No study has investigated when preventive treatment with lithium should be initiated in bipolar disorder.

To compare response rates among patients with bipolar disorder starting treatment with lithium early v. late.

Nationwide registers were used to identify all patients with a diagnosis of bipolar disorder in psychiatric hospital settings who were prescribed lithium during the period 1995–2012 in Denmark (n = 4714). Lithium responders were defined as patients who, following a stabilisation lithium start-up period of 6 months, continued lithium monotherapy without being admitted to hospital. Early v. late intervention was defined in two ways: (a) start of lithium following first contact; and (b) start of lithium following a diagnosis of a single manic/mixed episode.

Regardless of the definition used, patients who started lithium early had significantly decreased rates of nonresponse to lithium compared with the rate for patients starting lithium later (adjusted analyses: first v. later contact: P<0.0001; hazard ratio (HR) = 0.87, 95% CI 0.76–0.91; single manic/mixed episode v. bipolar disorder: P<0.0001; HR = 0.75, 95% CI 0.67–0.84).

Starting lithium treatment early following first psychiatric contact or a single manic/mixed episode is associated with increased probability of lithium response.

Although neurobiological models of obsessive–compulsive disorder (OCD) traditionally emphasise the central role of corticostriatal brain regions, studies of default mode network integrity have garnered increasing interest, but have produced conflicting results.

To resolve these discrepant findings by examining the integrity of default mode network subsystems in OCD.

Comparison of seed-based resting-state functional connectivity of 11 default mode network components between 46 patients with OCD and 46 controls using functional magnetic resonance imaging.

Significantly reduced connectivity within the dorsal medial prefrontal cortex self subsystem was identified in the OCD group, and remained significant after controlling for medication status and life-time history of affective disorders. Further, greater connectivity between the self subsystem and salience and attention networks was observed.

Results indicate that people with OCD show abnormalities in a neural system previously associated with self-referential processing in healthy individuals, and suggest the need for examination of dynamic interactions between this default mode network subsystem and other large-scale networks in this disorder.

Autism spectrum disorder (ASD) is associated with genetic risk on the oxytocin system, suggesting oxytocin involvement in ASD; yet oxytocin functioning in young children with ASD is unknown.

To assess baseline oxytocin in pre-schoolers with ASD and test whether oxytocin production may be enhanced by parent–child contact.

Forty pre-schoolers with high-functioning ASD were matched with 40 typically developing controls. Two home visits included an identical 45-minute social battery once with the mother and once with the father. Four saliva oxytocin samples were collected from each parent and the child during each visit.

Children with ASD had lower baseline oxytocin. Following 20 min of parent–child interactions, oxytocin normalised and remained high during social contact. Fifteen minutes after contact, oxytocin fell to baseline. Oxytocin correlated with parent–child social synchrony in both groups.

Oxytocin dysfunction in ASD is observed in early childhood. The quick improvement in oxytocin production following parent–child contact underscores the malleability of the system and charts future directions for attachment-based behavioural and pharmacological interventions.

Although manic episodes reportedly contribute to cognitive deficits in bipolar I disorder, the contribution of depressive episodes is poorly researched.

We investigated the impact of depressive episodes on cognitive function early in the course of bipolar I disorder.

A total of 68 patients and 38 controls from the Systematic Treatment Optimization Programme for Early Mania (STOP-EM) first-episode mania programme were examined. We conducted (a) a cross-sectional analysis of the impact of prior depressive episodes on baseline cognitive function and (b) a prospective analysis assessing the contribution of depression recurrence within 1 year following a first episode of mania on cognitive functioning.

The cross-sectional analysis showed no significant differences between patients with past depressive episodes compared with those without, on overall or individual domains of cognitive function (all P>0.09). The prospective analysis failed to reveal a significant group×time interaction for cognitive decline from baseline to 1 year (P = 0.99) in patients with a recurrence of depressive episodes compared with those with no recurrence. However, impaired verbal memory at baseline was associated with a depression recurrence within 1 year.

Although deficits in all domains of cognitive function are seen in patients early in the course of bipolar disorder, depressive episodes do not confer additional burden on cognitive function. However, poorer verbal memory may serve as a marker for increased susceptibility to depression recurrence early in the course of illness.

People with intellectual disabilities have a high risk of osteoporosis and fractures, which could partly be as a result of vitamin D deficiency.

To compare the serum vitamin D (25(OH)D) levels of 155 patients with intellectual disabilities under psychiatric care and 192 controls, investigate potential risk factors for vitamin D deficiency in people with intellectual disabilities and assess available treatments.

Cross-sectional observational study followed by treatment evaluation.

