‘Early intervention’ can refer to two different approaches-intervention when the psychosis is already evident and intervention before a psychosis is fully apparent. Each carries a distinctly different set of risks. The hoped-for benefits of early intervention in a fully evident psychosis are based on research that reveals an association between intervention early in the illness and good outcome. Those suffering from a psychosis of recent onset, however, are more likely to experience a spontaneous remission of illness, and this may readily explain the observed association. Early intervention in such cases of good-prognosis psychosis may lead to unnecessary and, sometimes, protracted treatment for those who would do well with no treatment. Intervention in the supposed prodromal phase of psychosis presents more serious hazards. The screening instruments currently available are inadequate for the accurate prediction of psychosis, and the risks of negative effects for the large numbers of people who screen false-positive are considerable. These risks include unnecessary fear of illness, restriction of life goals, use of medication and their side-effects.

We prospectively studied the long-term course of individuals with acute and transient psychotic disorders and a control group with positive schizophrenia matched for age and gender. Follow-up investigations using standardised instruments were performed at three time-points covering 7 years after the index episode or 12 years after the first episode. During follow-up, those with positive schizophrenia experienced a deterioration in their general functioning whereas those with acute and transient psychotic disorders retained their high level of functioning. At the end of the observation period, 12 out of 39 (31%) of those with acute and transient psychotic disorders were functioning well without medication compared with 0 out of 38 with positive schizophrenia.

Cross-sectional analysis of 441 individuals with bipolar disorder treated at a US health maintenance organisation investigated the distribution of manic and depressive symptoms in that illness. Clinically significant depressive symptoms occurred in 94.1% of those with (hypo)mania, while70.1% inadepressive episode had clinically significant manic symptoms. DSM-unrecognised depression-plus-hypomania was over twice as prevalent as DSM-recognised mixed episodes. Depressive symptoms were unimodally distributed in (hypo)mania. Depressive and manic symptoms were positively, not inversely correlated, and their co-occurrence was associated with worse quality of life. Implications for the DSM and ICD nosological systems are discussed.

We investigated the epidemiology of intentional self-poisoning in rural Sri Lanka by prospectively recording 2189 admissions to two secondary hospitals. Many patients were young (median age 25 years), male (57%) and used pesticides (49%). Of the 198 who died, 156 were men (case fatality 12.4%) and 42 were women (4.5%). Over half of female deaths were in those under 25 years old; male deaths were spread more evenly across age groups. Oleander and paraquat caused 74% of deaths in people under 25 years old; thereafter organophosphorous pesticides caused many deaths. Although the age pattern of self-poisoning was similar to that of industrialised countries, case fatality was more than 15 times higher and the pattern of fatal self-poisoning different.

Avolition affects quality of life in chronic schizophrenia. We investigated the relationship between unconstrained motor activity and the volume of key executive brain regions in 16 male patients with schizophrenia. Wrist-worn actigraphy monitors were used to record motor activity over a 20 h period. Structural magnetic resonance imaging brain scans were parcellated and individual volumes for anterior cingulate cortex and dorsolateral prefrontal cortex extracted. Patients' total activity was positively correlated with volume of left anterior cingulate cortex. These data suggest that the volume of specific executive structures may affect (quantifiable) motor behaviours, having further implications for models of the ‘will’ and avolition.

The validity of the clinical construct of post-traumatic stress disorder (PTSD) has been questioned in non-Western cultures. This report describes in-depth interviews exploring the experiences of women who were traumatised by the communal riots in Ahmedabad, India, in March 2002. Three specific narratives are presented which describe experiences that closely resemble re-experiencing, avoidance and hyperarousal. Thus, symptoms described as characteristic features of PTSD in biomedical classifications are clearly expressed by the women in our study, and are attributed by them to trauma and grief. We conclude that PTSD may be a relevant clinical construct in the Indian context.

Psychiatric disorders have been associated with poor outcome in individuals with chronic fatigue syndrome (CFS). This study examines the impact of psychiatric disorders on outcome of cognitive-behavioural therapy (CBT). Psychiatric diagnoses were assessed with a structured psychiatric interview in a CBT trial of 270 people with CFS. Lifetime and current psychiatric disorders were found in 50 and 32% respectively. No significant differences in fatigue severity and functional impairment following treatment were found between participants with and without psychiatric diagnoses.

The challenges of early diagnosis are similar in psychiatry to the rest of medicine. For potentially severe and persistent disorders there is great value in early diagnosis, however, only under certain conditions. Early diagnosis would not be justified if there were no efficacious treatments or if such treatments provided earlier would do more harm than good for those exposed. There is growing evidence that earlier and sustained intervention improves at least short-term outcomes. However, early intervention may be iatrogenic where systems of care are poor in quality. One thing is clear, the general pattern of care is still ‘too little, too late’ even in the most affluent countries. Consistent and extensive reform of health systems, with recognition of early intervention as an increasingly evidence-based ‘best buy’, represents one of the key priorities in international mental health.

Issues that undermine the early detection of schizophrenia include an inadequate grasp of the construct validity of the concept of schizophrenia, insufficient conceptualisation of psychosis and of the illness onset, and a general lack of a theoretical framework for psychopathology. Subjective experience is emphasised as a potentially promising domain for future research.

No intervention has been shown to be effective in preventing repetition of self-harm. In the 6-month follow-up of a large randomised controlled trial, we previously reported no effectiveness of the provision of a card offering 24-h crisis telephone consultation on repetition of self-harm. However, there was a possible benefit among those presenting following a first episode (OR=0.64, 95% CI 0.34–1.22). Here we report the 12-month follow-up of the trial. The results confirm no overall benefit of the intervention (OR=1.19, 95% CI 0.85–1.67). Among those with a first episode of self-harm, the possible benefit of the intervention had diminished (OR=0.89, 95% CI 0.52–1.52), although a modest effect cannot be excluded.