Predicting transitions to psychosis is difficult. Neuropsychology might facilitate predictions.

To report preliminary data on self-perceived and objectively measurable neurocognition in prodromal patients of the first German early recognition centre.

Subjective neuropsychological disturbances were assessed in 51 patients with potentially prodromal symptoms of schizophrenia. Initial neurocognitive functioning was compared with matched normals and patients with schizophrenia.

Self-perceived deficits mostly concerned perception, cognition and stress reactivity. Five transitions happened during the 15-month follow-up. Recently emerging or intensifying deficits were to some extent predictive of transition. Persons at risk performed worse than controls on objectively measured verbal capacity, attention and memory functions.

Neuropsychological deficits, either self-perceived or objectively measured, characterise persons at risk for schizophrenia and may contribute to predicting transitions.

Many studies have demonstrated early generalised cognitive impairment in schizophrenia.

To examine executive function in first-episode schizophrenia, characterise the nature of the impairment and specify any relationships with symptoms and duration of untreated psychosis (DUP).

Patients (n=136) and normal controls (n=81) were assessed with the Cambridge Automated Neuropsychological Test Battery, National Adult Reading Test IQ, and Scales for the Assessment of Positive and Negative Symptoms.

Memory and executive impairments in patients were independent of IQ level. Spatial working memory was impaired because of inadequate strategy use. On a planning task, patients showed reduced planning times and suboptimal problem-solving. On an attentional set-shifting task, 75% of patients were able to perform an extra-dimensional shift thought to be a core attribute of prefrontal cortex function. Those who failed had significantly longer DUP.

Prefrontal cortex function deteriorates at the onset of psychosis and continues to worsen over time.

Outcomes research involves the secondary analysis of data collected routinely by clinical services, in order to judge the effectiveness of interventions and policy initiatives. It permits the study of large databases of patients who are representative of ‘real world’ practice. However, there are potential problems with this observational design.

To establish the strengths and limitations of outcomes research when applied in mental health.

A systematic review was made of the application of outcomes research in mental health services research.

Nine examples of outcomes research in mental health services were found. Those that used insurance claims data have information on large numbers of patients but use surrogate outcomes that are of questionable value to clinicians and patients. Problems arise when attempting to adjust for important confounding variables using routinely collected claims data, making results difficult to interpret.

Outcomes research is unlikely to be a quick or cheap means of establishing evidence for the effectiveness of mental health practice and policy.

Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.

To estimate rates of fatal and non-fatal repetition of self-harm.

A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.

Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.

After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.

The efficacies of second-generation antipsychotic medications in reducing symptoms are reasonably well-documented, but their effects on cognition are less clearly understood.

To undertake an interim analysis of an open label, 2-year study examining the effects of quetiapine on cognition in patients with a first episode of schizophrenia and related disorders.

Cognitive testing was performed before quetiapine was initiated and repeated after 3, 6 and 12 months of treatment. To date, 13 patients have been fully assessed (mean dose 517.9 mg/day; s.d.=225.8).

Statistically significant improvement was noted on measures of attention (Continuous Performance Test; CPT), verbal productivity (Verbal Fluency Test) and executive function (Object Alternation Test) after 6 and 12 months of treatment. For the CPT, improvement was also noted after 3 months of treatment.

During treatment for 1 year with quetiapine, cognitive performance was improved in young patients with psychosis. Continued controlled investigations of the effects of quetiapine on cognition are desirable.

Evidence on the impact of case management is contradictory.

To discuss two different systematic reviews (one conducted by the authors and one conducted through the Cochrane collaboration) that came to contradictory conclusions about the impact of case management in mental health services.

We summarised the findings of the two reviews with respect to case management effectiveness, examined key methodological differences between the two approaches and discuss the impact of these on the validity of the results.

The differences in conclusions between the two reviews result from the differences in inclusion criteria, namely non-randomised trials, data from unpublished scales and data from variables with skewed distributions. The theoretical and empirical effects of these are discussed.

Systematic reviewers may face a trade-off between the application of strict criteria for the inclusion of studies and the amount of data available for analysis and hence statistical power. The available research suggests that case management is generally effective.

About 30% of people with depression do not respond to an antidepressant at the recommended dose and can be described as having treatment-refractory depression.

To summarise the findings from all randomised controlled trials (RCTs) that have assessed the efficacy of a pharmacological or psychological intervention for treatment-refractory depression.

We used a systematic search strategy to identify RCTs that included adults aged 18–75 years with a diagnosis of unipolar depression that had not responded to a 4-week course of a recommended dose of an antidepressant.

We identified 16 RCTs. None of the included trials assessed the efficacy of psychotherapy. All the trials were too small to detect an important clinical response. We found only two trials on lithium augmentation, which randomised 50 subjects in total.

There is little evidence to guide the management of depression that has not responded to a course of antidepressants. Treatment-refractory depression is an important public health problem and large pragmatic trials are needed to inform clinical practice.

Findings from neuroimaging studies complement our understanding of the wide-ranging neurobiological changes in trauma survivors who develop post-traumatic stress disorder (PTSD).

