group patients. Net benefit analysis indicated that the intervention was cost-effective.

Routine use of outcome measures as implemented in this study did not improve subjective outcomes, but was associated with reduced psychiatric inpatient admissions.

There is equivocal evidence of the effectiveness of adherence therapy in improving treatment adherence and clinical outcomes for people with schizophrenia.

To evaluate the effectiveness of adherence therapy in improving quality of life for people with schizophrenia.

A 52-week, single-blind, multicentre randomised controlled trial of the effectiveness of adherence therapy. Participants were individually randomised to receive eight sessions of adherence therapy or health education. Assessments were undertaken at baseline and at 52-week follow-up.

Adherence therapy was no more effective than health education in improving quality of life.

This effectiveness trial provides evidence for the lack of effect of adherence therapy in people with schizophrenia with recent clinical instability, treated in ordinary clinical settings.

Well-designed prospective studies of substance misuse in first-episode psychosis can improve our understanding of the risks associated with comorbid substance misuse and psychosis.

To examine the potential effects of substance misuse on in-patient admission and remission and relapse of positive symptoms in first-episode psychosis.

The study was a prospective 15-month follow-up investigation of 103 patients with first-episode psychosis recruited from three mental health services.

Substance misuse was independently associated with increased risk of in-patient admission, relapse of positive symptoms and shorter time to relapse of positive symptoms after controlling for potential confounding factors. Substance misuse was not associated with remission or time to remission of positive symptoms. Heavy substance misuse was associated with increased risk of in-patient admission, relapse and shorter time to relapse.

Substance misuse is an independent risk factor for a problematic recovery from first-episode psychosis.

No ecological studies have examined the relationship between area characteristics, individual characteristics and self-harm repetition.

To investigate the association between area-level factors and incidence and repetition of self-harm, and to identify which area-level factors are independently associated with repetition after adjustment for individual factors.

Prospective cohort study using the Manchester Self-Harm database. Adults who were resident in Manchester and presented to an emergency department following self-harm between 1997 and 2002 were included (n=4743). The main outcome measure was repeat self-harm within 6 months of the index episode.

Four individual factors (previous self-harm, previous psychiatric treatment, employment status, marital status) and one area-based factor (proportion of individuals who were of White ethnicity) were independently associated with repetition.

Repetition of self-harm may be more strongly related to individual factors than to area characteristics. We need to better understand the processes underlying ecological associations with suicidal behaviour before embarking on area-based interventions.

Causal relationships between vascular factors and late-life depression are controversial.

To investigate prospective associations between risk factors for vascular disease and incidence of late-life depression.

Of 661 community participants aged 65 years or over, without depression at baseline, 521 (79%) were re-evaluated 2 years later. At baseline and follow-up, a diagnostic interview for depression was carried out and information on vascular status, disability and cognitive function was gathered.

Pre-existing heart disease, incident stroke and lower baseline high-density lipoprotein cholesterol level were significantly associated with incidence of late-life depression, independently of disability and cognitive function.

These results provide some support for a vascular aetiology of late-life depression. However, important risk factors for cerebrovascular disease such as hypertension and diabetes were not implicated, and the associations with lipid levels might still be explained by affective states earlier in life.

Sub-syndromal symptoms in bipolar disorder impair functioning and diminish quality of life.

To examine factors associated with time spent with sub-syndromal symptoms and to characterise how these symptoms influence outcomes.

In a double-blind randomised maintenance trial, patients received either olanzapine or lithium monotherapy for 1 year. Stepwise logistic regression models were used to identify factors that were significant predictors of percentage time spent with sub-syndromal symptoms. The presence of sub-syndromal symptoms during the first 8 weeks was examined as a predictor of subsequent relapse.

Presence of sub-syndromal depressive symptoms during the first 8 weeks significantly increased the likelihood of depressive relapse (relative risk 4.67, P<0.001). Patients with psychotic features and those with a greater number of previous depressive episodes were more likely to experience sub-syndromal depressive symptoms (RR=2.51, P<0.001 and RR=2.35, P=0.03 respectively).

These findings help to identify patients at increased risk of affective relapse and suggest that appropriate therapeutic interventions should be considered even when syndromal-level symptoms are absent.

Evaluation of individuals at high genetic risk of schizophrenia is a powerful method for identifying precursors of the illness.

To identify aspects of personality, psychopathology and social development that differentiate high-risk and control individuals.

Adolescent and young-adult first-degree relatives (n=35) of people with schizophrenia or schizoaffective disorder and a control group (n=55) were compared on 36 measures at baseline of a longitudinal study Measures differentiating high-risk and control participants were related to four genetic loading indices.

