Professor Johann Christian Reil of Halle, Germany, first introduced the term ‘psychiatry’ in 1808. He argued that mental illness should be treated by physicians and that psychiatry required the very best medical practitioners. He stressed the important relationships between physical and mental factors in illness and the role of psychotherapy as one of the main treatment approaches in medicine. He was a strong advocate of humane treatment and reduction of stigma. Many of his ideas remain important today.

This editorial summarises the literature on the use of care pathways in psychiatry. Further, it considers the case-mix clusters used in care pathways in relation to health service financial tariff and currency systems, and also reviews the evidence for the effectiveness of clinical pathways.

The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.

Background

The safety of antidepressants in children and adolescents is being questioned and the efficacy of these drugs in juvenile depression remains uncertain.

Aims

To assess antidepressant efficacy in juvenile depression.

Method

Systematic review and meta-analysis of randomised controlled trials (RCTs) comparing responses to antidepressants, overall and by type, v. placebo in young people with depression.

Results

Thirty drug–placebo contrasts in RCTs lasting 8 weeks (median) involved 3069 participants (512 person-years) of average age 13.5 years. Meta-analysis yielded a modest pooled drug/placebo response rate ratio (RR=1.22, 95% CI 1.15–1.31), with little separation between antidepressant types. Findings were similar for response rate differences and corresponding number needed to treat (NNT): overall NNT=9; tricyclic antidepressants NNT=14 > serotonin reuptake inhibitors NNT=9 > other antidepressants NNT=8. Numbers needed to treat decreased with increasing age: children (NNT=21) > mixed ages (NNT=10) > adolescents (NNT=8).

Conclusions

Antidepressants of all types showed limited efficacy in juvenile depression, but fluoxetine might be more effective, especially in adolescents. Studies in children and in severely depressed, hospitalised or suicidal juvenile patients are needed, and effective, safe and readily accessible treatments for juvenile depression are urgently required.

Background

Consistent observation of raised rates of psychoses among Black and minority ethnic (BME) groups may possibly be explained by their lower socio-economic status.

Aims

To test whether risk for psychoses remained elevated in BME populations compared with the White British, after adjustment for age, gender and current socio-economic status.

Method

Population-based study of first-episode DSM–IV psychotic disorders, in individuals aged 18–64 years, in East London over 2 years.

Results

All BME groups had elevated rates of a psychotic disorder after adjustment for age, gender and socio-economic status. For schizophrenia, risk was elevated for people of Black Caribbean (incidence rate ratios (IRR)=3.1, 95% CI 2.1–4.5) and Black African (IRR=2.6, 95% CI 1.8–3.8) origin, and for Pakistani (IRR=3.1, 95% CI 1.2–8.1) and Bangladeshi (IRR=2.3, 95% CI 1.1–4.7) women. Mixed White and Black Caribbean (IRR=7.7, 95% CI 3.2–18.8) and White Other (IRR=2.1, 95% CI 1.2–3.8) groups had elevated rates of affective psychoses (and other non-affective psychoses).

Conclusions

Elevated rates of psychoses in BME groups could not be explained by socio-economic status, even though current socio-economic status may have overestimated the effect of this confounder given potential misclassification as a result of downward social drift in the prodromal phase of psychosis. Our findings extended to all BME groups and psychotic disorders, though heterogeneity remains.

Background

White-matter hyperintensities have been associated with both schizophrenia and mood disorders, particularly bipolar disorder, but results are inconsistent across studies.

Aims

To examine whether white-matter hyperintensities are a vulnerability marker for psychosis or are specifically associated with bipolar disorder.

Method

T2-weighted magnetic resonance imaging data were acquired in 129 individuals with first-episode psychosis (either affective or non-affective psychoses) and 102 controls who were randomly selected from the same geographical areas. Visual white-matter hyperintensity ratings were used for group and subgroup comparisons.

Results

There were no statistically significant between-group differences in white-matter hyperintensity frequency or severity scores. No significant correlations were found between white-matter hyperintensity scores and duration of illness, duration of untreated psychosis, or severity of psychotic, manic or depressive symptoms.

Conclusions

White-matter hyperintensities are not associated with vulnerability to psychosis in general, or specifically with affective psychoses. Further, first-episode psychosis investigations using more quantitative methods are warranted to confirm these findings.

Background

Tourette syndrome is a heterogeneous familial disorder for which the genetic mechanisms are unknown. A better characterisation of the phenotype may help identify susceptibility genes.

Aims

To extend previous factor-analytic studies of the syndrome.

Method

Symptom data from 410 people with Tourette syndrome were included in agglomerative hierarchical cluster and principal components analyses.

Results

Five factors were observed, characterised by: (1) socially inappropriate behaviours and other complex vocal tics; (2) complex motor tics; (3) simple tics; (4) compulsive behaviours; and (5) touching self. Individuals with co-occurring attention-deficit hyperactivity disorder had significantly higher factor scores on Factors 1 and 3, whereas individuals with co-occurring obsessive–compulsive disorder and behaviours had significantly higher factor scores for Factors 1–4.

