The main aim of this paper is to compare and contrast the methodological approaches of the new Global Burden of Disease 2010 Study (GBD 2010) with the original study conducted for 1990 (GBD 1990), in terms of calculating burden for mental and substance use disorders.

We reviewed the conceptual and methodological changes to GBD burden calculations in the GBD 2010 study, compared with previous studies. We then discuss the possible implications of these changes with respect to burden estimates for mental and substance use disorders.

It is not possible to compare burden estimates arising from the GBD 1990 study with the most recent burden estimates. There have been important advances in the categorisation and definition of mental disorders, and the input and computation of epidemiological models for disease distribution. There have also been major changes to conceptual and social value choices aimed at addressing concerns that arose following publication of earlier GBD studies.

Advancements to the GBD conceptual framework and method of calculating burden estimates has led to more accurate and equitable consideration of the burden for mental and substance use disorders. Proposed annual updates of GBD estimates by the Institute of Health Metrics and Evaluation provide an opportunity to continue to advance the evidence base that underpins the quantification of disease burden.

Population-based research on mental disorders needs to keep pace with trends in general epidemiology. At present, this requirement is complicated by uncertainty within the parent discipline about its future development. The present study examines proposals for new directions in strategy and methods and considers their significance for psychiatric epidemiology.

Narrative review, cross-checked by search of English-language journals of epidemiology for new trends and developments reported in the years from 2000 onwards.

The proposals reviewed here are divided into three groups:

1. 1. A new research paradigm of ‘eco-epidemiology’, which includes both individual risk factors and macro-environmental systems that mediate population levels of health and sickness.

2. 2. Improved ‘translation’ of research findings – i.e. more rapid and effective implementation of epidemiological evidence into health policy and practice.

3. 3. Adaptation of epidemiology to a globalised economy, with firmer regulation of funding and resources.

Each of these proposals has implications for psychiatric epidemiology. Workers in this field, however, are still preoccupied by relatively specific problems of definition, measurement and classification, and so far the current debates in general epidemiology are scarcely reflected. The proposals outlined above call for:

• • a working model of eco-epidemiology as it relates to psychiatric disorders;

• • implementation strategies to encourage more active participation in epidemiological research by community health services and caregiver organisations;

• • international collaborative projects that offer practical benefits in training and service facilities for the countries taking part.

Cross-national population data from the WHO World Mental Health surveys are used to compare role attainments and role impairments associated with binge-eating disorder (BED) and bulimia nervosa (BN).

Community surveys assessed 23 000 adults across 12 countries for BED, BN and ten other DSM-IV mental disorders using the WHO Composite International Diagnostic Interview. Age-of-onset was assessed retrospectively. Ten physical disorders were assessed using standard conditions checklists. Analyses examined reciprocal time-lagged associations of eating disorders (EDs) with education, associations of early-onset (i.e., prior to completing education) EDs with subsequent adult role attainments and cross-sectional associations of current EDs with days of role impairment.

BED and BN predicted significantly increased education (females). Student status predicted increased risk of subsequent BED and BN (females). Early-onset BED predicted reduced odds of current (at time of interview) marriage (females) and reduced odds of current employment (males). Early-onset BN predicted increased odds of current work disability (females and males). Current BED and BN were both associated with significantly increased days of role impairment (females and males). Significant BED and BN effects on adult role attainments and impairments were explained by controls for comorbid disorders.

Effects of BED on role attainments and impairments are comparable with those of BN. The most plausible interpretation of the fact that these associations are explained by comorbid disorders is that causal effects of EDs are mediated through secondary disorders. Controlled treatment effectiveness studies are needed to trace out long-term effects of BED–BN on secondary disorders.

To investigate the reasons behind difficulties in recruiting patients to randomized controlled trials (RCTs) in psychiatry and to examine a database of RCTs for differences between studies in mental health and other specialities.

A discussion of recent changes in research governance in the UK and Europe followed by an examination of the database of all trials supported by the Health Technology Assessment programme of the National Institute of Health Research in the UK between 1993 and 2007 to determine if three different measures, (i) time between grant approval and study start date, (ii) percentage of additional time given to extend recruitment and (iii) percentage of planned recruitment achieved, changed over the time period studied and differed between mental health, cancer and other medical disciplines.

Despite attempts in the UK to accelerate the process of clinical trials in recent years, there was a significant increase in the extension time for trials to be completed (p = 0.038) and the percentage of planned recruitment to mental health studies (71%) was significantly less than for cancer (90.3%) and other studies (86.1%) (p = 0.032).

These results suggest that, despite the priority afforded to the advancement of RCTs in healthcare, such studies are encountering increasing difficulty in recruiting to time and target. We suggest that this difficulty can be attributed, at least in part, to the excessively byzantine regulation and governance processes for health research in the UK, and unnecessary bureaucracy in the current National Health Service system. Mental health studies appear particularly vulnerable to delay and better systems to facilitate recruitment are required urgently for the evidence base to be improved and facilitate new cost-effective interventions.

