Individuals with anxiety disorders often do not receive an accurate diagnosis or adequate treatment in primary care.

To analyse the cost-effectiveness of an optimised care model for people with anxiety disorders in primary care.

In a cluster randomised controlled trial, 46 primary care practices with 389 individuals positively screened with anxiety were randomised to intervention (23 practices, 201 participants) or usual care (23 practices, 188 participants). Physicians in the intervention group received training on diagnosis and treatment of anxiety disorders combined with the offer of a psychiatric consultation–liaison service for 6 months. Anxiety, depression, quality of life, service utilisation and costs were assessed at baseline, 6-month and 9-month follow-up.

No significant differences were observed between intervention and control group on the Beck Anxiety Inventory, Beck Depression Inventory and EQ–5D during follow-up. Total costs were higher in the intervention group (€4911 v. €3453, P = 0.09). The probability of an incremental cost-effectiveness ratio <€50 000 per quality-adjusted life year was below 10%.

The optimised care model did not prove to be cost-effective.

Although schizotypal traits, such as anhedonia and aberrant perceptions, may increase the risk for schizophrenia-spectrum disorders, little is known about early-life characteristics that predict more pronounced schizotypal traits.

To examine whether birth size or several other early-life factors that have been previously linked with schizophrenia predict schizotypal traits in adulthood.

Participants of the Northern Finland 1966 Birth Cohort Study (n = 4976) completed a questionnaire on positive and negative schizotypal traits at the age of 31 years.

Lower placental weight, lower birth weight and smaller head circumference at 12 months predicted elevated positive schizotypal traits in women after adjusting for several confounders (P<0.02). Moreover, higher gestational age, lower childhood family socioeconomic status, undesirability of pregnancy, winter/autumn birth, higher birth order and maternal smoking during pregnancy predicted some augmented schizotypal traits in women, some in men and some in both genders.

The results point to similarities in the aetiology of schitzotypal traits and schizophrenia-spectrum disorders.

The community treatment order (CTO) is the legal framework by which people in the community are compelled to accept treatment. Both antipsychotic long-acting injections (LAIs) and CTOs are used to address treatment non-adherence.

To investigate the relationship between CTOs and LAI use in patients with schizophrenia.

Prescribing, demographic and CTO data were collected for patients from four community mental health clinics in Melbourne, Australia, in 1998 and 2002.

Against a background of increasing use of oral second-generation antipsychotic (SGA) medication and decreasing use of LAIs, the rates of CTO implementation doubled from 13% to 26% of patients with schizophrenia between 1998 and 2002. Proportionally more patients with a CTO are prescribed LAIs rather than oral SGAs.

The relationship between receiving an LAI and being subject to a CTO is significant, and reflects the consideration given to enhancing adherence in a community mental health setting.

Studies of diet and depression have focused primarily on individual nutrients.

To examine the association between dietary patterns and depression using an overall diet approach.

Analyses were carried on data from 3486 participants (26.2% women, mean age 55.6 years) from the Whitehall II prospective cohort, in which two dietary patterns were identified: ‘whole food’ (heavily loaded by vegetables, fruits and fish) and ‘processed food’ (heavily loaded by sweetened desserts, fried food, processed meat, refined grains and high-fat dairy products). Self-reported depression was assessed 5 years later using the Center for Epidemiologic Studies – Depression (CES–D) scale.

After adjusting for potential confounders, participants in the highest tertile of the whole food pattern had lower odds of CES–D depression (OR = 0.74, 95% CI 0.56–0.99) than those in the lowest tertile. In contrast, high consumption of processed food was associated with an increased odds of CES–D depression (OR = 1.58, 95% CI 1.11–2.23).

In middle-aged participants, a processed food dietary pattern is a risk factor for CES–D depression 5 years later, whereas a whole food pattern is protective.

Existing neuropsychological studies of obsessive–compulsive disorder (OCD) are cross-sectional and do not provide evidence of whether deficits are trait-related (antecedent and independent of symptomatology) or state-related (a consequence, dependent on symptomatology).

To investigate whether there are premorbid neuropsychological deficits associated with adult OCD.

Longitudinal data were collected from participants of the Dunedin Multidisciplinary Health and Developmental study. Neuropsychological data collected at age 13 were linked with age 32 diagnosis of OCD.

The group who had OCD at age 32 differed significantly from the control group with no OCD on their performance at age 13 on neuropsychological tests of visuospatial, visuoconstructive and visuomotor skills, controlling for gender and socioeconomic status, but did not differ on tests of general IQ or verbal ability. Performance of the group with OCD on tests of executive functioning was mixed.

Individuals with OCD have premorbid impairment in visuospatial abilities and some forms of executive functioning, consistent with biological models of OCD.