To determine whether neuroimaging studies had identified structural and functional changes specific to PTSD.

A review of all functional and structural neuroimaging studies of subjects with PTSD was carried out. Studies were identified using general medical and specific traumatic stress databases and paper searches of current contents and other secondary sources.

The most replicated structural finding is hippocampal volume reduction, which may limitthe proper evaluation and categorisation of experience. Replicated localised functional changes include increased activation ofthe amygdala after symptom provocation (which may reflect its role in emotional memory) and decreased activity of Broca's area at the same time (which may explain the difficulty patients have in labelling their experiences).

Evidence from neuroimaging studies has suggested areas ofthe brain that may be damaged by psychological trauma. The clinical implications ofthese neuroimaging findings need to be investigated further because they challenge traditional therapeutic approaches.

It is perceived that North American home treatment studies reveal greater success in reducing days in hospital than do European studies. There are difficulties in extrapolating findings internationally.

We aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital.

The results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted.

Most of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations.

North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.

The Department of Health and UK funding bodies have suggested that clinical academics work closely with mental health service users in research projects. Although there are helpful guidelines on the issues that have to be dealt with, there have been few examples of how this partnership research might be undertaken.

To illustrate the challenges in joint research projects.

We subjected the process of user involvement to ten questions which arose in the development of a joint research project. The answers are an amalgamation of the user and clinical researcher considerations and are affected by hindsight.

The involvement of the user-researcher changed the focus of the study and its design and content. More attention was paid to the intervention itself and the way in which it was delivered. This process increased the amount of time taken to carry out and write up the project as well as incurring financial costs for user consultation payments and dissemination.

This experience has clarified the contribution that users can make, for example by raising new research questions, by ensuring interventions are kept ‘user friendly’, and the selection of outcome measures.

Following the closure of asylums and widespread changes in the population distribution of people with learning disabilities, there has been little investigation of changing expenditure requirements of health authorities in England.

To compare expenditure on learning disability health services across England with the burden of services regionally, as estimated by numbers of people with learning disabilities.

A national database was set up using data from the National Audit Commission and the Department of Health. The spend/burden ratio was calculated and correlation tests for likely causes of inequality were applied.

There is widespread discrepancy from the median spend/burden ratio of £10 260 per person with learning disability. There is a positive correlation between ratios and levels of net exports of people funded by their local authority social services to reside ‘out of area’. Comparative underspending occurs in rural areas.

There are inequalities in levels of spending on learning disability services. Comparison of regions suggests resources may not be allocated fairly. Health authorities should ensure that population increases are mirrored by appropriate adjustments in expenditure.

In England and Wales, persons of African–Caribbean origin are more likely to be both imprisoned and admitted to secure hospitals.

To estimate population-based rates of imprisonment in different ethnic groups, and compare criminal behaviour and psychiatric morbidity.

We examined Home Office data on all persons in prison, and carried out a two-stage cross-sectional survey of 3142 remanded and sentenced, male and female, prisoners in all penal establishments in England and Wales in 1997.

We confirmed high rates of imprisonment for Black people and lower rates for South Asians. Different patterns of offending and lower prevalence of psychiatric morbidity were observed in Black prisoners.

Despite increased risks of imprisonment, African–Caribbeans show less psychiatric morbidity than White prisoners. This contrasts with the excess of African–Caribbeans in secure hospitals, an inconsistency possibly in part due to the effects of ethnic groups on admission procedures.

There is evidence that offenders consume diets lacking in essential nutrients and this could adversely affect their behaviour.

To test empirically if physiologically adequate intakes of vitamins, minerals and essential fatty acids cause a reduction in antisocial behaviour.

Experimental, double-blind, placebo-controlled, randomised trial of nutritional supplements on 231 young adult prisoners, comparing disciplinary offences before and during supplementation.

Compared with placebos, those receiving the active capsules committed an average of 26.3% (95% CI 8.3-44.33%) fewer offences (P=0.03, two-tailed). Compared to baseline, the effect on those taking active supplements for a minimum of 2 weeks (n=172) was an average 35.1% (95% CI 16.3-53.9%) reduction of offences (P < 0.001, two-tailed), whereas placebos remained within standard error.

Antisocial behaviour in prisons, including violence, are reduced by vitamins, minerals and essential fatty acids with similar implications for those eating poor diets in the community.

An association between stressful job conditions and depressive symptoms has been reported. This association could be explained by personality traits.

To examine the relationship between psychosocial factors at work and changes in depressive symptoms, taking into account personality traits.

The role of occupational characteristics, psychosocial stress and personality traits in predicting an increase of depressive symptoms was evaluated in 7729 men and 2790 women working at the French National Electricity and Gas Company, with a 3-year follow-up.

In men, high decision latitude was predictive of a decrease in the Centre for Epidemiologic Studies — Depression scale (CES-D) scores. In both genders, high job demands and low social support at work were predictive of increased scores, irrespective of personality traits and covariates.

Adverse psychosocial work conditions are predictors of depressive symptom worsening, independent of personality traits.