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Background: There is increasing evidence that smoking is a risk factor for severe mental illness, including bipolar disorder. Conversely, patients with bipolar disorder might smoke more (often) as a result of the psychiatric disorder.Aims: We conducted a bidirectional Mendelian randomisation (MR) study to investigate the direction and evidence for a causal nature of the relationship between smoking and bipolar disorder.Method: We used publicly available summary statistics from genome-wide association studies on bipolar disorder, smoking initiation, smoking heaviness, smoking cessation and lifetime smoking (i.e. a compound measure of heaviness, duration and cessation). We applied analytical methods with different, orthogonal assumptions to triangulate results, including inverse-variance weighted (IVW), MR-Egger, MR-Egger SIMEX, weighted-median, weighted-mode and Steiger-filtered analyses.Results: Across different methods of MR, consistent evidence was found for a positive effect of smoking on the odds of bipolar disorder (smoking initiation ORIVW = 1.46, 95% CI 1.28-1.66, P = 1.44 × 10-8, lifetime smoking ORIVW = 1.72, 95% CI 1.29-2.28, P = 1.8 × 10-4). The MR analyses of the effect of liability to bipolar disorder on smoking provided no clear evidence of a strong causal effect (smoking heaviness betaIVW = 0.028, 95% CI 0.003-0.053, P = 2.9 × 10-2).Conclusions: These findings suggest that smoking initiation and lifetime smoking are likely to be a causal risk factor for developing bipolar disorder. We found some evidence that liability to bipolar disorder increased smoking heaviness. Given that smoking is a modifiable risk factor, these findings further support investment into smoking prevention and treatment in order to reduce mental health problems in future generations. [ABSTRACT FROM AUTHOR]

Background: Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT). Aims: This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service. Method: Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire. Results: Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus. Conclusions: This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability. [ABSTRACT FROM AUTHOR]

Network meta-analysis (NMA) is a statistical technique for making direct and indirect comparisons between different treatment and control groups. Despite its many advantages, NMA may be misleading when evaluating networks that are disconnected, inconsistent or of low reliability and validity. We review how well the analysis of trials of adjunctive psychosocial treatment in bipolar disorder is served by NMA. We conclude with recommendations for future treatment trials in bipolar disorder and guidelines for NMAs. [ABSTRACT FROM AUTHOR]

BackgroundClinical trials have examined the efficacy of drugs to prevent relapse in patients with bipolar disorder, however, their design often limits generalisation to routine clinical practice.AimsTo estimate the effectiveness of drugs used for maintenance treatment in bipolar disorder.MethodWe used national registers to identify 35 022 individuals diagnosed with bipolar disorder and information on lithium, valproate, carbamazepine, lamotrigine, quetiapine and olanzapine treatment from 2006 to 2009. The main outcome was psychiatric hospital admissions. We used stratified cox regression to compare periods on and off medication within the same individual.ResultsMedication with lithium, valproate, lamotrigine, olanzapine and quetiapine was associated with reduced rates of admission to hospital. Lithium was more effective than quetiapine and olanzapine. The effects of specific drugs depended on the polarity of the mood episode.ConclusionsOur findings complement results from randomised controlled trails, but suggest that lithium is more effective than both quetiapine and olanzapine in routine clinical practice. [ABSTRACT FROM AUTHOR]

15 June 2020 We were dismayed to see that you recently published a piece calling patients taking esketamine 'unwitting guinea pigs participating in another pharmaceutical experiment'.1 (Lack of) style aside, the arguments advanced by Horowitz and Moncrieff to support their inflammatory statement do not hold up. Suicidality is a main component of TRD.2 The completed suicide rate in the esketamine development programme is 0.17 per 100 patient years, less than the completed suicide rate of 0.47 per 100 patient years in a recent meta-analysis of 15 000 patients with TRD.4 Fourth, the long-term efficacy and safety of TRD are better than the authors insinuate. Furthermore, the dosage schedule becomes less frequent as treatment progresses, so the amount of drug administered falls, which is clearly not in keeping with addiction. [Extracted from the article]