There have been conflicting reports on whether the length polymorphism in the promoter of the serotonin transporter gene (5-HTTLPR) moderates the antidepressant effects of selective serotonin reuptake inhibitors (SSRIs). We hypothesised that the pharmacogenetic effect of 5-HTTLPR is modulated by gender, age and other variants in the serotonin transporter gene.

To test the hypothesis that the 5-HTTLPR differently influences response to escitalopram (an SSRI) compared with nortriptyline (a noradrenaline reuptake inhibitor).

The 5-HTTLPR and 13 additional markers across the serotonin transporter gene were genotyped in 795 adults with moderate-to-severe depression treated with escitalopram or nortriptyline in the Genome Based Therapeutic Drugs for Depression (GENDEP) project.

The 5-HTTLPR moderated the response to escitalopram, with long-allele carriers improving more than short-allele homozygotes. A significant three-way interaction between 5-HTTLPR, drug and gender indicated that the effect was concentrated in males treated with escitalopram. The single-nucleotide polymorphism rs2020933 also influenced outcome.

The effect of 5-HTTLPR on antidepressant response is SSRI specific conditional on gender and modulated by another polymorphism at the 5' end of the serotonin transporter gene.

Susceptibility to depression results from genetic and non-familially shared environmental influences in high-income, Western countries. Environments may play a different role for populations in different contexts.

To examine heritability of depression in the first large, population-based twin study in a low-income country.

Lifetime depression and a broader measure of depression susceptibility (D-probe) were assessed in 3908 adult twins in Sri Lanka (the CoTASS study).

There were gender differences for the broad definition (D-probe), with a higher genetic contribution in females (61%) than males (4%). Results were similar for depression, but the prevalence was too low to estimate heritability for males.

Genetic influences on depression in women appear to be at least as strong in this Sri Lankan sample as in higher-income countries. Conclusions are less clear for men but suggest a larger role for environments rather than genes. The nature as well as the magnitude of environmental influences may also differ across populations.

Structural brain abnormalities have been described in individuals with an at-risk mental state for psychosis. However, the neuroanatomical underpinnings of the early and late at-risk mental state relative to clinical outcome remain unclear.

To investigate grey matter volume abnormalities in participants in a putatively early or late at-risk mental state relative to their prospective clinical outcome.

Voxel-based morphometry of magnetic resonance imaging data from 20 people with a putatively early at-risk mental state (ARMS–E group) and 26 people with a late at-risk mental state (ARMS–L group) as well as from 15 participants with at-risk mental states with subsequent disease transition (ARMS–T group) and 18 participants without subsequent disease transition (ARMS–NT group) were compared with 75 healthy volunteers.

Compared with healthy controls, ARMS–L participants had grey matter volume losses in frontotemporolimbic structures. Participants in the ARMS–E group showed bilateral temporolimbic alterations and subtle prefrontal abnormalities. Participants in the ARMS–T group had prefrontal alterations relative to those in the ARMS–NT group and in the healthy controls that overlapped with the findings in the ARMS–L group.

Brain alterations associated with the early at-risk mental state may relate to an elevated susceptibility to psychosis, whereas alterations underlying the late at-risk mental state may indicate a subsequent transition to psychosis.

Adolescents with first-episode psychosis have increased severity of neurological soft signs when compared with controls, but it is unclear whether increased severity of neurological soft signs is an expression of specific structural brain deficits.

To examine whether increased severity of neurological soft signs was associated with decreased brain volumes in adolescents with first-episode psychosis.

Brain scans were obtained for 70 adolescents (less than 18 years of age) with first-episode psychosis (duration of positive symptoms less than 6 months). Volumes were assessed using voxel-based morphometry and through segmentation of anatomical structures.

Increased severity of sensory integration neurological soft signs correlated with smaller right and left thalamus volume, whereas increased severity of sequencing of complex motor acts neurological soft signs correlated with smaller right caudate volume.

Neurological soft signs may be an easy-to-assess marker of region-specific structural brain deficits in adolescents with first-episode psychosis.

The short (s) allele of the serotonin transporter gene promoter (5-HTTLPR) may be associated with exposure to social adversities and the subsequent onset of depressive illness in adulthood.

To test in adolescents at high risk for depression whether the short ‘s’ allele is associated with levels of morning cortisol and the subsequent onset of a depressive episode.

High-risk adolescents (n = 403) were genotyped for 5-HTTLPR. Salivary samples were obtained on four consecutive school days within 1 h of waking from 393 (97.5%) individuals and 367 (91%) underwent a mental state reassessment at 12 months.

Multilevel analysis revealed higher levels of salivary cortisol in short allele carriers (s/s>s/l>l/l). A subsequent episode of depression was increased in those with higher cortisol and the ‘s’ allele, and independently by depressive symptoms at entry, in both genders.

The short allele of 5-HTTLPR may moderate the association between morning cortisol and the subsequent onset of a depressive episode.