High-risk participants older than 17 years showed more physical anhedonia, less positive involvement with peers and more problems with peers, siblings and the opposite gender. Older high-risk individuals also were less cooperative, less self-directed and less reward-dependent. Problems with peers and the opposite gender, as well as reward dependence, were related linearly to genetic loading.

Alterations in personality traits and social development are present in high-risk individuals, and may be markers for genetic liability toward the illness.

There has been controversy as to whether early intervention in psychosis can improve the outcome of the disorder.

To establish if there is an association between duration of untreated psychosis and the 4-year outcome of persons with a first episode of psychosis.

Prospective naturalistic follow-up study of the outcome of consecutive first presentations with DSM–IV psychosis attending a community-based psychiatric service.

A longer duration of untreated psychosis was associated with a significantly poorer functional and symptomatic outcome 4 years later. For schizophrenia and schizophreniform disorder, each increment in duration of untreated psychosis was associated with a 7.8 point decrease in global functioning and an increase in positive symptoms scores by 1.9 points.

This study extends the findings of short-term follow-up studies by confirming an association between duration of untreated psychosis and ‘midterm’ outcome.

Investigating the relationship between premorbid functioning and treatment response in schizophrenia is relevant to understanding the illness and predicting treatment outcomes.

To examine the relationship between premorbid characteristics and treatment response of people with recent-onset schizophrenia.

Data came from a large, double-blind trial of recent-onset psychosis treated with a flexible dose of risperidone or haloperidol. Median treatment length was 206 days. Premorbid functioning was categorised using the Cannon-Spoor Premorbid Adjustment Scale.

There were significant differences between the premorbid groups on change on the Positive and Negative Syndrome Scale, Clinical Global Impression severity and cognitive functioning and Extrapyramidal Symptoms Rating Scale. Patients in the ‘stable–good’ premorbid group (n=251) improved more than those in the ‘stable–poor’ (n=198) and ‘declining’ (n=81) groups. The ‘stable–good’ group received the lowest doses of antipsychotic and had the least extrapyramidal symptoms. Patients in the declining’ group had the highest dosages and the most extrapyramidal symptoms.

In first-episode psychosis good premorbid functioning is associated with better response to treatment and fewer extrapyramidal symptoms.

Few studies have examined the relative risks of switching into hypomania or mania associated with second-generation antidepressant drugs in bipolar depression.

To examine the relative acute effects of bupropion, sertraline and venlafaxine as adjuncts to mood stabilisers.

In a 10-week trial, participants receiving out-patient treatment for bipolar disorder (stratified for rapid cycling) were randomly treated with a flexible dose of one of the antidepressants, or their respective matching placebos, as adjuncts to mood stabilisers.

A total of 174 adults with bipolar disorder I, II or not otherwise specified, currently in the depressed phase, were included. All three antidepressants were associated with a similar range of acute response (49–53%) and remission (34–41%). There was a significantly increased risk of switches into hypomania or mania in participants treated with venlafaxine compared with bupropion or sertraline.

More caution appears indicated in the use of venlafaxine rather than bupropion or sertraline in the adjunctive treatment of bipolar depression, especially if there is a prior history of rapid cycling.

Depression rises markedly in adolescence, a time when increased and new genetic influences have been reported.

To examine ‘new’ and ‘stable’ genetic and environmental factors on depressive symptoms in adolescence and young adulthood.

A questionnaire survey investigated a sample of twin and sibling pairs at three time points over an approximately 3-year period. Over 1800 twin and sibling pairs reported depressive symptoms at the three time points. Data were analysed using multivariate genetic models.

Depressive symptoms at all time points were moderately heritable with substantial non-shared environmental contributions. Wave I genetic factors accounted for continuity of symptoms at waves 2 and 3. ‘New’ genetic effects at wave 2 also influenced wave 3 symptoms. New non-shared environmental influences emerged at each time point.

New genetic and environmental influences may explain age-related increases in depression across development.

The outcome and impact of major depression in developing countries are not clear.

To describe the outcome of major depression and compare the disability and patterns of service use among different outcome groups.

In a case cohort study, nested within a population-based survey of 68 000 participants using the Composite International Diagnostic Interview (CIDI), 300 participants were randomly selected from those with current major depression and 300 from those with no lifetime history. Participants were re-interviewed after 18–62 months to ascertain current diagnosis, psychological symptoms, disability and use of health services.

Of participants with major depression at baseline 26% also met criteria for major depression at follow up. Mortality ratio standardised for age and gender was 3.55 (95% CI 1.97 to 6.39). All indices of measure of disability were significantly higher in the persistently depressed group compared with the completely recovered group. Participants who had recovered partially resembled participants with persistent depression. Two-thirds of those with persistent depression had not sought any help.

Major depression was associated with mortality and disability Those with residual symptoms remained disabled. Help-seeking was unusual.