Background: Adjunctive antidepressant therapy is commonly used to treat acute bipolar depression but few studies have examined this strategy.Aims: To examine the efficacy of agomelatine v. placebo as adjuncts to lithium or valproate in bipolar depression.Method: Patients who were currently depressed despite taking lithium or valproate for at least 6 weeks were randomised to treatment with agomelatine (n = 172) or placebo (n = 172) for 8 weeks of acute therapy and 44 weeks of continuation therapy (trial registration: ISRCTN28588282).Results: No significant differences in improvement of depressive symptoms were observed between the two groups either at 8 weeks or 52 weeks on the primary efficacy measure of change in Montgomery-Åsberg Depression Rating Scale scores from baseline to end-point. Adverse events including switches into mania/hypomania were low and similar in both groups.Conclusions: Agomelatine adjunctive therapy was not superior to placebo adjunctive therapy for acute bipolar depression. [ABSTRACT FROM AUTHOR]

Background: North American studies show bipolar disorder is associated with elevated rates of problem gambling; however, little is known about rates in the different presentations of bipolar illness.Aims: To determine the prevalence and distribution of problem gambling in people with bipolar disorder in the UK.Method: The Problem Gambling Severity Index was used to measure gambling problems in 635 participants with bipolar disorder.Results: Moderate to severe gambling problems were four times higher in people with bipolar disorder than in the general population, and were associated with type 2 disorder (OR = 1.74, P = 0.036), history of suicidal ideation or attempt (OR = 3.44, P = 0.02) and rapid cycling (OR = 2.63, P = 0.008).Conclusions: Approximately 1 in 10 patients with bipolar disorder may be at moderate to severe risk of problem gambling, possibly associated with suicidal behaviour and a rapid cycling course. Elevated rates of gambling problems in type 2 disorder highlight the probable significance of modest but unstable mood disturbance in the development and maintenance of such problems. [ABSTRACT FROM AUTHOR]

Background People with intellectual disabilities have a high risk of osteoporosis and fractures, which could partly be as a result of vitamin D deficiency. Aims To compare the serum vitamin D (25(OH)D) levels of 155 patients with intellectual disabilities under psychiatric care and 192 controls, investigate potential risk factors for vitamin D deficiency in people with intellectual disabilities and assess available treatments. Method Cross-sectional observational study followed by treatment evaluation. Results Almost twice as many patients with intellectual disabilities had vitamin D deficiency (25(OH)D <50nmol/l) compared with controls (77.3% v. 39.6%, P<0.0001). In the intellectual disabilities group, winter season (P<0.0001), dark skin pigmentation (P<0.0001), impaired mobility (P = 0.002) and obesity (P=0.001) were independently associated with lower serum 25(OH)D. In most patients, 800IU colecalciferol daily normalised 25(OH)D levels. Conclusions Vitamin D deficiency is highly prevalent in people with intellectual disabilities, partly because of insufficient exposure to sunlight. Screening and treatment strategies, aiming to reduce these patients' high fracture risk, should be introduced. Similar strategies may be required in other psychiatric populations at risk for fractures and with a tendency to spend excessive time indoors. Declaration of interest V.F. and G.M.G. have received grants from the Baily Thomas Charitable Fund. G.M.G. has also received grants from Servier, and speaker honoraria or fees for advice from AstraZeneca, Cephalon/Teva, Eli Lilly, GSK, Lundbeck, Merck, Otsuka, Servier, Takeda and Sunovion. [ABSTRACT FROM AUTHOR]