The introduction of second generation antipsychotic (SGA) medication over a decade ago led to changes in prescribing practices; these drugs have eclipsed their predecessors as treatments for schizophrenia. However, the metabolic side effects of these newer antipsychotics have been marked and there are increasing concerns as to whether these novel drugs really are superior to their predecessors in terms of the balance between risks and benefits. In this article, we review the literature regarding comparisons between first generation antipsychotic (FGA) and SGA in terms of clinical effectiveness.

Large (n > 150) randomized-controlled trials (RCTs) comparing the effectiveness (efficacy and side effects) of FGA and SGA medications other than clozapine were reviewed, as were meta-analyses that included smaller studies.

The superiority in efficacy and reduced extrapyramidal side effects (EPSE) of SGAs is modest, especially when compared with low-dose FGAs. However, the high risk of weight gain and other metabolic disturbances associated with certain SGAs such as olanzapine is markedly higher than the risk with FGAs at the doses used in the trials.

The efficacy profiles of various FGAs and SGAs are relatively similar, but their side effects vary between and within classes. Overall, large pragmatic trials of clinical effectiveness indicate that the care used in prescribing and managing drug treatments to ensure tolerability may be more important than the class of drug used.

There is strong evidence that those with a long-standing psychotic disorder have fewer social contacts and less social support than comparison groups. There is less research on the extent of social contacts and support prior to or at the onset of psychosis. In the light of recent evidence implicating a range of social experiences and contexts at the onset of psychosis, it is relevant to establish whether social networks and support diminished before or at the time of onset and whether the absence of such supports might contribute to risk, either directly or indirectly. We, therefore, conducted a systematic review of this literature to establish what is currently known about the relationship between social networks, support and early psychosis.

We identified all studies investigating social networks and support in first episode psychosis samples and in general population samples with measures of psychotic experiences or schizotype by conducting systematic searches of electronic databases using pre-defined search terms and criteria. Findings were synthesized using non-quantitative approaches.

Thirty-eight papers were identified that met inclusion criteria. There was marked methodological heterogeneity, which limits the capacity to draw direct comparisons. Nonetheless, the existing literature suggests social networks (particularly close friends) and support diminished both among first episode samples and among non-clinical samples reporting psychotic experiences or with schizotype traits, compared with varying comparison groups. These differences may be more marked for men and for those from minority ethnic populations.

Tentatively, reduced social networks and support appear to pre-date onset of psychotic disorder. However, the substantial methodological heterogeneity among the existing studies makes comparisons difficult and suggests a need for more robust and comparable studies on networks, support and early psychosis.

The current debate concerning the forthcoming revisions of the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) lacks sufficient historical perspective on groundwork concepts in psychiatry, such as the nature of the disease entity, categorical typologies, dimensional models and their validity and utility.

To offer an overview of the evolution and metamorphoses of the conceptual basis of classification in psychiatry, with particular focus on psychotic disorders.

Discursive, proceeding from history of ideas to a critique of present dilemmas.

Much of the present-day discussion of basic issues concerning the classification of mental disorders is a replay of debates that took place in the earlier periods of scientific psychiatry.

The mainstream nosological paradigm adopted in psychiatry since early 20th century is in need to be critically examined and transcended with the help of concepts and methodological tools available today.

Global mental health movements increasingly highlight social integration as a key outcome for mental health services. This creates a pressing need to better articulate and measure this outcome. Much of the work in social integration thus far has been in high-income countries (HIC), and is not directly applicable across diverse socio-cultural environments. We discuss promising concepts and measures of social integration with potential for global cross-cultural application. Then, we present some of the challenges of developing measures for global and cross-cultural use, and suggest ways to confront these challenges. Although we focus primarily on adults with severe mental disorders in low- and middle-income countries (LMIC), the questions we raise are also relevant to children, other mental disorders and HIC.

We identify and describe four distinct conceptual frameworks for social integration that have emerged over the past decade. Then, we discuss the challenge of developing corresponding measures, and the further challenge of developing global cross-cultural measures. We suggest that a key concept shared across much previous and emerging work is active participation in community and civic life. As a platform for future development of global cross-cultural measures of this and other concepts, we propose guidelines and present examples of feasible, previously used strategies.

Emerging concepts of social integration hold great promise, but as yet, there are no corresponding measures suitable for global cross-cultural use. We propose that it is feasible to develop such measures, and that their development will facilitate the advance of community mental health services and the science of global mental health.

Mental health policy internationally varies in its support for recovery. The aims of this study were to validate an existing conceptual framework and then characterise by country the distribution, scientific foundations and emphasis in published recovery conceptualisations.