The majority of memory impairment studies in schizophrenia are cohort studies using laboratory-based tests, which make it difficult to estimate the true extent and relevance of memory impairment in patients with schizophrenia in the community.

To examine the extent of memory impairment in community-based patients with schizophrenia using a clinically relevant test.

All patients with schizophrenia (n = 190) in one catchment area were identified, of whom 133 were potentially eligible for the study; 73 patients volunteered to take part. They were assessed using the Rivermead Behavioural Memory Test (RBMT), the National Adult Reading Test, the Positive and Negative Syndrome Scale, the Health of the Nation Outcome Scales and the Office for National Statistics Classification of Occupation. Their performance on the memory test was compared with that of matched controls (n=71).

Patients as a group performed significantly worse (P < 0.001) than controls on the RBMT. Using the RBMT normative scores, 81% of patients were found to have impaired memory compared with 28% of controls.

Using a clinically relevant test, the majority of community-based patients with schizophrenia may have memory impairment.

Dimensional structures are established for many psychiatric diagnoses, but dimensions have not been compared between diagnostic groups.

To examine the structure of dimensions in psychosis, to analyse their correlations with disease characteristics and to assess the relative contribution of dimensions v. diagnosis in explaining these characteristics.

Factor analysis of the OPCRIT items of 191 Maudsley Family Study patients with schizophrenia, mood disorders with psychosis, schizoaffective disorder, and other psychotic illnesses, followed by regression of disease characteristics from factor scores and diagnosis.

Five factors were identified (mania, reality distortion, depression, disorganisation, negative); all were more variable in schizophrenia than in affective psychosis. Mania was the best discriminator between schizophrenia and affective psychosis; the negative factor was strongly correlated with poor premorbid functioning, insidious onset and worse course. Dimensions explained more of the disease characteristics than did diagnosis, but the explanatory power of the latter was also high.

Kraepelinian diagnostic categories suffice for understanding illness characteristics, but the use of dimensions adds substantial information.

The MacArthur Violence Risk Assessment Study (MacVRAS) in the USA provided strong evidence to support an actuarial approach in community violence risk assessment.

To examine the predictive accuracy of the MacVRAS measures, in addition to structured professional judgement, in a UK sample of patients discharged from in-patient care in the north-west of England.

A prospective study of 112 participants assessed pre-discharge and followed up at 24 weeks post-discharge. Pre-discharge measures were compared with prevalence of violent behaviour to determine predictive validity of risk factors.

Historical measures of risk and measures of psychopathy, impulsiveness and anger were highly predictive of community violence. The more dynamic clinical and risk management factors derived from structured professional judgement (rated at discharge) added significant incremental validity to the historical factors in predicting community violence.

Although static measures of risk relating to past history and personality make an important contribution to assessment of violence risk, consideration of current dynamic factors relating to illness and risk management significantly improves predictive accuracy.

Earlier studies have indicated poor long-term outcomes for patients with anorexia nervosa.

To study health and social outcomes of adolescent in-patients with anorexia nervosa in relation to prognostic factors.

A register study based on socio-economic and health data was conducted for a national cohort of female residents in Sweden born between 1968 and 1977, including 748 in-patients with anorexia nervosa.

At follow-up 9–14 years after hospital admission, 8.7% of patients with anorexia nervosa had persistent psychiatric health problems demanding hospital care and 21.4% were dependent on society for their main income; the stratified relative risks were 5.8 (95% CI 4.7–7.6) and 2.6 (2.3–3.0) respectively compared with the general female population. The mortality rate for patients with anorexia nervosa was 1.2% and the stratified risk ratio for maternity was 0.6 (95% CI 0.5–0.7). Long duration of hospital care and psychiatric comorbidity were predictors of persistent psychiatric problems and financial dependency on society.

The outcome in this cohort of adolescent in-patients with anorexia nervosa was considerably better than that reported in previous studies.

Little is known about the medium-term durability of cognitive–behavioural therapy (CBT) in a community sample of people with schizophrenia.

To investigate whether brief CBT produces clinically important outcomes in relation to recovery, symptom burden and readmission to hospital in people with schizophrenia at 1-year follow-up.

Participants (336 of 422 randomised at baseline) were followed up at a mean of 388 days (s.d. =53) by raters masked to treatment allocation (CBT or usual care).

At 1-year follow-up, participants who received CBT had significantly more insight (P=0.021) and significantly fewer negative symptoms (P=0.002). Brief therapy protected against depression with improving insight and against relapse; significantly reduced time spent in hospital for those who did relapse and delayed time to admission. It did not improve psychotic symptoms or occupational recovery, nor have a lasting effect on overall symptoms or depression at follow-up.

Mental health nurses should be trained in brief CBT for schizophrenia to supplement case management, family interventions and expert therapy for treatment resistance.