Background: Despite frequent use, little is known about the metabolic and endocrine side-effects of antipsychotics in individuals with intellectual disability.Aims: To compare indices of obesity, glucose, lipids and prolactin between antipsychotic-treated and antipsychotic-naive individuals with intellectual disability and also between participants with intellectual disability and controls from the general population.Method: Observational study comparing 138 antipsychotic-treated and 64 antipsychotic-naive participants with intellectual disability in one National Health Service trust with general population controls.Results: Antipsychotic treatment comprised: risperidone 48%,olanzapine 18%, thioxanthenes 10%, other 24%; monotherapy 95% of participants; mean treatment duration 8 years;median daily chlorpromazine equivalent dose 108 mg(range 16–667). Metabolic indices were the same or more favourable in the intellectual disability group than the general population control group but overweight/obesity and type 2 diabetes were more prevalent in the women in the intellectual disability group than the control group. Metabolic indices were similar, statistically or clinically, between the antipsychotic-treated and the antipsychotic-naive groups but there was a non-significant trend towards a higher rate of type 2 diabetes in the antipsychotic group. A total of 100%and 70% of participants on amisulpride/sulpiride and risperidone respectively had hyperprolactinaemia, with secondary hypogonadism in 77% and 4% of affected women and men.Conclusions: Antipsychotics, on average, did not increase metabolic risk,although the existence of a susceptible subgroup at risk of diabetes cannot be excluded. Some antipsychotics induced hyperprolactinaemic hypogonadism, requiring active management. However, our findings suggest that antipsychotics at the low doses routinely prescribed for people with intellectual disability are generally safe in relation to metabolic adverse effects, even if efficacy remains poorly defined. [ABSTRACT FROM AUTHOR]

Background: Valproate is one of the most used mood stabilisers for bipolar disorder, although the evidence for the effectiveness of valproate is sparse.Aims: To compare the effect of valproate v. lithium for treatment of bipolar disorder in clinical practice.Method: An observational cohort study with linkage of nationwide registers of all people with a diagnosis of bipolar disorder in psychiatric hospital settings who were prescribed valproate or lithium in Denmark during a period from 1995 to 2006.Results: A total of 4268 participants were included among whom 719 received valproate and 3549 received lithium subsequent to the diagnosis of bipolar disorder. The rate of switch/add on to the opposite drug (lithium or valproate), antidepressants, antipsychotics or anticonvulsants (other than valproate) was increased for valproate compared with lithium (hazard ratio (HR) = 1.86, 95% CI 1.59-2.16). The rate of psychiatric hospital admissions was increased for valproate v. lithium (HR = 1.33, 95% CI 1.18-1.48) and regardless of the type of episode leading to a hospital admission (depressive or manic/mixed). Similarly, for participants with a depressive index episode (HR = 1.87, 95% CI 1.40-2.48), a manic index episode (HR = 1.24, 95% CI 1.01-1.51) and a mixed index episode (HR = 1.44, 95% CI 1.04-2.01), the overall rate of hospital admissions was significantly increased for valproate compared with lithium.Conclusions: In daily clinical practice, treatment with lithium seems in general to be superior to treatment with valproate. [ABSTRACT FROM AUTHOR]

Background: Some people who take selective serotonin reuptake inhibitor (SSRI) antidepressants report that their experience of emotions is 'blunted'. This phenomenon is poorly understood.Aims: To understand patients' experiences of this phenomenon.Method: Qualitative study, gathering data through individual interviews, a group interview and validation interviews; and searching patient websites for relevant posts.Results: There was strong evidence that some people taking SSRIs experience significant emotional symptoms that they strongly attribute to their antidepressant. These emotional symptoms can be described within six key themes. A seventh theme represents the impact of these side-effects on everyday life, and an eighth represents participants' reasons for attributing these symptoms to their antidepressant. Most participants felt able to distinguish between emotional side-effects of antidepressants and emotional symptoms of their depression or other illness.Conclusions: Emotional side-effects of SSRIs are a robust phenomenon, prominent in some people's thoughts about their medication, having a demonstrable impact on their functioning and playing a role in their decision-making about antidepressant adherence. [ABSTRACT FROM AUTHOR]

Background: The neuropharmacological actions of antidepressants are well characterised but our understanding of how these changes translate into improved mood are still emerging.Aims: To investigate whether actions of antidepressant drugs on emotional processing are a mediating factor in the effects of these drugs in depression.Method: We examined key published findings that explored the effects of antidepressants on behavioural and functional magnetic resonance imaging (fMRI) measures of emotional processing.Results: Negative emotional bias has been reliably associated with depression. Converging results suggest that antidepressants modulate emotional processing and increase positive emotional processing much earlier than effects on mood. These changes in emotional processing are associated with neural modulation in limbic and prefrontal circuitry.Conclusions: Antidepressants may work in a manner consistent with cognitive theories of depression. Antidepressants do not act as direct mood enhancers but rather change the relative balance of positive to negative emotional processing, providing a platform for subsequent cognitive and psychological reconsolidation. [ABSTRACT FROM AUTHOR]

