This issue contains two editorials, one on community treatment orders and one on pathways between late-life depression and disability, and a review and commentary on second-generation antipsychotics. Other sets of papers examine various aspects of psychosis and mood disorders. Three final papers examine other topics.
Community treatment orders
In the first editorial, Burns & Dawson (pp. 1583–1586) note that compulsory treatment orders (CTOs) are a feature of most advanced mental health systems, but there remains a lack of experimental evidence of their benefits. The authors pose the question of whether it is ethical to continue with CTOs in the absence of such evidence and argue that responsibility for ensuring it is collected lies as much with governments as with researchers.
Pathways between late-life depression and disability
In the second editorial, Carrière et al. (pp. 1587–1590) note that research has consistently shown an association between late-life depression and disability but little is known about possible mechanisms. The authors further note that recent longitudinal studies have been inconsistent in the use of criteria to establish causality. They consequently argue that future research needs to adopt more stringent theoretical criteria for establishing the role of potential mechanisms mediating the relationship between late-life depression and disability.
Second-generation antipsychotics
Leucht et al. (pp. 1591–1602) review recent evidence and meta-analyses of the effectiveness of second-generation antipsychotics (SGAs) for schizophrenia. The authors conclude that the data show that SGAs are not a homogenous group, and suggest this classification be abandoned. They further conclude that the data are consistent across studies and suggest that SGAs are not a major treatment breakthrough. In response, Lewis's commentary (pp. 1603–1606) notes a number of strengths of Leucht et al.'s review, including the systematic examination of possible sources of bias, and challenges some conclusions, notably the suggestion that SGAs are not a class. In conclusion, Lewis concurs with Leucht et al. that SGAs are not the significant advance in treatment that was once thought.
Psychosis
Seven papers examine aspects of psychosis. In the first, Morrison et al. (pp. 1607–1616) examined the relationship between psychotic symptoms induced by Δ9-tetrahydrocannabinol (THC), a constituent of cannabis, and consequent anxiety and neuropsychological impairment in a sample of 22 healthy adults. The authors found that THC can induce a transient and acute psychotic reaction in healthy adults. There was no evidence that the extent of the psychotic reaction was related to degree of anxiety or cognitive impairment.
Valmaggia et al. (pp. 1617–1626) compared the cost-effectiveness of a service for people with an at-risk mental state for psychosis in south London (OASIS) with care as usual (CAU) using a decision model for periods of 12 and 24 months, with duration of untreated psychosis and rates of transition as key parameters. The authors found that, over the initial 12 months following presentation, the costs of OASIS were £1872 higher than CAU. After 24 months, the costs were £961 less than CAU. The authors conclude that services permitting early detection of individuals at high risk of psychosis may produce cost savings over time.
Fowler et al. (pp. 1627–1636) report findings from a preliminary single-blind, randomized controlled trial of cognitive behaviour therapy to improve social recovery among young people in the early stages of psychosis. In a comparison of 35 participants receiving CBT and treatment as usual (TAU) and 42 participants receiving TAU only, the authors found no effect for CBT in the full sample of participants. However, when stratified by diagnostic group there was evidence for the benefit of CBT for those with a non-affective psychosis, who showed significant improvements in weekly hours in constructive and structured activity and Positive and Negative Symptom Scale scores.
Brekke et al. (pp. 1637–1647) examined neurocognitive change, and associations with functional improvement and service use, in a sample of 130 individuals with schizophrenia assessed at baseline, 6 months and 12 months. The authors found evidence of neurocognitive and functional improvement over time. These improvements were correlated, such that those with functional improvement were more likely to show neurocognitive improvement. The authors further found service use was greatest in those who showed both neurocognitive and functional improvement.
O'Connor et al. (pp. 1649–1655) investigated cognitive deficits in a sample of 97 individuals at high risk for schizophrenia and 25 controls. The authors found that, after adjusting for IQ, high-risk individuals had significantly reduced spatial memory capacity and planning processing speed compared with controls. No similar differences were found for problem-solving and strategy performance after adjusting for IQ. The authors conclude that spatial memory capacity and planning processing speed may represent cognitive endophenotypes for schizophrenia.
