BJP Current News

Our ideas about the intrinsically pathological nature of hallucinations and delusions are being challenged by findings from epidemiology, neuroimaging and clinical research. Population-based studies using both self-report and interview surveys show that the prevalence of psychotic symptoms is far greater than had been previously considered, prompting us to re-evaluate these psychotic symptoms and their meaning in an evolutionary context. This non-clinical phenotype may hold the key to understanding the persistence of psychosis in the population. From a neuroscientific point of view, detailed investigation of the non-clinical psychosis phenotype should provide novel leads for research into the aetiology, nosology and treatment of psychosis.

In this issue, Zammit et al explore how five dichotomised risk factors work together to predict risk for non-affective psychosis in a large Swedish cohort. In this editorial, we review these findings, and comment on both the nature of additive v. multiplicative models and the meaning of statistical interactions.

Evidence-based mental healthcare is evolving rapidly. There is a need for well-tested and effective interventions that are suited to culturally diverse populations. This editorial considers the findings from the SITARA study. There are a substantial number of implications for research, policy and practice.

Background

Treatment of negative symptoms in chronic schizophrenia continues to be a major clinical issue.

Aims

To analyse the efficacy of add-on antidepressants for the treatment of negative symptoms of chronic schizophrenia.

Method

Systematic review and meta-analysis of randomised controlled trials comparing the effect of antidepressants and placebo on the negative symptoms of chronic schizophrenia, measured through standardised rating scales. Outcome was measured as standardised mean difference between end-of-trial and baseline scores of negative symptoms.

Results

There were 23 trials from 22 publications (n = 819). The antidepressants involved were selective serotonin reuptake inhibitors, mirtazapine, reboxetine, mianserin, trazodone and ritanserin; trials on other antidepressants were not available. The overall standardised mean difference was moderate (–0.48) in favour of antidepressants and subgroup analysis revealed significant responses for fluoxetine, trazodone and ritanserin.

Conclusions

Antidepressants along with antipsychotics are more effective in treating the negative symptoms of schizophrenia than antipsychotics alone.

Background

It is unclear whether altered hypothalamic–pituitary–adrenal (HPA) axis regulation, which frequently accompanies depression and anxiety disorders, represents a trait rather than a state factor.

Aims

To examine whether HPA axis dysregulation represents a biological vulnerability for these disorders, we compared cortisol levels in unaffected people with and without a parental history of depressive or anxiety disorders. We additionally examined whether possible HPA axis dysregulations resemble those observed in participants with depression or anxiety disorders.

Method

Data were from the Netherlands Study of Depression and Anxiety. Within the participants without a lifetime diagnoses of depression or anxiety disorders, three groups were distinguished: 180 people without parental history, 114 with self-reported parental history and 74 with CIDI-diagnosed parental history. These groups were additionally compared with people with major depressive disorder or panic disorder with agoraphobia (n = 1262). Salivary cortisol samples were obtained upon awakening, and 30, 45 and 60 min later.

Results

As compared with unaffected participants without parental history, unaffected individuals with diagnosed parental history of depression or anxiety showed a significantly higher cortisol awakening curve (effect size (d) = 0.50), which was similar to that observed in the participants with depression or anxiety disorders. Unaffected people with self-reported parental history did not differ in awakening cortisol levels from unaffected people without parental history.

Conclusions

Unaffected individuals with parental history of depression or anxiety showed a higher cortisol awakening curve, similar to that of the participants with depression or anxiety disorders. This suggests that a higher cortisol awakening curve reflects a trait marker, indicating an underlying biological vulnerability for the development of depressive and anxiety disorders.

Background

Antisocial personality disorder and psychopathy have been hypothesised to have a neurodevelopmental basis, but this proposition has not been formally tested.

Aims

This study tests the hypothesis that individuals with cavum septum pellucidum (CSP), a marker of limbic neural maldevelopment, will show higher levels of psychopathy and antisocial personality.

Method

Cavum septum pellucidum was assessed using anatomical magnetic resonance imaging in a community sample. Those with CSP (n = 19) were compared with those lacking CSP (n = 68) on antisocial personality, psychopathy and criminal offending.

Results

Those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls. The pervasiveness of this association was indicated by the fact that those lacking a diagnosis of antisocial personality disorder, but who were charged or convicted for an offence, had a more extensive CSP than non-antisocial controls. Results could not be attributed to prior trauma exposure, head injury, demographic factors or comorbid psychiatric conditions.