Negative parenting practices may be an environmental risk factor for subsequent conduct problems. Research on the association between parenting practices and callous–unemotional traits, a risk factor for conduct problems, has produced mixed findings.

To investigate whether negative parental discipline is a non-shared environmental risk factor for the development of conduct problems and callous–unemotional traits.

Longitudinal, multi-informant data from a community sample of twins were analysed using the monozygotic (MZ) twin differences design for 4508 twins (2254 twin pairs).

Within MZ twin pairs, the twin receiving more negative parental discipline at 7 years had more conduct problems (but not more callous–unemotional traits) at 12 years.

During the transition to early adolescence, negative parental discipline operates as a non-shared environmental risk factor for development of conduct problems, but not for the development of callous–unemotional traits.

The proportion of the global population aged 60 and over is increasing, more so in Latin America than any other region. Depression is common among elderly people and an important cause of disability worldwide.

To estimate the prevalence and correlates of late-life depression, associated disability and access to treatment in five locations in Latin America.

A one-phase cross-sectional survey of 5886 people aged 65 and over from urban and rural locations in Peru and Mexico and an urban site in Venezuela. Depression was identified according to DSM–IV and ICD–10 criteria, Geriatric Mental State–Automated Geriatric Examination for Computer Assisted Taxonomy (GMS–AGECAT) algorithm and EURO–D cut-off point. Poisson regression was used to estimate the independent associations of sociodemographic characteristics, economic circumstances and health status with ICD–10 depression.

For DSM–IV major depression overall prevalence varied between 1.3% and 2.8% by site, for ICD–10 depressive episode between 4.5% and 5.1%, for GMS–AGECAT depression between 30.0% and 35.9% and for EURO–D depression between 26.1% and 31.2%; therefore, there was a considerable prevalence of clinically significant depression beyond that identified by ICD–10 and DSM–IV diagnostic criteria. Most older people with depression had never received treatment. Limiting physical impairments and a past history of depression were the two most consistent correlates of the ICD–10 depressive episode.

The treatment gap poses a significant challenge for Latin American health systems, with their relatively weak primary care services and reliance on private specialists; local treatment trials could establish the cost-effectiveness of mental health investment in the government sector.

The typical pattern for intervention outcome studies for conduct problems has been for effect sizes to dissipate over time with decreasing effects across subsequent follow-ups.

To establish whether the short-term positive effects of a parenting programme are sustained longer term. To observe trends, and costs, in health and social service use after intervention.

Parents with children aged 36–59 months at risk of developing conduct disorder (n = 104) received intervention between baseline and first follow-up (6 months after baseline n = 86) in 11 Sure Start areas in North Wales. Follow-ups two (n = 82) and three (n = 79) occurred 12 and 18 months after baseline. Child problem behaviour and parenting skills were assessed via parent self-report and direct observation in the home.

The significant parent-reported improvements in primary measures of child behaviour, parent behaviour, parental stress and depression gained at follow-up one were maintained to follow-up three, as were improved observed child and parent behaviours. Overall, 63% of children made a minimum significant change (0.3 standard deviations) on the Eyberg Child Behavior Inventory problem scale between baseline and follow-up (using intention-to-treat data), 54% made a large change (0.8 standard deviations) and 39% made a very large change (1.5 standard deviations). Child contact with health and social services had reduced at follow-up three.

Early parent-based intervention reduced child antisocial behaviour and benefits were maintained, with reduced reliance on health and social service provision, over time.

Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia.

To review existing guidelines concerning antipsychotic use generally, and LAIs in particular, and how patients might be identified as potential candidates for LAI treatment.

Literature review.

Currently several first-generation and one second-generation antipsychotic LAIs are available, with others under development. Although the use of LAIs is widespread around the world, patterns of use vary widely. Important considerations regarding the use of LAIs include the indications for long-term pharmacotherapy in schizophrenia in general, the indications for LAIs, the risks associated with LAIs, the need to update guidelines and the issue of cost.

The use of these injections in first-episode psychosis and treatment-refractory schizophrenia is not currently a focus of recommendations, but should be considered. Long-acting injections remain an underutilised option in many countries despite frequent non-adherence with oral medication and subsequent relapse.

Women with borderline personality disorder have conflictual interpersonal relations that may extend to disrupted patterns of interaction with their infants.

To assess how women with borderline personality disorder engage with their 12 to 18-month-old infants in separation–reunion episodes.

We videotaped mother–infant interactions in separation–reunion episodes of the Strange Situation test. The mothers were women with borderline personality disorder, with depression, or without psychopathological disorder. Masked ratings of maternal behaviour were made with the Atypical Maternal Behavior Instrument for Assessment and Classification.

As predicted, a higher proportion (85%) of women with borderline personality disorder than women in the comparison groups showed disrupted affective communication with their infants. They were also distinguished by the prevalence of frightened/disoriented behaviour.

Maternal borderline personality disorder is associated with dysregulated mother–infant communication.