England has set an evidence based mental health strategy which encompasses where and how people are cared for and with what aims and goals in view. It has ensured that policy is well rooted in the known epidemiology of mental disorders, that policy does not only focus on those with severe mental disorders who need specific care, but also on those with less severe disorders in primary care, in the workplace and in prisons, and also on the integration and interface of mental health services with other agencies. It has also rooted policy within a coherent framework of prevention mental health promotion, primary, secondary and tertiary prevention and prevention of mortality), and is driving that policy by measuring health outcomes as well as inputs and processes.

Aims – To define the epidemiological and clinical characteristics of Post Stroke Depression (PSD) and to evaluate treatment options. Methods – Systematic search using Medline electronic database limited to studies published from year 2000 to 2004, was carried out. Manual search was also performed. Results – Depression after stroke is a common event. The same, stroke incidence in depressed patients is more frequent than by chance. Risk of underdiagnosing a patient with former stroke is high. Disability after stroke is frequent, with compromission of quality of life of patients and relatives. Antidepressants are efficacious in PSD treatment, even if complete remission is difficult to obtain. Conclusions – There is enough evidence concerning epidemiology, pathogenesis, clinical and therapy to justify psychiatrists' interest on relationship between stroke and depression.

Declaration of Interest: in the past two years PP, GSL, PS have received no fees or other financial support from pharmaceutical companies, GM has received speaker fees from Sanofi-Aventis, Lundbeck, Bayer Health Care, Boehringer Ingelheim, Novo Mordisk.

Objective – To determine the most cost-effective oral therapy for the treatment of Major Depressive Disorder (MDD) in Italy. Method – We conducted a pharmacoeconomic evaluation based on a decision analytic model that examined the treatment of major depressive disorder (MDD) in Italy. The analysis compared the serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine extended-release (venlafaxine XR), to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). A meta-analysis was performed to determine the clinical rates of success. The meta-analytic rates were applied to the decision analytic model to calculate the expected cost and expected outcomes for each anti-depressant comparator. Cost-effectiveness was determined using the expected values for both a successful outcome, and a composite measure of outcome termed ‘symptom-free days’. A policy analysis was conducted to estimate the financial impact to the Servizio Sanitario Nazionale (SSN). Results – Treatment of MDD with venlafaxine XR yielded the highest overall efficacy rates for outpatients (73.7%) versus SSRIs (61.4%) and TCAs (59.3%), and inpatients (62.3%) versus SSRIs (58.6%) and TCAs (58.2%). Venlafaxine XR had the lowest dropout rates due to lack of efficacy (4.8%) versus SSRIs (8.4%) and TCAs (6.8%), and adverse drug reactions (10.9%) versus SSRIs (17.4%) and TCAs (23.1%). Initiating treatment of MDD with venlafaxine XR yielded the lowest expected cost for outpatients and for inpatients. The total resulting savings for the SSN at a 5% venlafaxine XR utilization was estimated between L 963 million and L 3,210 million. Conclusion – This study confirms that venlafaxine XR is generally a cost-effective treatment of MDD. Additionally, the results of this investigation suggest that increased utilization of venlafaxine XR will favorably impact the SSN.

Objective - The aim of this study was to asses type and prevalence of Personality Disorders (PDs) and their patterns of comorbidity with Axis I disorders in a sample of psychiatric inpatients. Setting - The sample consisted of 300 subjects admitted to a psychiatric unit on a voluntary bases for an index episode. The study was conducted over a period of 12 months, from 1.11.1997 to 31.10.1998. Main outcome measures - The Italian version of SCID-II-PQ (Structured Clinical Interview for DSM-III-R personality disorders, with Personality Questionnaire-PQ- a self report questionnaire). Results - More than half the patients had at least one personality disorder. The mean of disorders per patient was 2.83±1.93 (±SD). The most prevalent Axis II disorders were Borderline PD (30.7%), Obsessive-compulsive PD (30.7%) and Avoidant PD (25.3%). Women were significantly more likely than men to meet criteria for Dependent PD and Avoidant PD. Man showed significantly more frequently than women Antisocial PD. Significant associations (p<0.05) were found for comorbidity of Mood Disorders and Avoidant PD, and for Psicoactive Use Disorders and Antisocial PD. Conclusions - Our study confirms the high prevalence of PDs in psychiatric inpatients and showes some interesting associations between Axis I and Axis II disorders. These results can't be generalized to outpatients because our clinical sample involved mainly severely ill inpatients, but they raise questions about the exact nature of PDs and of the relationship with Axis I disorders. Further research involving outpatients and general population is needed to examine factors that could affect development and course of Personality Disorders.

