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Journal: The British journal of psychiatry : the journal of mental science


BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Concepts: Clinical trial, Hospital, Positive predictive value, Psychiatry


BackgroundBipolar disorder and schizophrenia are associated with increased mortality relative to the general population. There is an international emphasis on decreasing this excess mortality.AimsTo determine whether the mortality gap between individuals with bipolar disorder and schizophrenia and the general population has decreased.MethodA nationally representative cohort study using primary care electronic health records from 2000 to 2014, comparing all patients diagnosed with bipolar disorder or schizophrenia and the general population. The primary outcome was all-cause mortality.ResultsIndividuals with bipolar disorder and schizophrenia had elevated mortality (adjusted hazard ratio (HR) = 1.79, 95% CI 1.67-1.88 and 2.08, 95% CI 1.98-2.19 respectively). Adjusted HRs for bipolar disorder increased by 0.14/year (95% CI 0.10-0.19) from 2006 to 2014. The adjusted HRs for schizophrenia increased gradually from 2004 to 2010 (0.11/year, 95% CI 0.04-0.17) and rapidly after 2010 (0.34/year, 95% CI 0.18-0.49).ConclusionsThe mortality gap between individuals with bipolar disorder and schizophrenia, and the general population is widening.

Concepts: Schizophrenia, Major depressive disorder, Epidemiology, Relative risk, Bipolar disorder


Background Little is known about the relative extent of crime against people with severe mental illness (SMI). Aims To assess the prevalence and impact of crime among people with SMI compared with the general population. Method A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey. Results Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population. Conclusions People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Concepts: Violent crime, Crime, Violence against women, Psychiatry, Violence, Mental illness, Odds ratio, Domestic violence


Persecutory delusions may be unfounded threat beliefs maintained by safety-seeking behaviours that prevent disconfirmatory evidence being successfully processed. Use of virtual reality could facilitate new learning.

Concepts: Core issues in ethics, Paranoia, Virtual reality, Belief, Schizophrenia, Delusional disorder, Persecutory delusions, Delusion


There has been a substantial rise in ‘economic suicides’ in the Great Recessions afflicting Europe and North America. We estimate that the Great Recession is associated with at least 10 000 additional economic suicides between 2008 and 2010. A critical question for policy and psychiatric practice is whether these suicide rises are inevitable. Marked cross-national variations in suicides in the recession offer one clue that they are potentially avoidable. Job loss, debt and foreclosure increase risks of suicidal thinking. A range of interventions, from upstream return-to-work programmes through to antidepressant prescriptions may help mitigate suicide risk during economic downturn.

Concepts: Recession, Unemployment, Business cycle, Late-2000s recession


BackgroundSupervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.AimsTo synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.MethodRandomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.ResultsSix RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit ‘street’ heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).ConclusionsSIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

Concepts: Evidence-based medicine, Clinical research, Scientific method, Clinical trial, Effectiveness, Methadone, Heroin, Randomized controlled trial


Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness among young people.

Concepts: Effect, Effectiveness, Clinical trial


There is conflicting evidence about the relationship between vitamin D deficiency and depression, and a systematic assessment of the literature has not been available.

Concepts: Vitamin, Vitamins, Evidence-based medicine, Meta-analysis, Systematic review, Vitamin D


This study assessed whether a novel psychosocial intervention could reduce symptoms of postnatal depression (PND) in the first 40 weeks post-birth. Analyses were carried out of 134 mothers with symptoms of PND randomised into 10 weeks of group singing workshops or group play workshops for them and their babies, or usual care (trial registration: NCT02526407). Overall, among all mothers with symptoms of PND, there was a non-significant faster improvement in symptoms in the singing group (F 4,262 = 1.66, P = 0.16, η 2 = 0.012). When isolating mothers with moderate-severe symptoms of PND, this result became significant, with a faster improvement in symptoms in the singing group (F 3.9,139.8 = 2.74, P = 0.033, η 2 = 0.028). Declaration of interest None.

Concepts: Bipolar disorder, Intervention, Singing, Pharmaceutical industry, Childbirth, Randomized controlled trial


BackgroundStudies have shown that a mother’s history of child maltreatment is associated with her child’s experience of internalising and externalising difficulties.AimsTo characterise the mediating pathways that underpin this association.MethodData on a mother’s history of child maltreatment, depression during pregnancy, postnatal depression, maladaptive parenting practices and her child’s experience of maltreatment and internalising and externalising difficulties were analysed in an Avon Longitudinal Study of Parents and Children (ALSPAC) sample of 9397 mother-child dyads followed prospectively from pregnancy to age 13.ResultsMaternal history of child maltreatment was significantly associated with offspring internalising and externalising difficulties. Maternal antenatal depression, postnatal depression and offspring child maltreatment were observed to significantly mediate this association independently.ConclusionsPsychological and psychosocial interventions focused around treating maternal depression, particularly during pregnancy, and safeguarding against adverse childhood experiences could be offered to mothers with traumatic childhood histories to help protect against psychopathology in the next generation.

Concepts: Longitudinal study, Childbirth, Pregnancy, Mediation, Sociology, Mother, Parent, Psychological trauma