Background: Depression is associated with neural abnormalities in emotional processing.Aims: This study explored whether these abnormalities underlie risk for depression.Method: We compared the neural responses of volunteers who were at high and low-risk for the development of depression (by virtue of high and low neuroticism scores; high-N group and low-N group respectively) during the presentation of fearful and happy faces using functional magnetic resonance imaging (fMRI).Results: The high-N group demonstrated linear increases in response in the right fusiform gyrus and left middle temporal gyrus to expressions of increasing fear, whereas the low-N group demonstrated the opposite effect. The high-N group also displayed greater responses in the right amygdala, cerebellum, left middle frontal and bilateral parietal gyri to medium levels of fearful v. happy expressions.Conclusions: Risk for depression is associated with enhanced neural responses to fearful facial expressions similar to those observed in acute depression. [ABSTRACT FROM AUTHOR]

Background There is uncertainty about the efficacy of lamotrigine in bipolar depressive episodes. Aims To synthesise the evidence for the efficacy of lamotrigine in bipolar depressive episodes. Method Systematic review and meta-analysis of individual patient data from randomised controlled trials comparing lamotrigine with placebo. Results Individual data from 1072 participants from five randomised controlled trials were obtained. More individuals treated with lamotrigine than placebo responded to treatment on both the Hamilton Rating Scale for Depression (HRSD)(relative risk (RR)=1.27, 95% Cl 1.09-1.47, P=0.002) and Montgomery- ]ksberg Depression Rating Scale (MADRS) (RR=1.22, 95% CI 1.06-1.41, P=0.005). There was an interaction (P=0.04) by baseline severity of depression: lamotrigine was superior to placebo in people with HRSD score >24 (RR=1.47, 95% Cl 1.16-1.87, P=0.001) but not in people with HRSD score ≤24 (RR=1.07, 95% CI 0.90-1.27, P=0.445). Conclusions There is consistent evidence that lamotrigine has a beneficial effect on depressive symptoms in the depressed phase of bipolar disorder. The overall pool effect was modest, although the advantage over placebo was larger in more severely depressed participants. Declaration of Interest J.R.C. is a member of the psychiatry advisory board for GlaxoSmithKline. J.R.G. is Chief Investigator and G.M.G. is a co-investigator on the independent Medical Research Council-funded trial: Comparative Evaluation of QUEtiapine- Lamotrigine combination v. quetiapine monotherapy (and folic acid v. placebo) in people with bipolar depression (CEQUEL). [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

ABSTRACTBackgroundThe cognitive impairment of older depressed patients with late- as opposed to early-onset illness may show important differences, in that patients with early onset may suffer predominantly from impaired episodic memory, and those with late onset mainly from reductions of executive function and processing speed.MethodWe searched Medline and EMBASE as well as individual papers' reference lists for relevant publications, recording comparisons in neuropsychological test results between early-onset depression (EOD), late-onset depression (LOD) and healthy volunteers. Effect sizes are presented for cognitive domains, such as executive function, processing speed, episodic memory, semantic memory and mental state examination.ResultsPatients with LOD showed greater reductions in processing speed and executive function than patients with EOD and controls. Both patient groups showed reduced function in all domains, except mental state, compared with controls.ConclusionPronounced executive deficits are typical of the late-onset patients described in published studies, while episodic memory impairment is not specific to early-onset illness. Possible reasons and confounders are discussed. [ABSTRACT FROM AUTHOR]

Background. Cognitive theories associate depression with negative biases in information processing. Although negatively biased cognitions are well documented in depressed patients and to some extent in recovered patients, it remains unclear whether these abnormalities are present before the first depressive episode. Method. High neuroticism (N) is a well-recognized risk factor for depression. The current study therefore compared different aspects of emotional processing in 33 high-N never-depressed and 32 low-N matched volunteers. Awakening salivary cortisol, which is often elevated in severely depressed patients, was measured to explore the neurobiological substrate of neuroticism. Results. High-N volunteers showed increased processing of negative and/or decreased processing of positive information in emotional categorization and memory, facial expression recognition and emotion-potentiated startle (EPS), in the absence of global memory or executive deficits. By contrast, there was no evidence for effects of neuroticism on attentional bias (as measured with the dot-probe task), over-general autobiographical memory, or awakening cortisol levels. Conclusions. These results suggest that certain negative processing biases precede depression rather than arising as a result of depressive experience per se and as such could in part mediate the vulnerability of high-N subjects to depression. Longitudinal studies are required to confirm that such cognitive vulnerabilities predict subsequent depression in individual subjects. [ABSTRACT FROM AUTHOR]

