We have reported the advantageous clinical outcome of adding cognitive therapy to medication in the prevention of relapse of bipolar disorder.

This 30-month study compares the cost-effectiveness of cognitive therapy with standard care.

We randomly allocated 103 individuals with bipolar 1 disorder to standard treatment and cognitive therapy plus standard treatment. Service use and costs were measured at 3-month intervals and cost-effectiveness was assessed using the net-benefit approach.

The group receiving cognitive therapy had significantly better clinical outcomes. The extra costs were offset by reduced service use elsewhere. The probability of cognitive therapy being cost-effective was high and robust to different therapy prices.

Combination of cognitive therapy and mood stabilisers was superior to mood stabilisers alone in terms of clinical outcome and cost-effectiveness for those with frequent relapses of bipolar disorder.

Geographical variation in the prevalence of common mental disorders has not been explained adequately.

To investigate whether regional mental health differences in Wales would persist after having taken into account the characteristics of individuals and regional social deprivation.

Data from the 1998 Welsh Health Survey were used. Common mental disorders were assessed with the mental health index included in the Short-Form 36 health survey (SF–36). The data were analysed using a multi–level linear regression model.

Of the total variance in the mental health index, 1.47% occurred at regional level (95% CI 0.56–2.38). Adjustment for individual characteristics did not explain the between-region variation. A higher area deprivation score was associated with a higher score on the mental health index.

Mental health differences in Wales are partly explained by the level of regional social deprivation.

Personality pathology constitutes a major form of psychopathology in adolescents.

To examine the reliability and validity of a Q-sort instrument for assessing adolescent personality pathology designed for clinically experienced informants.

A sample of 294 randomly selected psychiatrists and psychologists each provided data on a current patient, aged 14–18 years. Clinicians completed several measures, including the Shedler–Westen Assessment Procedure for Adolescents (SWAP–200–A).

Factor analysis identified II dimensions of adolescent personality: psychopathology/malignant narcissism, dysphoria/inhibition, psychological health, histrionic sexualisation, schizotypy, sexual conflict, emotional dysregulation, anxious obsessionality, peer rejection, delinquent behaviour and attentional dysregulation. These correlated in predicted ways with a range of criterion variables, including measures of adaptive functioning, Axis II pathology, the Five Factor Model and the Child Behavior Checklist.

The SWAP–200–A shows promise as an instrument for assessing personality pathology in adolescents. Trait dimensions such as delinquent behaviour and emotional dysregulation may prove useful additions to a classification of personality.

Needs for care in service users with schizophrenia are often defined by professionals and focus on basic needs for health and social care rather than broader existential issues.

To examine the perceptions of users and formal and informal carers of the needs of people with non-affective psychosis.

A qualitative study was conducted involving focus groups of service users and informal and formal carers in a major Brazilian city Results Existential needs were the most important theme for people with psychotic disorders. Informal and formal carers mainly regarded such needs as secondary to needs for health, housing, leisure and work. Carers usually reduced the existential questioning of the ill person to symptoms or the result of a privation such as lack or failure of medication and its consequences.

We require an approach to service users wherein respect and understanding are prized as the first needs from which all others will naturally follow. We also need to give greater priority to existential issues in validated schedules that measure needs in clinical work and research.

The incidence of post-traumatic stress disorder (PTSD) after traumatic brain injury is unclear. One issue involves the validity of diagnosis using self-report questionnaires.

To compare PTSD ‘caseness' arising from questionnaire self-report and structured interview.

Participants (n=34) with traumatic brain injury were recruited. Screening measures and self-report questionnaires were administered, followed by the structured interview.

Using questionnaires, 59% fulfilled criteria for PTSD on the Post-traumatic Diagnostic Scale and 44% on the Impact of Events Scale, whereas using structured interview (Clinician-Administered PTSD Scale) only 3% were ‘cases'. This discrepancy may arise from confusions between effects of PTSD and traumatic brain injury.

After traumatic brain injury, PTSD self-report measures might be used for screening but not diagnosis.

It is a widely shared belief that an increase in mental health literacy will result in an improvement of attitudes towards people with mental illness.

To examine how the German public's causal attributions of schizophrenia and their desire for social distance from people with schizophrenia developed over the 1990s.

A trend analysis was carried out using data from two representative population surveys conducted in the Länder constituting the former Federal Republic of Germany in 1990 and 2001.

Parallel to an increase in the public's tendency to endorse biological causes, an increase in the desire for social distance from people with schizophrenia was found.

The assumption underlying current anti-stigma programmes that there is a positive relationship between endorsing biological causes and the acceptance of people with mental illness appears to be problematic.

Irritable bowel syndrome often leads to impaired functioning.

To assess the contribution of psychiatric disorders to impaired outcome in severe irritable bowel syndrome.

Patients with severe irritable bowel syndrome entering a psychological treatment trial (n=257) were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry. Outcomes were number of days of restricted activity, role limitation (physical) score of the Short Form Health Survey and costs.