Update and modification of a previously published systematic review and narrative synthesis of recovery conceptualisations published in English.

A total of 7431 studies were identified and 429 full papers reviewed, from which 105 conceptualisations in 115 papers were included and quality assessed using established rating scales. Recovery conceptualisations were identified from 11 individual countries, with 95 (91%) published in English-speaking countries, primarily the USA (47%) and the UK (25%). The scientific foundation was primarily qualitative research (53%), non-systematic literature reviews (24%) and position papers (12%). The conceptual framework was validated with the 18 new papers. Across the different countries, there was a relatively similar distribution of codings for each of five key recovery processes.

Recovery as currently conceptualised in English-language publications is primarily based on qualitative studies and position papers from English-speaking countries. The conceptual framework was valid, but the development of recovery conceptualisations using a broader range of research designs within other cultures and non-majority populations is a research priority.

It is timely to ask what epidemiology has brought to our knowledge about mental illness and what information is proving of particular value. In this task, the first step is to identify the truly fundamental questions that the epidemiology of mental disorders should be expected to answer. This review is selectively directed at four such questions.

A small number of significant publications were identified.

The extent to which some major questions in epidemiology have been answered is examined.

When considered alongside epidemiological knowledge elsewhere in medicine, psychiatric epidemiology has indisputably proved to be a powerful tool. Descriptive studies have been particularly useful for advocacy and policy, while analytic studies of aetiology have yielded some valuable clues. There are now signs that linkage with neuroscience will bring further progress in understanding the causes of mental disorders.

Although schizophrenia has been considered a distinct disease entity for the past century, its precise definition and etio-pathophysiology remain obscure and its treatment remains unsatisfactory. In this review, we summarize our state of knowledge about the etiology, pathophysiology, clinical features, and treatment of schizophrenia.

The inadequacy of the major conceptual models of schizophrenia is a major roadblock in providing a coherent explanation for the known facts of this illness, despite these limitations and its changing definitions, the construct of schizophrenia does convey useful information: (i) patients diagnosed as having schizophrenia do have a real disease – they experience both suffering and disability; (ii) a diagnosis of schizophrenia does suggest a distinctive clinical profile – a characteristic long-term course; an admixture of positive, negative, and cognitive symptoms; (iii) a diagnosis of schizophrenia has clear treatment and prognostic implications – likelihood of benefit from antipsychotic treatment and likelihood of incomplete recovery; and (iv) schizophrenia satisfies criteria for a valid diagnostic entity better than almost any other psychiatric diagnosis.

On the other hand, the concept of schizophrenia has serious shortcomings. First, it is not a single disease entity – it has multiple etiological factors and pathophysiological mechanisms but common phenotypic features. Second, its clinical manifestations are so diverse that its extreme variability has been considered by some to be a core feature. Third, its boundaries remain ill defined and not clearly demarcated from other clinical entities.

A necessary next step is to deconstruct schizophrenia as an entity into component dimensions –endophenotypes linked to unique etiological and pathophysiological processes that may yield unique treatment targets. Innovative approaches are needed to elucidate the biological substrates of these entities because such clarity is vital for replicable research. We conclude by identifying the critical gaps in our knowledge, and unmet needs in our approaches to care, and outline steps that can move the field forward.

Investment in innovative mental health care services requires the use of scarce resources that could be used in alternative ways. Economic evaluation is essential to ensure that such an investment is appropriately compared with investment elsewhere.

A non-systematic review of mental health evaluations identifies key methodological issues pertaining to economic studies.

Economic evaluations require the measurement and combination of costs and outcomes, and clarity about how this measurement is undertaken is required. Regarding costs, important considerations relate to the perspective to be taken (e.g., health service or societal), method of measurement (patient self-report or use of databases) and valuation (actual costs, fees or expenditure). Decision makers frequently need to compare evidence both within and between clinical areas and therefore there is a tension between the use of condition specific and generic outcome measures. Quality-adjusted life years are frequently used in economic evaluations, but their appropriateness in mental health care studies is still debated.

Economic evaluations in the area of mental health care are increasing in number and it is essential that researchers continue to develop and improve methods used to conduct such studies.

This systematic review examines interventions for care of people with co-morbid chronic medical illness and anxiety/depression disorders – a group with high risks for morbidity and mortality.

Systematic search of Medline 1995 to January 2011 for randomized controlled trials of treatment interventions designed for adult outpatients with diagnosed chronic medical illness (diabetes mellitus, cardiovascular disorders, and chronic respiratory disorders) and anxiety/depression disorders.

Six trials studied complex interventions based on the chronic care model, and eight trials studied psychosocial interventions. Most interventions addressed the mental health aspect of the co-morbidity and showed improvements in anxiety/depression but not in the co-morbid medical disorder.

Further research might focus on interventions integrating mental health treatment with enhanced medical care components, incorporating shared-decision making and information technology advances.