Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault

Introduction

Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD.

Methods

Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes.

Results

Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls.

Conclusion

Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Cytokines, Oxidative Stress and Cellular Markers of Inflammation in Schizophrenia

In this article, we review current evidence linking immune dysfunction in schizophrenia and related psychotic disorders focusing particularly on circulating cytokines, oxidative stress and cellular markers of inflammation in various stages on illness from drug-naïve first episode psychosis to chronic schizophrenia. Acute psychotic episode is associated with low-grade systemic inflammation in some patients, as reflected by increased concentrations of cytokines and other inflammatory markers in peripheral blood. Evidence from general population-based longitudinal cohort studies reporting an association between elevated inflammatory markers in childhood/adolescence and risk of schizophrenia and related psychosis subsequently in adulthood suggest that inflammation could be a causal risk factor for psychosis rather than simply be a consequence of illness. Mendelian randomization studies also suggest that associations between IL-6, CRP and schizophrenia are likely to be causal. In addition, we discuss evidence for disruptions in oxidative stress markers and CSF cytokine levels in schizophrenia, and potential reasons for reported trans-diagnostic associations for inflammatory cytokines including role of early-life adversity/maltreatment. We argue that low-grade inflammation is a clinically useful feature, because it is associated with poor response to antipsychotic medication in first episode psychosis. We discuss clinical implications for immunological understanding of schizophrenia including scope for clinical trials of anti-inflammatory agents and notable gaps in current knowledge, and offer suggestions for future research.

Topiramate and Metformin Are Effective Add-On Treatments in Controlling Antipsychotic-Induced Weight Gain: A Systematic Review and Network Meta-Analysis

Background: Antipsychotic drugs may lead to side effects such as obesity, diabetes, dyslipidemia, and cardiovascular disease. The current systematic review and network meta-analysis analyzes and provides an update on the clinical performance of these add-ons in comparison to placebo on body weight and body mass index (BMI) reductions. Methods: A comprehensive literature search was performed on electronic databases: PubMed (1946-), Embase (1974-), Cochrane library (1992-), and OpenGrey (2000-) until 31 July 2018. Network meta-analyses, comparing the body weight change, BMI change and withdrawn due to adverse events of different pharmacological add-ons, was performed using a multivariate meta-regression model with random-effects, adopting a frequentist approach. To rank the prognosis for all add-ons, we used surface under the cumulative ranking (SUCRA) values. Outcomes: From 614 potential studies identified, 27 eligible studies (n = 1,349 subjects) were included. All the studies demonstrated low to moderate risk of bias. For the analysis of body weight change, all add-ons except Ranitidine showed significant weight reductions comparing to placebo. The effectiveness rank based on SUCRA results from highest to lowest was Sibutramine, Topiramate, Metformin, Reboxetine, Ranitidine, and placebo. A similar pattern was seen for BMI change. The analysis of safety outcome did not detect significantly increased withdrawn number from the add-ons. Current evidence showed relatively good tolerance and safety of using the pharmacological add-ons. Interpretation: Topiramate and Metformin are effective add-on treatments in controlling antipsychotic-induced weight gain, comparing to placebo. They are well tolerated in short-term period. Although Sibutramine has the highest rank of the effectiveness, its license has been withdrawn in many countries due to its adverse effects. Hence, Sibutramine should not be adopted to treat antipsychotic-induced weight gain.

Prediction Models of Functional Outcomes for Individuals in the Clinical High-Risk State for Psychosis or With Recent-Onset Depression: A Multimodal, Multisite Machine Learning Analysis

IMPORTANCE

Social and occupational impairments contribute to the burden of psychosis and depression. There is a need for risk stratification tools to inform personalized functional-disability preventive strategies for individuals in at-risk and early phases of these illnesses.

OBJECTIVE

To determine whether predictors associated with social and role functioning can be identified in patients in clinical high-risk (CHR) states for psychosis or with recent-onset depression (ROD) using clinical, imaging-based, and combined machine learning; assess the geographic, transdiagnostic, and prognostic generalizability of machine learning and compare it with human prognostication; and explore sequential prognosis encompassing clinical and combined machine learning.

DESIGN, SETTING, AND PARTICIPANTS

This multisite naturalistic study followed up patients in CHR states, with ROD, and with recent-onset psychosis, and healthy control participants for 18 months in 7 academic early-recognition services in 5 European countries. Participants were recruited between February 2014 and May 2016, and data were analyzed from April 2017 to January 2018.

AIN OUTCOMES AND MEASURES

Performance and generalizability of prognostic models.