Objective - This article describes the short-term and at 6 months follow-up results of an intensive cognitive-behavioural group treatment on subjects affected by Panic Disorder with or without Agoraphobia (DSM IV criteria). Design and Setting - We studied a group of 22 subjects treated in the public Centro Psico Sociale of Zogno (Bergamo) and valuated them with self-rated instruments inherent the life satisfaction (SF/36) and symptoms and ament (PAAAS; MSPS, STAI-X1, STAI-X2). The results indicate significant improvements at the end of treatment and at a 6 months follow up. Conclusions - We are studying the long-term results with others follow up valuations. The most important result, anyway, is the demonstration that also in an Italian public mental health centre, as in many foreign countries, is possible to treat patients affected by Anxiety Disorders with effectual and relatively low cost tecniques and that is possible to introduce objective results indicators in the routinary clinical activity.

Objective. - To test by means of ROC analysis the performance of the Symptom Questionnaire (SQ) of Kellner and Fava against an interview designed for making DSM-III diagnoses in 517 subjects. To analyse the trend of SQ scores at 3 months, 1 year and 2 years after the first interview in a sample of 112 persons. Design. - Cross-sectional and longitudinal analysis of the distributions of SQ scores in DSM-III cases and in non-cases. Setting. - General practice, hospital medical wards and emergency departments of Regione Emilia Romagna. Main outcome measures. - Symptom Questionnaire, Bech Mini-compendium to formulate DSM-III diagnoses. Results. - The SQ reached high sensitivity and specificity levels (80%, 76% in general practice, 86%, 74% in hospital medical wards, 83%, 85% in emergency departments with the cut-off scores of 24, 24 and 26, respectively). SQ scores show a similar trend in cases and in non-cases, with a significant drop at three months. Conclusions. - The SQ seems to be an adequate screening tool in the above-mentioned settings, but its length and the assistance sometimes needed during the compilation make its use in the emergency departments problematic.

The approach-avoidance conflict (AAC), i.e. the competing tendencies to undertake goal-directed actions or to withdraw from everyday life challenges, stands at the basis of humans' existence defining behavioural and personality domains. Gray's Reinforcement Sensitivity Theory posits that a stable bias toward approach or avoidance represents a psychopathological trait associated with excessive sensitivity to reward or punishment. Optogenetic studies in rodents and imaging studies in humans associated with cross-species AAC paradigms granted new emphasis to the hippocampus as a hub of behavioural inhibition. For instance, recent functional neuroimaging studies show that functional brain activity in the human hippocampus correlates with threat perception and seems to underlie passive avoidance. Therefore, our commentary aims to (i) discuss the inhibitory role of the hippocampus in approach-related behaviours and (ii) promote the integration of functional neuroimaging with cross-species AAC paradigms as a means of diagnostic, therapeutic, follow up and prognosis refinement in psychiatric populations.

Aims - The article describes the evolution of Outsider Art from the birth of its term in 1972 to the present and its emancipation from the margin to the markets, still in progress. Results - Tracing the evolution of Outsider Art evidences a stark contradiction. On one hand the art world of collectors, historians, art dealers and admirateurs, accepts without reservation artwork that for many years was kept in a marginal position, compared to the “insider” art establishment. On the other hand art experts can not agree on a universal definition of this category of art. The particular status of the outsider artists is one of the reasons that causes difficulty in reaching a definition of Outsider Art. Significant atelier experiences with psychiatric patients delineate the difference between an Outsider Art work and a work produced by Art Therapy. Conclusions - The art market of art dealers and art collectors can be identified as the place where these contradictions dissolve, and where the Outsider Art category finds its ultimate legitimation and international recognition.

The Cochrane Collaboration represents a quite successful example of a grass roots international effort aimed at contributing the growing demand for valid and reliable information on the effects of health care intervention, eagerly sought by consumers, patients, doctors and policy makers worldwide. The Cochrane Collaboration is fully aware that part of its success is due to the originality of its founding principles and that the challenge ahead is to maintain its ‘Cochrane Collaboration brand’ while understanding how a mature organisation can cope with the expectations of the relevant stakeholders with whom it seeks to collaborate. In this editorial reference is made to the strategic reflections emerged from the internal review that the organisation has recently completed to guide its years ahead.