Ethnic density, nicotine dependence and patient-reported outcomes in psychosis

In the Journal this month, the complex concept of ethnic density in relation to psychosis risk in ethnic minority groups is explored by Das-Munshi et al (pp. ), utilising data from the Ethnic Minorities Psychiatric Illness Rates in the Community (EMPIRIC) survey. The authors confirmed that those living in areas of low own-group ethnic density were more likely to report psychotic experiences but they found that the association was most marked for Indian people and less marked for those of African–Caribbean ethnicity. It was also apparent that those living in areas of lower own-group density suffered more discrimination, poorer social support and more chronic strains. In a linked editorial, van Os (pp. ) highlights the evidence for ecological effect modification, which appears to characterise known patterns of increased risk in psychosis associated with ethnic minority status, and calls for future research aimed at understanding how the social environment interacts with personal characteristics to increase risk for psychosis, particularly research that is ‘diagnosis assumption-free’.

The elevated prevalence of smoking among those with psychosis is well known but the relationship between smoking and clinical factors is not well established. In a geographically defined population of individuals with schizophrenia, Krishnadas et al (pp. ) confirmed that smoking prevalence was approximately twice that of the general population, and these rates appear to have changed little over time. The authors also found an association between severe nicotine dependence and positive symptom scores, whereas those with mild–moderate dependence had higher negative symptom scores. The authors comment on the need for longitudinal studies to establish causality given the cross-sectional nature of their study.

Across mental health services in general, and including those providing care to individuals with psychosis, patient-reported outcomes (PROs) have become increasingly popular. Reininghaus & Priebe (pp. ) report on a conceptual and methodological review of PRO measurement in psychosis, focusing on the four most widely used PROs – treatment satisfaction, subjective quality of life, needs for care and quality of the therapeutic relationship. The authors found a lack of research focused on the methodological quality of measures and, among those existing studies, they found evidence of overlap between measures intended to address different PROs. The authors recommend use of short and distinct measures with clinical relevance and good psychometric properties.

Predicting and treating depression

Common genetic variants such as the BDNF Val/66/Met polymorphism are known to interact with environmental adversity to increase risk for depression. Given that individual differences in cortisol levels are also known to be associated with such risk, Herbert et al (pp. ) undertook to examine these factors in concert in a sample of premenopausal women. They found evidence of interaction between morning salivary cortisol levels and the polymorphism in relation to predicting new depressive episodes.

Originally designed to prevent relapse/recurrence of depression, mindfulness-based cognitive therapy (MBCT) has been considered beneficial only to those with more than two prior depressive episodes. Concerned that such a view may not be evidence-based, Geschwind et al (pp. ) examined the efficacy of MBCT on reduction of residual depressive symptoms, comparing individuals who had experienced fewer than three with those who had experienced three or more prior depressive episodes. Superiority of MBCT to the control condition was found across both subgroups with no interaction apparent between treatment status and subgroup. In a linked editorial, Williams & Ridgway (pp. ) highlight the challenges of offering this intensive intervention more widely and call for the development and testing of lower-intensity versions of the therapy.

Mental health in the context of conflict and humanitarian emergency

Two papers in the Journal this month focus on mental health needs in particularly challenging environments – pre- and post-conflict Nepal and humanitarian settings in both Jordan and Nepal. Kohrt et al (pp. ) analysed data from a prospective study examining depression and anxiety before and after the People's War in Nepal. The authors found evidence of an increase in both depression and anxiety post-conflict but the former was not significant when adjustment was made for ageing. The increase in prevalence of anxiety was associated with conflict exposure but no particularly vulnerable demographic groups were identified. The authors conclude that the mental health impact of conflict exposure needs to be seen in the context of other psychiatric risk factors and that trajectories to different disorders may differ. In a linked editorial, Silove (pp. ) warns against focusing on a single diagnosis, namely post-traumatic stress disorder (PTSD), in relation to guiding the development of emergency programmes in conflict-affected societies and argues for a prioritisation of community-based interventions for those whom mental disorder undermines their capacity, and often the capacity of their family members, to survive in challenging post-conflict environments. Utilising data from Jordan (displaced Iraqi people) and Nepal (Bhutanese refugees), Jordans et al (pp. ) confirmed an association between past traumatic exposure and current distress but found that this was mediated by current perceived needs, particularly in the Jordanian sample. The authors conclude that attempts to mitigate the impact of trauma exposure in humanitarian settings must involve a focus not only on the trauma but on ongoing daily stressors.