Almost twice as many patients with intellectual disabilities had vitamin D deficiency (25(OH)D <50 nmol/l) compared with controls (77.3% v. 39.6%, P<0.0001). In the intellectual disabilities group, winter season (P<0.0001), dark skin pigmentation (P<0.0001), impaired mobility (P = 0.002) and obesity (P = 0.001) were independently associated with lower serum 25(OH)D. In most patients, 800 IU colecalciferol daily normalised 25(OH)D levels.

Vitamin D deficiency is highly prevalent in people with intellectual disabilities, partly because of insufficient exposure to sunlight. Screening and treatment strategies, aiming to reduce these patients' high fracture risk, should be introduced. Similar strategies may be required in other psychiatric populations at risk for fractures and with a tendency to spend excessive time indoors.

The impact of longitudinal psychiatric comorbidity, parenting and social characteristics on attention-deficit hyperactivity disorder (ADHD) medication use is still poorly understood.

To assess the baseline and longitudinal influences of behavioural and environmental factors on ADHD medication use.

Survival regressions with time-dependent covariates were used to model data from a population-based longitudinal birth cohort. The sample (n = 1920) was assessed from age 5 months to 10 years. Measures of children's psychiatric symptoms, parenting practices and social characteristics available at baseline and during follow-up were used to identify individual and family-level features associated with subsequent use of ADHD medication.

Use of ADHD medication ranged from 0.2 to 8.6% between ages 3.5 to 10 years. Hyperactivity–inattention was the strongest predictor of medication use (hazard ratio (HR) = 2.75, 95% CI 2.35–3.22). Among all social variables examined, low maternal education increased the likelihood of medication use (HR = 2.09, 95% CI 1.38–3.18) whereas immigrant status lowered this likelihood (HR = 0.40, 95% CI 0.17–0.92).

Beyond ADHD symptoms, the likelihood of receiving ADHD medication is predicted by social variables and not by psychiatric comorbidity or by parenting. This emphasises the need to improve global interventions by offering the same therapeutic opportunities (including medication) as those received by the rest of the population to some subgroups (i.e. immigrants) and by diminishing possible unnecessary prescriptions.

Research on gene×environment interaction in major depressive disorder (MDD) has thus far primarily focused on candidate genes, although genetic effects are known to be polygenic.

To test whether the effect of polygenic risk scores on MDD is moderated by childhood trauma.

The study sample consisted of 1645 participants with a DSM-IV diagnosis of MDD and 340 screened controls from The Netherlands. Chronic or remitted episodes (severe MDD) were present in 956 participants. The occurrence of childhood trauma was assessed with the Childhood Trauma Interview and the polygenic risk scores were based on genome-wide meta-analysis results from the Psychiatric Genomics Consortium.

The polygenic risk scores and childhood trauma independently affected MDD risk, and evidence was found for interaction as departure from both multiplicativity and additivity, indicating that the effect of polygenic risk scores on depression is increased in the presence of childhood trauma. The interaction effects were similar in predicting all MDD risk and severe MDD risk, and explained a proportion of variation in MDD risk comparable to the polygenic risk scores themselves.

The interaction effect found between polygenic risk scores and childhood trauma implies that (1) studies on direct genetic effect on MDD gain power by focusing on individuals exposed to childhood trauma, and that (2) individuals with both high polygenic risk scores and exposure to childhood trauma are particularly at risk for developing MDD.

Individuals with a mental health disorder appear to be at increased risk of medical illness.

To examine rates of medical illnesses in patients with bipolar disorder (n = 1720) and to examine the clinical course of the bipolar illness according to lifetime medical illness burden.

Participants recruited within the UK were asked about the lifetime occurrence of 20 medical illnesses, interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and diagnosed according to DSM-IV criteria.

We found significantly increased rates of several medical illnesses in our bipolar sample. A high medical illness burden was associated with a history of anxiety disorder, rapid cycling mood episodes, suicide attempts and mood episodes with a typically acute onset.

Bipolar disorder is associated with high rates of medical illness. This comorbidity needs to be taken into account by services in order to improve outcomes for patients with bipolar disorder and also in research investigating the aetiology of affective disorder where shared biological pathways may play a role.

None.

In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population.

To examine the quality of assessment and treatment of physical health problems in people with schizophrenia.

Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey.

Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received.

Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.

Care pathways for women needing expensive, secure hospital care are poorly understood.

To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type.

Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fisher's exact tests for categorical data. Thematic analysis was used for free text data.

The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone.

Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

Most developmental studies on suicide do not take into account individual variations in suicide trajectories.

Using a life course approach, this study explores developmental models of suicide trajectories.

Two hundred and fourteen suicides were assessed with mixed methods. Statistical analysis using combined discrete-time survival (DTS) and growth mixture modelling (GMM) generated various trajectories, and path analysis (Mplus) identified exogenous and mediating variables associated with these trajectories.