At baseline, depressive disorder (29% of patients), panic (12%) and neurasthenia (35%) were associated with impairment; number of psychiatric disorders was associated in a dose–response fashion (P=0. 005). At follow-up, depressive disorder and neurasthenia were associated with role limitation score. Improved depression was associated with improved role functioning.

Depressive, panic and neurasthenic disorders contribute to poor outcomes in severe irritable bowel syndrome, and appropriate treatment should be available to these patients.

There is a need for reliable assessment tools that are suitable for the counselling and the psychological therapy services in primary and secondary care settings.

To test the suitability and utility of the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE–OM) and CORE–Assessment (CORE–A) assessment tools.

Service intake data were analysed from counselling and psychological therapy services in 32 primary care settings and 17 secondary care settings.

Completion rates exceeded 98% in both of the settings sampled. Intake severity levels were similar but secondary care patients were more likely to score above the risk cut-off and the severe threshold and to have experienced their problems for a greater duration.

The CORE–OM and CORE–A are suitable assessment tools that show small but logical differences between psychological therapy services in primary- and secondary-based care.

There is little consensus about which outcome measures to use in mental healthcare.

To investigate the relationship between the items in four staff-rated measures recommended for routine use.

Correlation analysis of total scores and factor analysis using combined data from the Health of the Nation Outcome Scales (HoNOS). The Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), the Threshold Assessment Grid (TAG) and the Global Assessment of Functioning (GAF) were performed. Procrustes analysis on factors and scales, and Ward's cluster analysis to group the items, were applied.

The total scores of the measures were moderately correlated. The Procrustes analysis, factor analysis and cluster analysis all agreed on better coverage of the patients' problems by HoNOS and CANSAS.

A global severity factor accounts for 16% of the variance, and is best measured with TAG or GAF. The CANSAS and HoNOS each provide a detailed characterisation of the patient; only CANSAS provides information about met needs.

Charcoal-burning, a new suicide method, emerged in Hong Kong during the latest economic recession. With-in 2 months charcoal-burning had become the third most common suicide method.

To examine the characteristics of suicides by charcoal-burning, and to delineate the pathways linking macro-level economic and social changes with the subjective experiences of those surviving a charcoal-burning suicide attempt.

Both quantitative and qualitative methods were used. In the coroner's records study, the first 160 cases of suicide by charcoal-burning were compared with a control group. In the ethnographic enquiry, we interviewed 25 consecutive informants who had survived serious suicide attempt using charcoal-burning.

People who completed suicide by the charcoal-burning method were more likely to have been economically active and physically healthy, and were less likely to have had pre-existing mental illness. Charcoal-burning suicide was associated with overindebtedness. Media reports were pivotal in linking overindebtedness and financial troubles with charcoal-burning.

The political economy of suicide by charcoal-burning illustrated how historical, socio-economic and cultural forces shaped the lived experience that preceded suicide.

The diagnosis of psychopathy is important for violence risk assessment.

To investigate whether the syndromal structure of psychopathy, as measured by the Psychopathy Checklist – Revised (PCL–R), is the same in the UK and North America, and whether this measure yields scores that are equivalent in these two regions.

Confirmatory factor analytic and item response theory methods were applied to large samples of PCL–R ratings.

The syndromal structure of psychopathy was invariant across cultures, three distinct factors underpinning the superordinate syndrome of psychopathy. However, PCL–R scores were not equivalent across cultures: the same level of psychopathy was associated with lower PCL–R scores in the UK. Items that reflected affective symptoms had the highest cross-cultural stability.

Scores on the PCL–R obtained in the UK are not directly comparable with those obtained in North America. Care must be exercised when the PCL–R is used to make important clinical decisions in the UK.

Research has identified three personality subtypes in patients with eating disorders: emotionally dysregulated, constricted and high-functioning/perfectionistic.

To see whether the subtypes are distinguished in ways indicative of valid classification, notably in patterns of adaptive functioning, comorbidity, treatment response and therapeutic interventions.

A random sample of experienced clinicians provided data on 145 patients with bulimic symptoms, including data on eating disorder symptoms, DSM–IV comorbidity, personality pathology, treatment response and treatment interventions.

Patients categorised as dysregulated had the poorest functioning, most comorbidity and worst outcome, followed by patients in the constricted and high-functioning groups. The three subtypes elicited different therapeutic interventions and accounted for substantial incremental variance in outcome, holding constant the severity of eating disorder symptoms and presence of other Axis I disorders.

The data provide accumulating evidence for the validity of three personality subtypes in patients with eating disorders.

Previous studies of paranoia have assessed only limited numbers of paranoid thoughts, and have not considered the experience from a multidimensional perspective or examined the relationship between different suspicious thoughts.

To assess a wide range of paranoid thoughts multidimensionally and examine their distribution, to identify the associated coping strategies and to examine social–cognitive processes and paranoia.

Six questionnaire assessments were completed by 1202 individuals using the internet.

