BJP Current News

This issue includes the findings from the largest randomised controlled trial ever conducted with bilateral, unilateral and bifrontal electroconvulsive therapy (ECT). The background to the study and its findings are discussed.

Background

It is not clear whether the effects of cognitive–behavioural therapy and other psychotherapies have been overestimated because of publication bias.

Aims

To examine indicators of publication bias in randomised controlled trials of psychotherapy for adult depression.

Method

We examined effect sizes of 117 trials with 175 comparisons between psychotherapy and control conditions. As indicators of publication bias we examined funnel plots, calculated adjusted effect sizes after publication had been taken into account using Duval & Tweedie’s procedure, and tested the symmetry of the funnel plots using the Begg & Mazumdar rank correlation test and Egger’s test.

Results

The mean effect size was 0.67, which was reduced after adjustment for publication bias to 0.42 (51 imputed studies). Both Begg & Mazumbar’s test and Egger’s test were highly significant (P<0.001).

Conclusions

The effects of psychotherapy for adult depression seem to be overestimated considerably because of publication bias.

Background

Legislation and practice of involuntary hospital admission vary substantially among European countries, but differences in outcomes have not been studied.

Aims

To explore patients’ views following involuntary hospitalisation in different European countries.

Method

In a prospective study in 11 countries, 2326 consecutive involuntary patients admitted to psychiatric hospital departments were interviewed within 1 week of admission; 1809 were followed up 1 month and 1613 3 months later. Patients’ views as to whether the admission was right were the outcome criterion.

Results

In the different countries, between 39 and 71% felt the admission was right after 1 month, and between 46 and 86% after 3 months. Females, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant.

Conclusions

International differences in legislation and practice may be relevant to outcomes and inform improvements in policies, particularly in countries with poorer outcomes.

Background

Adverse childhood experiences have been associated with a variety of mental health problems in adult life.

Aims

To examine whether this reported link between childhood experiences and mental health disorders in adult life applies in a Sub-Saharan African setting where cultural and family attributes may be different.

Method

A multistage random sampling was used in the Nigerian Survey of Mental Health and Well-Being (NSMHW) to select respondents for face-to-face interviews. Assessments of family-related adverse childhood experiences and lifetime mental health disorders were conducted with the Composite International Diagnostic Interview (CIDI 3.0).

Results

Almost half of the respondents had experienced an adverse childhood experience within the context of the family before they were 16 years of age. Associations between adverse childhood experiences and adult mental health disorders were few and were attenuated when clustering of adverse childhood experience and disorder comorbidities were accounted for. There was an elevated likelihood of adult substance use disorders among individuals who had experienced family violence and neglect or abuse. Parental psychopathology was associated with a significantly increased risk for developing mood disorders.

Conclusions

Adverse childhood experiences reflecting violence in the family, parental criminality and parental mental illness and substance misuse were more likely to have significant mental health consequences in adulthood.

Background

The relationship between partner alcohol use and violence as risk factors for poor mental health in women is unclear.

Aims

To describe partner-related and other psychosocial risk factors for common mental disorders in women and examine interrelationships between these factors.

Method

Data are reported on 821 women aged 18–49 years from a larger population study in north Goa, India. Logistic regression models evaluated the risks for women’s common mental disorders and tested for mediation effects in the relationship between partner alcohol use and these disorders.

Results

Excessive partner alcohol use increased the risk for common mental disorders two- to threefold. Partner violence and alcohol-related problems each partially mediated the association between partner excessive alcohol use and these mental disorders. Women’s own violence-related attitudes were also independently associated with them.

Conclusions

Partner alcohol use, partner violence and women’s violence-related attitudes must be addressed to prevent and treat common mental disorders in women.

Background

Only some women with recurrent major depressive disorder experience postnatal episodes. Personality and/or cognitive styles might increase the likelihood of experiencing postnatal depression.

Aims

To establish whether personality and cognitive style predicts vulnerability to postnatal episodes over and above their known relationship to depression in general.

Method

We compared personality and cognitive style in women with recurrent major depressive disorder who had experienced one or more postnatal episodes (postnatal depression (PND) group, n=143) with healthy female controls (control group, n=173). We also examined parous women with recurrent major depressive disorder who experienced no perinatal episodes (non-postnatal depression (NPND) group, n=131).

Results

The PND group had higher levels of neuroticism and dysfunctional beliefs, and lower self-esteem than the control group. However, there were no significant differences between the PND and NPND groups.

Conclusions

Established personality and cognitive vulnerabilities for depression were reported by women with a history of postnatal depression, but there was no evidence that any of these traits or styles confer a specific risk for the postnatal onset of episodes.

Background

Morphological abnormalities of the superior temporal gyrus have been consistently reported in schizophrenia, but the timing of their occurrence remains unclear.

Aims

To determine whether individuals exhibit superior temporal gyral changes before the onset of psychosis.

