Self-harm remains an important public health problem and two sets of clinical guidelines have been published recently. While these include elements of accepted good practice they are not evidence-based. Further research mightconcentrate on either very large trials of low-intensity interventions or smaller trials of longer-term psychological treatments. The current management of self-harm may be improved by shifting professionals’ views, involving usersin staff training, and changing service provision - perhaps moving from risk assessment to needs assessment.

Background Numerous studies have examined the neural correlates of episodic memory deficits in schizophrenia, yielding both consistencies and discrepancies in the reported patterns of results. Aims To identify in schizophrenia the brain regions in which activity is consistently abnormal across imaging studies of memory. Method Data from 18 studies meeting the inclusion criteria were combined using a recently developed quantitative meta-analytic approach. Results Regions of consistent differential activation between groups were observed in the left inferior prefrontal cortex, medial temporal cortex bilaterally, left cerebellum, and in other prefrontal and temporal lobe regions. Subsequent analyses explored memory encoding and retrieval separately and identified between-group differences in specific prefrontal and medial temporal lobe regions. Conclusions Beneath the apparent heterogeneity of published findings on schizophrenia and memory, a consistent and robust pattern of group differences is observed as a function of memory processes.

Background Few studies have examined samples of people with cannabis-induced psychotic symptoms. Aims To establish whether cannabis-induced psychotic disorders are followed by development of persistent psychotic conditions, and the timing of their onset. Method Data on patients treated for cannabis-induced psychotic symptoms between 1994 and 1999 were extracted from the Danish Psychiatric Central Register. Those previously treated for any psychotic symptoms were excluded. The remaining 535 patients were followed for at least 3 years. In a separate analysis, the sample was compared with people referred for schizophrenia-spectrum disorders for the firsttime, but who had no history of cannabis-induced psychosis. Results Schizophrenia-spectrum disorders were diagnosed in 44.5% of the sample. New psychotic episodes of any type were diagnosed in 77.2%. Male gender and young age were associated with increased risk. Development of schizophrenia-spectrum disorders was often delayed, and 47.1% of patients received a diagnosis more than a year after seeking treatment for a cannabis-induced psychosis. The patients developed schizophrenia at an earlier agethanpeople in the comparison group (males, 24.6 v. 30.7 years, females, 28.9 v. 33.1 years). Conclusions Cannabis-induced psychotic disorders are of greatclinical and prognostic importance.

Background Studies of chronic schizophrenia suggest that there are subgroups with different profiles of cognitive impairment. Aims To determine whether such heterogeneityis present at illness onset and any relationship to clinical variables. Method Ninety-three community patients with first-episode schizophrenia and 50 healthy volunteers were assessed for premorbid (Revised National Adult ReadingTest) and current IQ, memory and executive function. Results Half of those with schizophrenia had preserved IQ in the normal range but there was evidence of a specific impairment in spatial working memory even in those with high/average IQ; 37 out of 93 (40%) had generalised cognitive decline. Those with low premorbid IQ were significantly younger atillness onset. For the entire group, age at onset correlated positively with premorbid but not current IQ. Conclusions At illness onset, cognitive heterogeneityis present in people with schizophrenia, with a high proportion having undergone general cognitive decline. However, working memory impairment may be a common feature. Lower premorbid IQ is a risk factor for an earlier onset.

Background Emotion recognition impairments have been demonstrated in schizophrenia, but few studies have examined whether these reflect generalised or specific perceptual deficits or are associated with illness course. Aims To examine the nature of emotion recognition abnormalities in patients with schizophrenia at different stages of illness. Method We examined the performance of 50 in-patients with early-stage schizophrenia, 50 with chronic schizophrenia and 50 healthy controls on the Benton Facial Recognition Test, Facial Emotion Recognition Test and Voice Emotion Recognition Test. Results Patients with chronic schizophrenia were significantly more impaired than other groups on the emotional tasks, even after controlling for impairments in non-emotional stimuli. Individual emotion recognition accuracy for the two sensory modalities was not significantly positively correlated for either group with schizophrenia. Conclusions Emotion recognition deficits in schizophrenia are trait features of the disorder and increase with illness duration.

Background Measures have not taken account of the relative importance patients place on various outcomes. Aims To construct and evaluate a multidimensional, preference-weighted mental health index. Method Each of over 1200 patients identified the relative importance of improvement in six domains: social life, energy, work, symptoms, confusion and side-effects. A mental health index was created in which measures of well-being in these six domains were weighted for their personal importance. Results The strongest preference was placed on reducing confusion and the least on reducing side-effects. There was no significant difference between the unweighted and preference-weighted mental health status measures and they had similar correlations with global health status measures. Patients with greater preference for functional activities such as work had less preference for medical model goals such as reducing symptoms and had less symptoms. Conclusions A preference-weighted mental health index demonstrated no advantage over an unweighted index.

Background Substantial weight gain is common with many atypical antipsychotics. Aims To evaluate the extent, time course and predictors of weight gain and its effect on study retention among people with first-episode psychosis treated with olanzapine or haloperidol. Method Survival analysis assessed time to potentially clinically significant weight gain (≥7%) and the effect of weight gain on study retention. Weight gain during the 2-year study was summarised using last-observation-carried-forward (LOCF), observed cases and study completion approaches. Results After 2 years of treatment, LOCF mean weight gain was 10.2 kg (s.d.=10.1) for olanzapine (n=131) and 4.0 kg (s.d.=7.3) for haloperidol (n=132); observed cases mean weight gain was 15.4 kg (s.d.=10.0) for olanzapine and 7.5 kg (s.d.=9.2) for haloperidol. Change in body massindex was significantly predicted only by treatment group (P < 0.0001). Conclusions Olanzapine was associated with significantly greater weight gain than haloperidol, with both leading to greater weight gain than previously described.