Conclusions

These findings add to the growing body of evidence that Tourette syndrome is not a unitary condition and can be disaggregated into more homogeneous symptom components.

Background

Violence is an uncommon but significant problem associated with schizophrenia.

Aims

To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence.

Method

Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication.

Results

Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence.

Conclusions

Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

Background

There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care.

Aims

To assess whether such risk assessments decrease the incidence of violence and coercion.

Method

A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients.

Results

Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease.

Conclusions

Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards.

Background

A pilot trial in Sri Lanka among patients with medically unexplained symptoms revealed that cognitive–behavioural therapy (CBT) administered by a psychiatrist was efficacious.

Aims

To evaluate CBT provided by primary care physicians in a comparison with structured care.

Method

A randomised control trial (n=75 in each arm) offered six 30 min sessions of structured care or therapy. The outcomes of the two interventions were compared at 3 months, 6 months, 9 months and 12 months.

Results

In each arm, 64 patients (85%) completed the three mandatory sessions. No difference was observed between groups in mean scores on the General Health Questionnaire or the Bradford Somatic Inventory, or in number of complaints or patient-initiated consultations at 3 months. For both groups, all outcome measures improved at 3 months, and remained constant in the follow-up assessments.

Conclusions

Cognitive–behavioural therapy given by primary care physicians after a short course of training is no more efficacious than structured care. Natural remission is an unlikely explanation for improvements in people with chronic medically unexplained symptoms, but lack of a ‘treatment as usual’ arm limits further conclusions. Further research on enhanced structured care, medical assessment and structured care incorporating simple elements of CBT principles is worthy of consideration.

Background

Postgraduate courses on cognitive–behavioural therapy (CBT) assess various competencies using essays, case studies and audiotapes or videotapes of clinical work.

Aims

To evaluate how reliably a well-established postgraduate course assesses CBT competencies.

Method

Data were collected on two cohorts of trainees (n=52). Two examiners marked trainees on: (a) two videotapes of clinical practice; (b) two case studies; and (c) three essays.

Results

Essay examinations were more reliable than case studies, which in turn were more reliable than videotaped assessments. The reliability of the latter two assessments was considerably lower than that commonly expected of high-stakes examinations. To assess reliably standard CBT competencies, postgraduate courses would need to examine about 5 essays, 12 case studies and 19 videotapes.

Conclusions

Reliable assessment of standard competencies is complex and resource intensive. There would need to be a marked increase in the number of samples of clinical work assessed to be able to make reliable judgements about proficiency.

Background

Drugs of dependence cause dopamine release in the rat striatum. Human neuroimaging studies have shown an increase in dopamine in the equivalent region in response to stimulants and other drugs.

Aims

We tested whether opioids provoke dopamine release and its relationship to the subjective experience.

Method

In two combined studies 14 heroin addicts on methadone maintenance treatment underwent two positron emission tomography brain scans of the dopamine system using [11C]-raclopride following an injection of placebo and either 50 mg intravenous diamorphine or 10 mg subcutaneous hydromorphone in a double-blind, random order design.

Results

Both opioids produced marked subjective and physiological effects, but no measurable change in [11C]-raclopride binding.

Conclusions

The absence of a dopamine response to opioid agonists contrasts with that found with stimulant drugs and suggests dopamine may not play the same role in addiction to opioids. This questions the role of dopamine in the subjective experience of heroin in opioid addicts.

Background

Suicide rates vary by occupation but this relationship has not been frequently studied.

Aims

To identify the occupations with significantly high suicide rates in England and Wales in 2001–2005 and to compare these with rates from previous decades.

Method

Mortality data from death registrations in England and Wales over the calendar years 2001–2005 were used to calculate proportional mortality ratios (PMRs) and standardised mortality ratios (SMRs) for both men and women aged 20–64 years by their occupation.

Results

Among men, in 2001–2005, construction workers, and plant and machine operatives had the greatest number of suicides. The highest PMRs were for health professionals (PMR=164) and agricultural workers (PMR=133). Among women, administrative and secretarial workers had the greatest number of suicides yet the highest PMRs were found for health (PMR=232), and sport and fitness (PMR=244) occupations.

Conclusions

Excess mortality from suicide remains in some occupational groups. The apparent changes in suicide patterns merits further exploration, for example examining the prevalence of depression and suicidal ideation in medical practitioners, dentists, veterinarians, agricultural workers, librarians and construction workers.

Theory of mind deficits in schizophrenia have been parsed into mental state reasoning and mental state decoding components. We report that mental state decoding as measured by the ‘Eyes task’ better predicted social function than mental state reasoning as measured by the ‘Hinting task’ in 73 out-patients with chronic schizophrenia. Mental state decoding task performance also partly mediated the influence of basic neuropsychological performance on social function. We discuss these findings in terms of the accumulating evidence that mental state decoding has particular relevance for understanding deficits in social function in schizophrenia.