Two groups share common risk factors, and independently of these major risk factors, they have different developmental trajectories: the first group experienced a high burden of adversity and died by suicide in their early 20s; and the second group experienced a somewhat moderate or low burden of adversity before they took their own life. Structural equation modelling identified variables specific to the early suicide trajectory: conduct and behavioural difficulties, social isolation/conflicts mediated by school-related difficulties, the end of a love relationship, and previous suicide attempts.

Psychosocial adversity between 10 and 20 years of age may warrant key periods of intervention.

Most studies of post-traumatic stress disorder (PTSD) in low- and middle-income countries (LMICs) have focused on ‘high-risk’ populations defined by exposure to trauma.

To estimate the prevalence of post-traumatic stress disorder (PTSD) in a LMIC, the conditional probability of PTSD given a traumatic event and the strength of associations between traumatic events and other psychiatric disorders.

Our sample contained a mix of 3995 twins and 2019 non-twins. We asked participants about nine different traumatic exposures, including the category ‘other’, but excluding sexual trauma.

Traumatic events were reported by 36.3% of participants and lifetime PTSD was present in 2.0%. Prevalence of non-PTSD lifetime diagnosis was 19.1%. Of people who had experienced three or more traumatic events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.

Despite high rates of exposure to trauma, this population had lower rates of PTSD than high-income populations, although the prevalence might have been slightly affected by the exclusion of sexual trauma. There are high rates of non-PTSD diagnoses associated with trauma exposure that could be considered in interventions for trauma-exposed populations. Our findings suggest that there is no unique relationship between traumatic experiences and the specific symptomatology of PTSD.

© Royal College of Psychiatrists 2014. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

All antipsychotic medications carry warnings of increased mortality for older adults, but little is known about comparative mortality risks between individual agents.

To estimate the comparative mortality risks of commonly prescribed antipsychotic agents in older people living in the community.

A retrospective, claims-based cohort study was conducted of people over 65 years old living in the community who had been newly prescribed risperidone, olanzapine, quetiapine, haloperidol, aripiprazole or ziprasidone (n = 136 393). Propensity score-adjusted Cox proportional hazards models assessed the 180-day mortality risk of each antipsychotic compared with risperidone.

Risperidone, olanzapine and haloperidol showed a dose–response relation in mortality risk. After controlling for propensity score and dose, mortality risk was found to be increased for haloperidol (hazard ratio (HR) = 1.18, 95% CI 1.06–1.33) and decreased for quetiapine (HR = 0.81, 95% CI 0.73–0.89) and olanzapine (HR = 0.82, 95% CI 0.74–0.90).

Significant variation in mortality risk across commonly prescribed antipsychotics suggests that antipsychotic selection and dosing may affect survival of older people living in the community.

Research on paranoia in adults suggests a spectrum of severity, but this dimensional approach has yet to be applied to children or to groups from different countries.

To investigate the structure, prevalence and correlates of mistrust in children living in the UK and Hong Kong.

Children aged 8–14 years from the UK (n = 1086) and Hong Kong (n = 1412) completed a newly developed mistrust questionnaire as well as standard questionnaire measures of anxiety, self-esteem, aggression and callous–unemotional traits.

Confirmatory factor analysis of the UK data supported a three-factor model – mistrust at home, mistrust at school and general mistrust – with a clear positive skew in the data: just 3.4%, 8.5% and 4.1% of the children endorsed at least half of the mistrust items for home, school and general subscales respectively. These findings were replicated in Hong Kong. Moreover, compared with their peers, ‘mistrustful’ children (in both countries) reported elevated rates of anxiety, low self-esteem, aggression and callous–unemotional traits.

Mistrust may exist as a quantitative trait in children, which, as in adults, is associated with elevated risks of internalising and externalising problems.

Considerable variations in the incidence of psychosis have been observed across countries, in terms of age, gender, immigration status, urbanicity and socioeconomic deprivation.

To evaluate the incidence rate of first-episode psychosis in a large area of north-eastern Italy and the distribution of the above-mentioned risk factors in individuals with psychoses.

Epidemiologically based survey. Over a 3-year period individuals with psychosis on first contact with services were identified and diagnosed according to ICD-10 criteria.

In total, 558 individuals with first-episode psychosis were identified during 3 077 555 person-years at risk. The annual incidence rate per 100 000 was 18.1 for all psychoses, 14.3 for non-affective psychoses and 3.8 for affective psychoses. The rate for all psychoses was higher in young people aged 20–29 (incidence rate ratio (IRR) = 4.18, 95% CI 2.77–6.30), immigrants (IRR = 2.26, 95% CI 1.85–2.75) and those living in the most deprived areas (IRR = 2.09, 95% CI 1.54–2.85).

The incidence rate in our study area was lower than that found in other European and North American studies and provides new insights into the factors that may increase and/or decrease risk for developing psychosis.