Background Longitudinal studies have been in conclusive in identifying alcohol as a risk factor for anxiety and depression. Aims To examine whether excessive alcohol consumption is a risk factor for anxiety and depression in the general population, and whether anxiety and depression are risk factors for excessive alcohol consumption. Method Data were analysed from the 18-month follow-up of the Psychiatric Morbidity Among Adults Living in Private Households, 2000 survey. Results Hazardous and dependent drinking were not associated with onset of anxiety and depression at follow-up. Binge-drinking was non-significantly associated with incident anxiety and depression (adjusted OR=1.36, 95% CI 0.74-2.50). Abstainers were less likely to have new-onset anxiety and depression at follow-up. Anxiety and depression or sub-threshold symptoms at baseline were not associated with incident hazardous or binge-drinking at follow-up, but there was weak evidence linking sub-threshold symptoms with onset of alcohol dependence (adjusted OR=2.04, 95% CI 0.84-4.97). Conclusions Excessive alcohol consumption was not associated with the onset of anxiety and depression but abstinence was associated with a lower risk. Sub-threshold symptoms were weakly associated with new-onset alcohol dependence.

Background Most studies of mortality in psychiatric patients have investigated in-patients rather than those attending out-patient clinics or primary care, where most receive treatment. Aims To evaluate the mortality risk in mental illness for patients in contact with psychiatric services or primary care (n=221 048) across Nova Scotia (population 936 025). Method A population-based record-linkage analysis was made of the period 1995-2000, using an inception cohortto calculate mortality rate ratios. Results The mortality rate was 1.74, with increased ratios for all major causes of death. Male mortality was almost double that of females after controlling for demographic factors, treatment setting and place of residence. Patients of lower income, in specialist psychiatric settings, and with dementia or psychoses were also at greater risk. However, in absolute numbers, 72% of deaths occurred in patients who had only seen their general practitioner. Conclusions Mortality risk is increased in all psychiatric patients, not just those who have received in-patient treatment.

Background Bipolar disorder has been ranked seventh among the worldwide causes of non-fatal disease burden. Aims To estimate the cost-effectiveness of interventions for reducing the global burden of bipolar disorder. Method Hospital- and community-based delivery of two generic mood stabilisers (lithium and valproic acid), alone and in combination with psychosocial treatment, were modelled for14 global sub-regions. A population model was employed to estimate the impact of different strategies, relative to no intervention. Total costs (in international dollars (I$)) and effectiveness (disability-adjusted life years (DALYs) averted) were combined to form cost-effectiveness ratios. Results Baseline results showed lithium to be no more costly yet more effective than valproic acid, assuming an anti-suicidal effect for lithium but not for valproic acid. Community-based treatment with lithium and psychosocial care was mostcost-effective (cost per DALY averted: I$2165-6475 in developing sub-regions; I$5487-21123 in developed sub-regions). Conclusions Community-based interventions for bipolar disorder were estimated to be more efficient than hospital-based services, each DALY averted costing between one and three times average gross national income.

Background Autistic traits are widely distributed in the general population, but the boundaries of the autistic spectrum are unclear. Whole-population surveys of unselected samples of children are hampered by the lackof appropriate screening instruments. Aims To assess whether the Social and Communication Disorders Checklist (SCDC) fulfils the need for a sensitive measure of autistic traits, which can be completed in a few minutes and which measures heritable characteristics in both males and females. Method A12-item scale, the SCDC, was completed by three independent samples drawn from a twin register, a group with Turner syndrome and children with a diagnosis of autistic-spectrum disorder attending clinics. The data were used to establish the heritability, reliability and validity of the checklist. Results Traits measured by the SCDC were highly heritable in both genders (0.74). Internal consistency was excellent (0.93) and test – retest reliability high (0.81). Discriminant validity between pervasive developmental disorder and other clinical groups was good, discrimination from non-clinical samples was better; sensitivity (0.90), specificity (0.69). Conclusions The SCDC is a unique and efficient first-level screening questionnaire for autistic traits.

Background The stability of eating disorder diagnoses has received little research attention. Aims To examine the course of the full range of clinical eating disorders. Method A sample of 192 women with a current DSM–IV eating disorder (55 with anorexia nervosa,108 with bulimia nervosa and 29 with eating disorder not otherwise specified) were assessed three timesover 30 months using a standardised interview. Results Although the overarching category of ‘eating disorder’ was relatively stable, the stability of the three specific eating disorder diagnoses waslow, with just a third of participants retaining their original diagnosis. This was due onlyin part to remission since the remission rate was low across all three diagnoses. Conclusions There is considerable diagnostic flux within the eating disorders but a low overall remission rate. This suggests that underpinning their psychopathology may be common biological and psychological causal and maintaining processes.

Background The development of single-sex medium secure units for women has been driven by concern about the vulnerability of womento sexual abuse and exploitation in mixed-sex secure settings. Less is known about how women patients and staff perceive gender segregation and their experiences in single-sex units. Aims To examine the impact of gender segregation on the safety of women patients detained in medium secure psychiatric facilities. Method A qualitative study was conducted involving individual interviews with 58 male and female staff and 31 women patients in single-sex and mixed-sex medium secure units throughout England and Wales. Results Women patients in both types of units reported high levels of actual and threatened physical and sexual violence. Women in single-sex units reported intimidation, threats and abuse by other women patients, although they were less vulnerable to sexual abuse and exploitation and serious physical assault. Conclusions Further development of single-sex secure units for women may not be justified on the grounds of safety issues alone. Risk assessment of forensic psychiatric patients must include a full assessment of their safety within the psychiatric setting.

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.

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.