Abstract: Clinical guidelines for treatment and research of bipolar disorder greatly benefit from the synthesis of data from individual studies. The British Association for Psychopharmacology bases its guidelines on evidence from opinions (level D) to systematic reviews of primary trial data (level A). The report details conclusions of its 1-day consensus meeting to develop guidelines covering diagnosis, clinical management, pharmacotherapy for acute episodes, relapse prevention and treatment discontinuation. Monotherapy for long-term management is preferred, having reduced side-effects and drug interactions and improved compliance. Combination therapy is often preferred for acute episodes, using antipsychotics for mania or antidepressants for depression. Increased efficacy may be attributed to multiple mechanisms of action and potentially lower doses. In clinical practice, maintenance monotherapy has limited success for chronic episodes and polypharmacy is frequently used, though the best combination remains unclear. A new collaborative approach based on simple clinical trials is required to change current medical practice. [Copyright &y& Elsevier]

Background: Recovery in bipolar disorder is central to its definition but is rarely complete. Previous work has suggested that neuropsychological impairment persists during the euthymic state but has been confounded partly by mild affective symptoms in remitted patients.Aims: To characterise neuropsychological functioning in the euthymic phase of bipolar disorder with an emphasis on tasks of executive functioning.Method: Thirty euthymic patients with bipolar disorder were compared with thirty healthy controls on neuropsychological tasks differentially sensitive to damage within prefrontal cortex.Results: Bipolar I patients were impaired on tasks of attentional set shifting, verbal memory and sustained attention. Only sustained attention deficit survived controlling for mild affective symptoms. This deficit was related to progression of illness, but was none the less present in a subgroup of patients near illness onset.Conclusions: Sustained attention deficit may represent a neuropsychological vulnerability marker for bipolar disorder, providing a focus for further understanding of the phenotype and analysis of the neuronal networks involved. [ABSTRACT FROM AUTHOR]

Background While depression is known to involve a disturbance of mood, movement and cognition, its associated cognitive deficits are frequently viewed as simple epiphenomena of the disorder. Aims To review the status of cognitive deficits in depression and their putative neurobiological underpinnings. Method Selective computerised review of the literature examining cognitive deficits in depression and their brain correlates. Results Recent studies report both mnemonic deficits and the presence of executive impairment — possibly selective for set-shifting tasks — in depression. Many studies suggest that these occur independent of age, depression severity and subtype, task `difficulty', motivation and response bias: some persist upon clinical recovery'. Conclusions Mnemonic and executive deficits do not appear to be epiphenomena of depressive disorder. A focus on the interactions between motivation, affect and cognitive function may allow greater understanding of the interplay between key aspects of the dorsal and ventral aspects of the prefrontal cortex in depression. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic fatigue syndrome (CFS) and depressive illness share many, but not all, features.Aims: To test the hypothesis that patients with CFS have abnormal cerebral perfusion, that differs from that in patients with depressive illness.Method: We recruited 30 patients with CFS who were not depressed, 12 depressed patients and 15 healthy volunteers. Regional cerebral perfusion at rest was assessed using region of interest (ROI) and voxel-based statistical parametric mapping (SPM) techniques.Results: On SPM analysis there was increased perfusion in the right thalamus, pallidum and putamen in patients with CFS and in those with depressive illness. CFS patients also had increased perfusion in the left thalamus. Depressed patients differed from those with CFS in having relatively less perfusion of the left prefrontal cortex. The results were similar on ROI analysis.Conclusions: Abnormal cerebral perfusion patterns in CFS subjects who are not depressed are similar but not identical to those in patients with depressive illness. Thalamic overactivity may be a correlate of increased attention to activity in CFS and depression; reduced prefrontal perfusion in depression may be associated with the greater neuropsychological deficits in that disorder. [ABSTRACT FROM AUTHOR]