Conclusions

Our findings appear to be the first to provide evidence for a neurodevelopmental brain abnormality in those with antisocial personality disorder and psychopathy, and support the hypothesis that early maldevelopment of limbic and septal structures predisposes to the spectrum of antisocial behaviours.

Background

Current classifications of personality disorders do not classify severity despite clinical practice favouring such descriptions.

Aims

To assess whether an existing measure of severity of personality disorder predicted clinical pathology and societal dysfunction in a community sample.

Method

UK national epidemiological study in which personality status was measured using the screening version of the Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II) and reclassified to five levels using a modified severity index. Associations between levels of severity of personality pathology and social, demographic and clinical variables were measured.

Results

Of 8391 individuals interviewed and their personality status assessed, only a minority (n = 1933, 23%) had no personality pathology. The results supported the hypothesis. More severe personality pathology was associated incrementally with younger age, childhood institutional care, expulsion from school, contacts with the criminal justice system, economic inactivity, more Axis I pathology and greater service contact (primary care and secondary care, all P<0.001). Significant handicap was noted among people with even low levels of personality pathology. No differences contradicted the main hypothesis.

Conclusions

A simple reconstruction of the existing classification of personality disorder is a good predictor of social dysfunction and supports the development of severity measures as a critical requirement in both DSM–V and ICD–11 classifications.

Background

Epidemiological data on alcohol-induced psychotic disorder and delirium (alcohol-induced psychotic syndrome, AIPS) are scarce.

Aims

To investigate the epidemiology of AIPS, the risk factors for developing AIPS among people with alcohol dependence, and mortality associated with alcohol dependence with or without AIPS, in a sample drawn from the general population of Finland.

Method

A general population sample of 8028 persons were interviewed with the Composite International Diagnostic Interview and screened for psychotic disorders using multiple sources. Best-estimate diagnoses of psychotic disorders were made using the Structured Clinical Interview for DSM–IV Axis I Disorders and case notes. Data on hospital reatments and deaths were collected from national registers.

Results

The lifetime prevalence was 0.5% for AIPS and was highest (1.8%) among men of working age. Younger age at onset of alcohol dependence, low socioeconomic status, father’s mental health or alcohol problems and multiple hospital treatments were associated with increased risk of AIPS. Participants with a history of AIPS had considerable medical comorbidity, and 37% of them died during the 8-year follow-up.

Conclusions

Alcohol-induced psychotic disorder is a severe mental disorder with poor outcome.

Background

For complex multifactorial diseases it seems likely that co-exposure to two risk factors will show a greater than additive relationship on disease risk.

Aims

To test whether greater than additive relationships occur between risk factors for psychosis.

Method

A cohort study of 50 053 Swedish conscripts. Data on IQ, cannabis use, psychiatric diagnoses, disturbed behaviour and social relations assessed at age 18 were linked to admissions with any non-affective psychoses over a 27-year follow-up period. Statistical interactions between risk factors were examined under both additive and multiplicative models.

Results

There was some evidence of interaction for eight of the ten combinations of risk factors under additive models, but for only one combination under multiplicative models.

Conclusions

Multiplicative models describe the joint effect of risk factors more adequately than additive ones do. However, the implications of finding interactions as observed here, or for most interactions reported to date, remain very limited.

Background

Studies of self-harm in Black and minority ethnic (BME) groups have been restricted to single geographical areas, with few studies of Black people.

Aims

To calculate age- and gender-specific rates of self-harm by ethnic group in three cities and compare characteristics and outcomes.

Method

A population-based self-harm cohort presenting to five emergency departments in three English cities during 2001 to 2006.

Results

A total of 20 574 individuals (16–64 years) presented with self-harm; ethnicity data were available for 75%. Rates of self-harm were highest in young Black females (16–34 years) in all three cities. Risk of self-harm in young South Asian people varied between cities. Black and minority ethnic groups were less likely to receive a psychiatric assessment and to re-present with self-harm.

Conclusions

Despite the increased risk of self-harm in young Black females fewer receive psychiatric care. Our findings have implications for assessment and appropriate management for some BME groups following self-harm.

Background

Female prisoners are 20 times more likely to die by suicide than women of the same age in the general population. However, risk factors and indicators of vulnerability for suicide in this group are not well-known.

Aims

We investigated prevalence of psychiatric disorders in women prisoners who had recently engaged in near-lethal self-harm (cases) and others who had never carried out near-lethal attempts in prison (controls).