Kircher et al. (pp. 1657–1665) examined the association between the dystrobrevin-binding protein 1 (DTNBP1) gene, a candidate susceptibility gene for schizophrenia, and personality traits and cognitive function in a sample of 521 healthy subjects. The authors found significantly lower scores on a measure of schizoptypal personality and interpersonal deficits in carriers of the A-risk allele. There were no associations with cognition. The authors conclude that genetic variation of the DTNBP1 genotype may exert gene-specific modulating effects on schizophrenia endophenotypes at the population level.
In the final paper on aspects of psychosis, MacCabe et al. (pp. 1667–1676) investigated lifetime reproductive output over two generations of patients with psychosis and their unaffected siblings in a sample of 12168 subjects drawn from the Uppsala 1915–1929 Birth Cohort. The authors found that those with schizophrenia had fewer children, an association that was partly explained by lower marriage rates. The authors further found that there was no evidence of any compensatory increase in reproduction in unaffected siblings of those with schizophrenia. Those with an affective psychosis and their relatives did not differ from the general population on any measure of fertility.
Mood disorders
Four further papers examine aspects of mood disorders. In the first, Hybels et al. (pp. 1677–1688) investigated the relationship between sub-threshold symptoms of depression and functional limitations in a sample of older adults drawn from the Duke Established Populations for Epidemiologic Studies of the Elderly. The authors found that having six or more symptoms predicted a significant increase in functional limitations 3–4 years later. At higher numbers of symptoms there was no evidence of a further increase in functional limitations. The authors conclude that the relationship between depressive symptoms and functional change is complex and may not be linear.
Coryell et al. (pp. 1689–1695) examined persistence and change of symptoms of depression and mania over a 20-year period in a sample of 148 individuals with bipolar I disorder drawn from the National Institute of Mental Health Collaborative Depression Study. The authors found that, regardless of age at onset, there was evidence that depressive symptoms became increasingly dominant over time and that an earlier age of onset was associated with persistence of depressive symptoms.
Vuorilheto et al. (pp. 1697–1707) investigated the course and outcome of depressive disorders over 18 months in a sample of 123 primary-care patients drawn from the Vantaa Primary Care Depression Study. The authors found that, of those with major depressive disorder (MDD), 25% achieved and remained in full remission and 25% remained in a major depressive episode. The remainder suffered from residual symptoms and recurrences. Time to remission and recurrence were predicted by severity, co-morbid substance use, physical illness, and cluster C personality disorder. Of sub-syndromal patients, 25% went on to develop MDD.
Richmond et al. (pp. 1709–1720) examined the effect of post-injury depression on return to pre-injury levels of function in a sample of 248 individuals followed for 18 months after presentation to an emergency department for an injury. The authors found that, during the year post-injury, 18% of the sample developed depression. After adjusting for a number of potential confounders, the depressed group were least likely to return to pre-injury levels of: activities in daily living; instrumental activities of daily living; and pre-injury work status.
Other topics
In the first of three final papers on other topics, Coid et al. (pp. 1721–1731) investigated associations between social functioning and service use and Axis I and Axis II disorders in individuals with borderline personality disorder (BPD) in a sample of 8397 in the UK. The authors found that 58% of those with BPD reported consultation with a health professional in the preceding year and 13% reported a lifetime psychiatric admission. BPD was independently associated with comorbid psychotic, depressive and anxiety disorders, but not impaired functioning. The authors note that these findings indicate that a sub-group of those with BPD do not have comorbid disorders and are relatively high functioning.
Haaland et al. (pp. 1733–1743) examined neuropsychological function in a sample of 35 individuals with BPD and 35 controls. The authors found that, independent of IQ, those with BPD had reduced executive functioning compared with controls. No other neurocognitive differences were found. The authors conclude that those with BPD show a selective deficit in executive functioning, a finding that is consistent with studies that have identified frontal regions as potential biological substrate of BPD.
In the final paper, Himpel et al. (pp. 1745–1751) investigated temporal information processing using discrimination tasks in a sample of 54 sib-pairs with at least one child with attention deficit hyperactivity disorder (ADHD) and 40 control children aged 6–18 years. The authors found that children with ADHD, but not their siblings, were impaired on discrimination tasks with longer intervals. Both those with ADHD and their siblings were impaired on discrimination tasks with shorter intervals. The authors conclude that discrimination of longer intervals may be a ‘disease marker’ whereas discrimination of brief intervals may be a ‘vulnerability marker’.