Background Imaging studies in depression of the elderly are often small and highly selective. Aims To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up. Method Patients (n=175, age range 65-91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECTscans were carried out at referral and at two-year follow-up. Results Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up. Conclusions The patient group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age. [ABSTRACT FROM AUTHOR]

Background: The aetiology of treatment-resistant major depression is little understood; its apparent intractability may reflect brain abnormality.Method: Magnetic resonance images of the brains of 20 subjects with major depression lasting for two years or more were compared with 20 healthy control subjects and 20 other subjects who had completely recovered from depression. Subjects were individually matched for age, gender, years of education and premorbid IQ. Grey matter was segmented from the images, and compared between groups on a voxel-by-voxel basis.Results: Subjects with chronic depression showed reduced grey matter density in the left temporal cortex including the hippocampus. There was also a trend for reduction in the right hippocampus. Left hippocampal grey matter density was correlated with measures of verbal memory, supporting the functional significance of the observed magnetic resonance imaging changes.Conclusions: Our results potentially challenge the accepted view of depression as a functional and fully reversible illness, implying instead that more permanent brain changes may be associated with chronicity. Confirmatory longitudinal and prospective studies are required to determine whether these differences pre-date the onset of depression or are the result of the chronic illness process or its treatment. [ABSTRACT FROM AUTHOR]

Background: The spontaneous diurnal variation of mood and other symptoms provides a substrate for the examination of the relationship between symptoms and regional brain activation in depression.Method: Twenty unipolar depressed patients with diurnal variation of mood were examined at 8 a.m. and 8 p.m. with neuropsychological measures, clinical ratings and single photon emission tomography (SPET). Brain perfusion maps were spatially transformed into standard stereotactic space and compared pixel-by-pixel. A parametric (correlational) analysis was used to examine the relationship between symptom severity and brain perfusion, both between and within subjects.Results: Global depression severity and an independent 'vital' depression factor were associated in subjects with increased perfusion in cingulate and other paralimbic areas. In addition there was a probable association between an increase in an anxious-depression factor and reduced frontal neocortical perfusion.Conclusions: Depressive symptom changes are associated with metabolic changes in the cingulate gyrus and associated paralimbic structures. [ABSTRACT FROM AUTHOR]

Background: Patients with schizophrenia differ from controls in several measures of brain structure and function, but it is uncertain how these relate to clinical features of the illness. We dichotomised patient groups by treatment response to test the hypothesis that treatment-resistant patients exhibit more marked biological abnormalities than treatment-responsive patients.Method: Twenty treatment-responsive and 20 treatment-resistant patients with schizophrenia, matched for sex, age, and illness duration, were compared by magnetic resonance imaging, single photon emission tomography, and detailed neuropsychological assessment.Results: Brain-imaging variables were not statistically related to treatment response, although poorly responsive patients had lower volumes of most brain structures. Several highly significant differences emerged between patient groups on neuropsychological testing. Episodic memory functioning distinguished patient groups even after we controlled for global cognitive impairment.Conclusions: Cerebral structure and blood flow have a limited effect on treatment response in schizophrenia, but long-term episodic memory impairment is associated with, and may predict, poor prognosis. [ABSTRACT FROM AUTHOR]

The article comments on the implications for the use of lithium in the treatment of bipolar affective disorder. In 14 studies involving 257 patients, 50 percent of new episodes of illness occurred within three months of stopping treatment. The length of treatment averaged 30 months. Mania was more common than depression in the first three months of discontinuation.