Method

We interviewed 60 cases and 60 controls from all closed female prison establishments in England and Wales. In addition to gathering details of sociodemographic, criminological and clinical history, we assessed participants’ current and lifetime disorders using the Mini-International Neuropsychiatric Interview. Associations between near-lethal self-harm and psychiatric disorders were adjusted for age, educational qualifications (any v. none) and remand status (sentenced v. unsentenced).

Results

At the time of their near-lethal self-harm, 53 cases (88%) were on ACCT (Assessment, Care in Custody and Teamwork), the system for the care of prisoners at risk of suicide and self-harm in England and Wales. Cases had significantly greater levels of psychiatric morbidity than controls, and more comorbidity. The strongest associations with near-lethal self-harm were with current depression (age-adjusted odds ratio (OR) = 23.7, 95% CI 9.0–62.3), the presence of two or more diagnoses (age-adjusted OR = 18.3, 95% CI 5.9–56.9), a history of psychiatric in-patient treatment (OR = 25.4, 95% CI 5.7–113.5) and previous attempted suicide, especially in prison (OR = 129, 95% CI 27–611). The only tested diagnoses not associated with near-lethal self-harm were antisocial personality disorder, substance use and eating disorders. Adjusting for sociodemographic and criminological variables did not significantly alter any of these findings.

Conclusions

This research underlines the importance of psychiatric risk factors for suicide in custody and in particular comorbidity. The finding that a formal care plan was in place for most cases at the time of their near-lethal act is indicative of good risk detection, but also suggests high levels of unmet need. Given the potential complexity of their mental health needs, interventions incorporating pharmacological and psychological treatments should be considered for at-risk prisoners.

Background

British Pakistani women have a high prevalence of depression. There are no reported psychosocial interventions for depression in ethnic minorities in the UK.

Aims

To determine the efficacy of a social group intervention compared with antidepressants, and whether the combination of the two is more efficacious than either alone.

Method

A total of 123 women with depression participated in the primary care-based cluster randomised controlled trial (ISRCTN19172148). Outcome measures were severity of depression (Hamilton Rating Scale for Depression), social functioning and satisfaction at 3 and 9 months.

Results

Greater improvement in depression in the social intervention group and the combined treatment group compared with those receiving antidepressants alone fell short of significance. There was significantly greater improvement in social functioning in the social intervention and combined treatment groups than in the antidepressant group at both 3 and 9 months.

Conclusions

Pakistani women with depression found the social groups acceptable and their social function and satisfaction improved if they received social treatment compared with the receipt of antidepressants alone.

Background

Media reporting of suicide has repeatedly been shown to trigger suicidal behaviour. Few studies have investigated the associations between specific media content and suicide rates. Even less is known about the possible preventive effects of suicide-related media content.

Aims

To test the hypotheses that certain media content is associated with an increase in suicide, suggesting a so-called Werther effect, and that other content is associated with a decrease in suicide, conceptualised as a Papageno effect. Further, to identify classes of media articles with similar reporting profiles and to test for associations between these classes and suicide.

Method

Content analysis and latent class analysis (LCA) of 497 suicide-related print media reports published in Austria between 1 January and 30 June 2005. Ecological study to identify associations between media item content and short-term changes in suicide rates.

Results

Repetitive reporting of the same suicide and the reporting of suicide myths were positively associated with suicide rates. Coverage of individual suicidal ideation not accompanied by suicidal behaviour was negatively associated with suicide rates. The LCA yielded four classes of media reports, of which the mastery of crisis class (articles on individuals who adopted coping strategies other than suicidal behaviour in adverse circumstances) was negatively associated with suicide, whereas the expert opinion class and the epidemiological facts class were positively associated with suicide.

Conclusions

The impact of suicide reporting may not be restricted to harmful effects; rather, coverage of positive coping in adverse circumstances, as covered in media items about suicidal ideation, may have protective effects.

Pernicious anaemia can present with psychiatric symptoms before haematological or neurological manifestations appear. We describe a young woman who presented with insidious onset catatonia without evidence of psychosis or depression. Blood count and mean cell volume were normal and neurological findings were equivocal. Low B12 levels and intrinsic factor antibodies were found only by chance when they were included in a battery of further investigations. B12 replacement was followed by prompt improvement. This case provides an argument for wider screening for B12 deficiency in certain individuals with psychiatric disorders.