In the treatment of resistant schizophrenia, a number of meta-analyses attempted to quantify the efficacy and tolerability of antipsychotic (AP) polypharmacy v. monotherapy with contradictory results. Recently, a systematic review and meta-analysis of randomised controlled trials investigated the efficacy and tolerability of AP combination v. monotherapy in schizophrenia. It included 31 studies: 21 double-blind (considered high-quality studies) and 10 open-label (considered low-quality studies). The meta-analysis showed that, overall, the combination of two APs was more effective than monotherapy in terms of symptom reduction (standardised mean difference (SMD) = −0.53, 95% confidence interval (CI) −0.87 to −0.19); however, this result was confirmed only in the subgroup of low-quality studies. Negative symptoms improved when combining a D2 antagonist with a D2 partial agonist (SMD = −0.41, 95% CI −0.79 to −0.03) both in double-blind and open-label studies. In the present commentary, the results of this systematic review are critically discussed in terms of their clinical and research implications.

An extensive literature documented a mortality differential for natural causes between psychiatric patients and the general population. Less clear is the pattern for cancer diseases. Methodological problems arise when trying to explain such mortality gap: selection bias and reverse causation; time-dependent confounders that are also intermediate variables; complex relationships within a life course have to be considered. We try to explain such problems in terms of causal graphs. Excess risk for causes of death which are not attributable to higher prevalence of risk factors or treatment side-effects and higher mortality rates for avoidable causes have been also documented. These findings underline the need for research on health promotion and preventive programs targeted to psychiatric patients.

Aim – Instruments to measure the process - the daily activities of home care workers - have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries. Methods – Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for each RQC response category and rater agreement with a criterion measure (coded vignettes) were evaluated. Results – Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories. Conclusions – The new RQC may support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions. Declaration of Interest: The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Declaration of Interest: The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Objective — This work proposes a series of indicators, based on routine data collection system adopted in the Emilia Romagna Region, with the aim of describing the quality and quantity of psychiatric care and the connections of psychiatric structures. We are bearing in mind the Plan aimed to Mental Health Care 1994-1996 and the Efficiency and quality indicators of National Health System (SSN) devised by the Department of Health of national government. Method — A working group has been instituted by the regional authority to define the indicators (definition of meaning, formula, danger level, finality, level od utilisation, data source and frequency of survey, congruent with the regional information system. Results — We present 105 indicators grouped according to the psychiatric structure they are aimed at (comunity centers, acute admissions wards, semiresidential and residential facilities, former mental hospitals, district mental health department) and according to code in three lists: 1) general indicators; 2) probing indicators; 3) outcome indicators. Conclusions — This set of indicators though created for local usage is aimed on objetives defined by the national Department of Health and can therefore be of interest for other Italian regions. Modular costruction permits flexible application ad adaptation to less complex information systems. Part of this system is since 1977 part of routine information flux in Emilia Romagna.

Objective — Advocacy in the mental health services field is gaining importance since the traditional role of mental health hospitals is changing, particularly in North America and in Western Europe. This review will define advocacy, its goals and fundamental principles. It will then delineate the skills and strategies needed for any intervention on behalf of a patient or a group of patients. It will also deal with the issues and approaches most frequently raised and used, and finally, with the limits of advocacy. Method — The method used for this review was mainly a recension of the literature concerning advocacy throughout North America and Europe, having in view to see emerging the principal stakes and concerns related to this process. Results — Advocacy has a significant impact patients' awareness of their rights and their capacity to exercise them. It also prevents potential abuse of patients. On the other hand, some patients have an increased opportunity to cease treatment, and this could lead to serious medical consequences. There is also the possibility of retaliation from staff, as a result of being involved with an advocate. The combination of high quality care and effective advocacy is the best guarantee that a mental health patient will get the care he wants and needs with human dignity.

Policymaking and the care of people with schizophrenia are still recovering from the shock of the arrival of a more objective way of appraising the best available evidence. It is still early days. There are several directions that practice and policy could go and there are indications that the rebuilding is not the same as what has gone before. After the earthquake we should be able to build more wisely.