A case of Munchausen's syndrome was probably caused by brain damage sustained during a necessary cholecystectomy. Doctors should not be discouraged from seeking treatable disorder because of such patients' behaviour. [ABSTRACT FROM AUTHOR]

To examine the neuropsychiatric effects of infection with HIV, 220 drug users (27 HIV negative, 193 HIV positive) completed tests evaluating premorbid intelligence, memory, non-verbal performance, information processing speed, and mood. When these measures were compared cross-sectionally by the severity of HIV illness, symptomatic patients (in CDC stage IV) were impaired on Trails B, two-choice decision time, delayed recall of the Wechsler Logical Memory Test and most components of the Auditory Verbal Learning Test. These findings imply reduced capacity for concentration, speed of thought and memory. When 101 patients were retested a mean of 16 months after their initial assessment, performance on Trails A and B, Block Design and delayed recall of the Wechsler Logical Memory Test deteriorated more for patients at, or progressing within, CDC stage IV, than performance of patients at stage III. The results broadly correspond to the cross-sectional findings. However, there was a decline in all tests of memory function for the sample independent of clinical staging. This may be evidence of brain involvement before the appearance of other symptoms. Self-rated measures of mood did not change cross-sectionally, progressively, or interactively with time and stage of HIV illness, and cannot account for the changes in cognitive function observed. Change in drug use, similarly, does not account for the cognitive findings. Four (5%) of the retested subjects developed AIDS dementia complex, but most of the performance and memory impairments seen were subclinical despite the destructive neuropathology presumed to underlie intellectual decline in patients with HIV infection.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

The association between parental attempted suicide and child abuse was investigated in 114 mothers with children aged five years and under, referred to a general hospital following suicide attempts. The risk was greatly increased in the attempted suicide mothers, compared with both similar mothers at risk for depression and general population control mothers; well-documented risk of child abuse was identified in 29.8% of those who attempted suicide. No major differences were found between the attempted suicide mothers whose children were at risk and those whose children were not at risk. During the general hospital assessment of mothers with young children who attempt suicide, careful enquiry concerning the relationship with the children is essential. [ABSTRACT FROM AUTHOR]

Psychiatry has long identified schizophrenia as its defining disorder, its heartland as it has been called. In the past 20 years, this has had a number of negative consequences for psychiatry as a medical specialty, which result from the uncertainty of diagnosis and an increasing emphasis on demedicalising services in an attempt to provide social care outside hospital. These changes have probably increased the stigma attached to psychiatric practice and threaten to deskill doctors. They have also meant that services for other disorders do not meet the needs of patients. To continue to allow schizophrenia to be the paradigm condition is against the interests of psychiatrists and their patients. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Treatment-resistant and Multi-therapy resistant criteria for bipolar depression: A consensus definition" which appeared in the December 6, 2018 issue.

Treatment of bipolar disorder with antidepressants tested almost exclusively in unipolar cases is common but unsupported by an appropriate body of evidence. This anomaly is highlighted by a large Taiwanese study, which implies that patients with depression difficult to treat with antidepressants are quite likely to be diagnosed subsequently with bipolar disorder. [ABSTRACT FROM AUTHOR]

Law 180 eliminated psychiatric hospitals for the care of people with chronic psychosis in Italy. After 30 years, we review the consequences for the practice of psychiatry in Italy and parallels for England and Wales. We argue that the substitution of legal/political direction for clinical leadership means psychiatrists may cease to merit the privileges and responsibilities of being doctors. [ABSTRACT FROM AUTHOR]

We used functional magnetic resonance imaging to investigate the effects of short-term treatment with reboxetine, a selective noradrenaline reuptake inhibitor, on emotional facial processing in healthy volunteers. Reboxetine was associated with a reduced amygdala response to fearful faces and increased activation to happy v. neutral facial expressions in the right fusiform gyrus, relative to placebo treatment and in the absence of changes in mood. Our results show that reboxetine modulates the neural substrates of emotional processing, highlighting a mechanism by which drug treatment could normalise negative bias in depression and anxiety. [ABSTRACT FROM AUTHOR]

The article discusses the use of the term, hypomania. The original Greek definition of hypomania is hierarchically below or beneath mania. The article notes that the definitions of affective disorder in DSM-IV and ICD-10 differ for elated states and the differences are magnified by their different usage on the ground.

The article presents a reply to comments made about placebo-controlled trials of lithium prophylaxis in manic-depressive disorder. According to the author, the resolve of clinicians to treat and follow up patients long term is not always what it might be, and patient compliance is the major single factor limiting clinicians' intentions. The author believes that there is a need for more patients in randomized studies of lithium prophylaxis to increase confidence in its efficacy.

A letter to the editor is presented in response to an article about paranoid psychosis in AIDS.