Paranoid thoughts occurred regularly in approximately a third of the group. Increasing endorsement of paranoid thoughts was characterised by the recruitment of rarer and odder ideas. Higher levels of paranoia were associated with emotional and avoidant coping, less use of rational and detached coping, negative attitudes to emotional expression, submissive behaviours and lower social rank.

Suspiciousness is common and there may be a hierarchical arrangement of such thoughts that builds on common emotional concerns.

Established legal mandates and high expectations for psychiatric advance directives are not matched by empirical evidence documenting their actual implementation.

To explore the interests, concerns and planning activities of informed mental health service users contemplating such directives.

Standard qualitative research techniques were used: field observations, interviews, focus groups, archival research and key informant interviews; 33 persons participated in the interviews and focus groups. Transcripts were coded and analysed for thematic content, and results were member-checked.

Training set in motion labour-intensive projects: conceptualising how a psychiatric advance directive would work in one's life, mobilising resources, reviewing past experiences and assessing risks. Especially meaningful was the prospect of being treated as a responsible agent in future interactions with the mental health system.

Advance directives are best thought of as complex planning tools for future psychiatric crisis management, rather than focal interventions to enhance compliance. Research is needed to explore the institutional response to this prospective decision-sharing initiative.

Research on stigma often focuses on general public attitudes and overlooks patients' subjective experiences of everyday stigma arising from significant others.

To document and compare the interpersonal experiences of stigma in patients with schizophrenia and patients with diabetes mellitus in Hong Kong.

Four focus groups were conducted to generate a self-report questionnaire. Data were collected from out-patients with schizophrenia (n=320) and diabetes (n=160).

Significantly more patients with schizophrenia (>40%) than diabetes (average 15%) experienced stigma from family members, partners, friends and colleagues. Over 50% anticipated stigma and about 55% concealed their illness. Dysphoria occurred in over half.

Interpersonal (especially intrafamilial) stigma was pervasive, hard to avoid and devastating to patients with schizophrenia. Family support had to be realised rather than assumed, despite the emphasis on relationship bonds in Chinese society Programmes that build the family as a rehabilitative resource should start early to reduce the development and adverse impacts of stigma.

The concept of transference has broadened to a recognition that patients often express enduring relational patterns in the therapeutic relationship.

To examine the structure of patient relational patterns in psychotherapy and their relation with DSM–IV personality disorder symptoms.

A random sample of psychologists and psychiatrists (n=181) completed a battery of instruments on a randomly selected patient in their care.

Exploratory factor analysis identified five transference dimensions: angry/entitled, anxious/preoccupied, avoidant/counterdependent, secure/engaged and sexualised. These were associated in predictable ways with Axis II pathology; four mapped on to adult attachment styles. An aggregated portrait of transference patterns in narcissistic patients provided a clinically rich, empirically based description of transference processes that strongly resembled clinical theories.

The ways patients interact with their therapists can provide important data about their personality, attachment patterns and interpersonal functioning. These processes can be measured in clinically sophisticated and psychometrically sound ways. Such processes are relatively independent of clinicians' theoretical orientation.

Obsessive–compulsive behaviours are common and disabling in autistic-spectrum disorders (ASD) but little is known about how they compare with those experienced by people with obsessive–compulsive disorder (OCD).

To make such a comparison.

A group of adults with high-functioning ASD (n=40) were administered the Yale–Brown Obsessive–Compulsive Scale and Symptom Checklist and their symptoms compared with a gender-matched group of adults with a primary diagnosis of OCD (n=45). OCD symptoms were carefully distinguished from stereotypic behaviours and interests usually displayed by those with ASD.

The two groups had similar frequencies of obsessive–compulsive symptoms, with only somatic obsessions and repeating rituals being more common in the OCD group. The OCD group had higher obsessive–compulsive symptom severity ratings but up to 50% of the ASD group reported at least moderate levels of interference from their symptoms.

Obsessions and compulsions are both common in adults with high-functioning ASD and are associated with significant levels of distress.

Prediction of suicide risk is difficult in clinical practice.

To identify changes in clinical presentation predictive of suicide in patients treated for repeated episodes of self-poisoning.

A nested case–control study used the Hunter Area Toxicology Service database to identify exposure variables and the National Death Index to identify suicide. Cases were patients who had hospital treatment on more than one occasion between 15 January 1987 and 31 December 2000.

There were 31 cases, for which 93 controls were selected. Study variables associated with an increased risk of subsequent suicide were an increase in the number of drugs ingested (odds ratio 2.59, 95% CI 1.48–4.51), an increase in the dose ingested (OR1.33, 95% CI 1.01–1.76), an increase in coma score (OR 1.71, 95% CI 1.11–2.66), a decrease in Glasgow Coma Score (OR 1.21, 95% CI 1.03–1.43) and an increase in drug or alcohol misuse (OR 2.33, 95% CI 1.06–5.10).

Patients who have escalating severity of self-poisoning episodes are at high risk of completed suicide.