Highlights of this issue

DEPRESSION: PREVENTION, PREVALENCE AND TREATMENT

There is a particular focus on affective disorders in the Journal this month. Smit et al () consider the cost-effectiveness of an intervention designed to prevent progression to depression among those with sub-threshold illness presenting in primary care. The cognitive–behavioural minimal contact psychotherapeutic intervention led to improvements in outcome and lower costs compared with usual care. Bobak et al () report the prevalence of depressive symptoms in urban centres in three formerly communist countries (Russia, Poland and the Czech Republic) to be relatively high (19–23% for men and 34–44% for women). Depressive symptoms were associated with binge-drinking, deprivation and being divorced or widowed. Time-limited psychotherapeutic interventions may have cost benefits and are often preferred by patients. Hakkaart-van Roijen et al () found that mean direct costs of treatment were significantly lower for brief therapy compared with cognitive–behavioural therapy (CBT) or care as usual in a randomised controlled study involving patients with depression and anxiety. There were, however, no significant differences in overall cost-utility or quality-adjusted life-years between the three groups. Among adult out-patients with treated major depressive disorder, randomisation to duloxetine, an inhibitor of serotonin and noradrenaline reuptake, was associated with longer time to relapse, better efficacy, improved well-being and improved quality of life compared with placebo for those previously responsive to the drug (Perahia et al, ).

BIPOLAR DISORDER: DEFICITS IN EUTHYMIC PATIENTS AND CBT FOR SEVERE ILLNESS

In a study based in New Delhi, Goswami et al () confirmed the presence of neurocognitive deficits, particularly in executive functioning, in euthymic patients with bipolar disorder compared with controls. They further found that soft neurological signs and social disability were also widespread in the bipolar group. In linking the neurocognitive and neurological findings, the authors point to the importance of dysfunction in fronto-striatal and thalamic pathways in this disorder. The impact of CBT compared with treatment as usual was assessed in a pragmatic randomised controlled trial involving a clinically representative sample of individuals with recurrent bipolar disorder by Scott et al (). Overall, recurrence by 18 months was common and no significant differences were found between the treatment groups except when the analysis was restricted to those with fewer than 12 previous episodes – adjunctive CBT was more effective in this group.

ANTIDEPRESSANTS: IMPACT ON SUICIDE RATES AND COST-EFFECTIVENESS

Reseland et al () undertook an assessment of trends in suicide rates and antidepressant sales over the period 1961 to 2000–2003 in Norway, Sweden, Denmark and Finland. During the 1990s antidepressant sales increased and suicide rates declined in the region but the suicide rate reductions in Sweden and Denmark preceded the rise in antidepressant sales by more than 10 years, and in all four countries the rate reductions appeared to precede the widespread use of selective serotonin reuptake inhibitors (SSRIs). Identifying the need for a prospective cost-effectiveness comparison of different classes of antidepressants in UK primary care, Kendrick et al () conducted an open-label randomised trial of tricyclic antidepressants (TCAs), SSRIs and lofepramine for treatment of newly diagnosed depression. Overall their findings tend to support the recommendation that SSRIs should be considered as first-choice for treatment of depression in primary care. Although TCAs were cheaper, differences between the groups in overall costs, cost-effectiveness and cost-utility were not significant.

IMMIGRANTS TO THE NETHERLANDS AND ETHNICITY IN HIGH SECURITY

In a Dutch study by Mulder et al (), first- and second-generation immigrants from non-Western countries were found to be at high risk of contact with psychiatric emergency services, particularly for psychotic disorders, and were also more likely to be admitted compulsorily. The latter finding appeared to be due to symptom severity, dangerous behaviour, lack of motivation for treatment and lower levels of functioning. In a sample obtained from the three high-security psychiatric hospitals in England, Black patients were found to be overrepresented by a factor of 8.2 (Leese et al, ). The authors also identified high levels of unmet need in this group.

PERSONALITY DISORDER AND SUBSTANCE MISUSE

In a cross-sectional study of young Australian adults, Moran et al () report that 19% met criteria for personality disorder with associations found between such disorder and both social disadvantage and common mental disorder. Those with personality disorder were also at higher risk for having a substance use disorder independent of social disadvantage and common mental disorder.