Method

We used magnetic resonance imaging to examine grey matter volumes of the superior temporal gyrus and its subregions (planum polare, Heschl’s gyrus, planum temporale, and rostral and caudal regions) in 97 antipsychotic-naive individuals at ultra-high risk of psychosis, of whom 31 subsequently developed psychosis and 66 did not, and 42 controls.

Results

Those at risk of psychosis had significantly smaller superior temporal gyri at baseline compared with controls bilaterally, without any prominent subregional effect; however, there was no difference between those who did and did not subsequently develop psychosis.

Conclusions

Our findings indicate that grey matter reductions of the superior temporal gyrus are present before psychosis onset, and are not due to medication, but these baseline changes are not predictive of transition to psychosis.

Background

Age at the first psychotic episode and an interval between the onset of epilepsy and that of psychosis reflect developmental processes of interictal psychosis. However, factors relating to these indices remain unknown.

Aims

To identify clinical variables that are associated with the timing of the development of interictal psychosis.

Method

In 285 adults with epilepsy with interictal psychosis, effects of epileptic (epilepsy type), organic (intellectual functioning) and genetic (family history of psychosis) variables on timing of the development of psychosis were examined.

Results

The mean interval between the onset of epilepsy and that of psychosis was 14.4 years. Some psychosis occurred within a few years of the first seizure. Generalised epilepsy, normal intellectual function and a positive family history of psychosis were associated with early onset of psychosis.

Conclusions

Early development of interictal psychosis in people with epilepsy may reflect other individual vulnerabilities to psychosis rather than epilepsy-related damage.

Background

The epidemiology of rapid-cycling bipolar disorder in the community is largely unknown.

Aims

To investigate the epidemiological characteristics of rapid-cycling and non-rapid-cycling bipolar disorder in a large cross-national community sample.

Method

The Composite International Diagnostic Interview (CIDI version 3.0) was used to examine the prevalence, severity, comorbidity, impairment, suicidality, sociodemographics, childhood adversity and treatment of rapid-cycling and non-rapid-cycling bipolar disorder in ten countries (n = 54 257).

Results

The 12-month prevalence of rapid-cycling bipolar disorder was 0.3%. Roughly a third and two-fifths of participants with lifetime and 12-month bipolar disorder respectively met criteria for rapid cycling. Compared with the non-rapid-cycling, rapid-cycling bipolar disorder was associated with younger age at onset, higher persistence, more severe depressive symptoms, greater impairment from depressive symptoms, more out-of-role days from mania/hypomania, more anxiety disorders and an increased likelihood of using health services. Associations regarding childhood, family and other sociodemographic correlates were less clear cut.

Conclusions

The community epidemiological profile of rapid-cycling bipolar disorder confirms most but not all current clinically based knowledge about the illness.

Background

Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements.

Aims

To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT.

Method

This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold.

Results

All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43–66%) with right unilateral, 61% with bifrontal (95% CI 50–71%) and 64% (95% CI 53–75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments.

Conclusions

Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Background

Attention-deficit hyperactivity disorder (ADHD) is recognised as a common, disabling condition. Little information is available regarding the long-term outcomes for individuals with ADHD in the UK.

Aims

To examine the 5-year outcome for a UK cohort of children with diagnosed, treated ADHD and identify whether maternal and social factors predict key outcomes.

Method

One hundred and twenty-six school-aged children (mean age 9.4 years, s.d. = 1.7) diagnosed with ADHD were reassessed 5 years later during adolescence (mean age 14.5 years, s.d. = 1.7) for ADHD, conduct disorder and other antisocial behaviours.

Results

Most adolescents (69.8%) continued to meet full criteria for ADHD, were known to specialist services and exhibited high levels of antisocial behaviour, criminal activity and substance use problems. Maternal childhood conduct disorder predicted offspring ADHD continuity; maternal childhood conduct disorder, lower child IQ and social class predicted offspring conduct disorder symptoms.

Conclusions

The treatment and monitoring of ADHD need to be intensified as outcomes are poor especially in offspring of mothers with childhood conduct disorder symptoms.

We conducted an exploratory controlled trial to examine the efficacy of restricting access to charcoal in preventing suicides from carbon monoxide poisoning by charcoal burning in Hong Kong. All charcoal packs were removed from the open shelves of major retail outlets in the intervention region for 12 months; in the control region, charcoal packs were displayed as usual. The suicide rate from charcoal burning was reduced by a statistically significant margin in the intervention region (P<0.05) but not in the control region. We observed no significant change in the suicide rate using other methods in either location.

Among those who present to the emergency department for self-harm, many will repeat. Self-harm repetition is an outcome of interest in both observational and intervention studies. However, few such studies analyse the number of repeat self-harm presentations. Here, hurdle models are introduced as a potentially useful statistical method for these analyses. Emergency department data from the Province of Ontario, Canada, are used to illustrate an example of implementing hurdle models and interpreting their results.