RESULTS

A total of 116 individuals in CHR states (mean [SD] age, 24.0 [5.1] years; 58 [50.0%] female) and 120 patients with ROD (mean [SD] age, 26.1 [6.1] years; 65 [54.2%] female) were followed up for a mean (SD) of 329 (142) days. Machine learning predicted the 1-year social-functioning outcomes with a balanced accuracy of 76.9% of patients in CHR states and 66.2% of patients with ROD using clinical baseline data. Balanced accuracy in models using structural neuroimaging was 76.2% in patients in CHR states and 65.0% in patients with ROD, and in combined models, it was 82.7% for CHR states and 70.3% for ROD. Lower functioning before study entry was a transdiagnostic predictor. Medial prefrontal and temporo-parieto-occipital gray matter volume (GMV) reductions and cerebellar and dorsolateral prefrontal GMV increments had predictive value in the CHR group; reduced mediotemporal and increased prefrontal-perisylvian GMV had predictive value in patients with ROD. Poor prognoses were associated with increased risk of psychotic, depressive, and anxiety disorders at follow-up in patients in the CHR state but not ones with ROD. Machine learning outperformed expert prognostication. Adding neuroimaging machine learning to clinical machine learning provided a 1.9-fold increase of prognostic certainty in uncertain cases of patients in CHR states, and a 10.5-fold increase of prognostic certainty for patients with ROD.

CONCLUSIONS AND RELEVANCE

Precision medicine tools could augment effective therapeutic strategies aiming at the prevention of social functioning impairments in patients with CHR states or with ROD.

The benefit of minocycline on negative symptoms of schizophrenia in patients with recent-onset psychosis (BeneMin): a randomised, double-blind, placebo-controlled trial

BACKGROUND

The antibiotic minocycline has neuroprotective and anti-inflammatory properties that could prevent or reverse progressive neuropathic changes implicated in recent-onset schizophrenia. In the BeneMin study, we aimed to replicate the benefit of minocycline on negative symptoms reported in previous pilot studies, and to understand the mechanisms involved.

METHODS

In this randomised, double-blind, placebo-controlled trial, we recruited people with a schizophrenia-spectrum disorder that had begun within the past 5 years with continuing positive symptoms from 12 National Health Service (NHS) trusts. Participants were randomly assigned according to an automated permuted blocks algorithm, stratified by pharmacy, to receive minocycline (200 mg per day for 2 weeks, then 300 mg per day for the remainder of the 12-month study period) or matching placebo, which were added to their continuing treatment. The primary clinical outcome was the negative symptom subscale score of the Positive and Negative Syndrome Scales (PANSS) across follow-ups at months 2, 6, 9, and 12. The primary biomarker outcomes were medial prefrontal grey-matter volume, dorsolateral prefrontal cortex activation during a working memory task, and plasma concentration of interleukin 6. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN49141214, and the EU Clinical Trials register (EudraCT) number is 2010-022463-35I.

FINDINGS

Between April 16, 2013, and April 30, 2015, we recruited 207 people and randomly assigned them to receive minocycline (n=104) or placebo (n=103). Compared with placebo, the addition of minocycline had no effect on ratings of negative symptoms (treatment effect difference -0·19, 95% CI -1·23 to 0·85; p=0·73). The primary biomarker outcomes did not change over time and were not affected by minocycline. The groups did not differ in the rate of serious adverse events (n=11 in placebo group and n=18 in the minocycline group), which were mostly due to admissions for worsening psychiatric state (n=10 in the placebo group and n=15 in the minocycline group). The most common adverse events were gastrointestinal (n=12 in the placebo group, n=19 in the minocycline group), psychiatric (n=16 in placebo group, n=8 in minocycline group), nervous system (n=8 in the placebo group, n=12 in the minocycline group), and dermatological (n=10 in the placebo group, n=8 in the minocycline group).

INTERPRETATION

Minocycline does not benefit negative or other symptoms of schizophrenia over and above adherence to routine clinical care in first-episode psychosis. There was no evidence of a persistent progressive neuropathic or inflammatory process underpinning negative symptoms. Further trials of minocycline in early psychosis are not warranted until there is clear evidence of an inflammatory process, such as microgliosis, against which minocycline has known efficacy.

FUNDING

National Institute for Health Research Efficacy and Mechanism Evaluation (EME) programme, an MRC and NIHR partnership.

The relapse rate and predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication

BACKGROUND

To determine the "real world" relapse rate in patients with first-episode psychosis (FEP) who had discontinued antipsychotic medication and identify socio-demographic and clinical factors associated with the risk of relapse.

METHODS

Quantitative data were obtained via case-note review on 63 patients with FEP who had discontinued antipsychotic medication from Birmingham Early Intervention Service between 2012 and 2015. The follow-up period was until either: an occurrence of a relapse; end of 12-month study period; end of patient's case-note record. Relapse was defined as a return of symptoms requiring one of the following: home treatment, hospital admission or was based on clinical teams' decision as having a relapse. A pro-forma targeted pre-defined socio-demographic and clinical factors. Survival analysis was undertaken to estimate the 12-month relapse rate following discontinuation of antipsychotics and Cox regression performed to identify relapse predictors.

RESULTS

The Kaplan-Meier 12-month relapse estimate was 67% (95% confidence interval, 54%, 80%). Significant factors (P < .05) independently associated with an increased risk of relapse following discontinuation of antipsychotic medication were: male gender, not being in education, employment or training (NEET) and number of previous psychiatric hospital admissions.

CONCLUSIONS

Relapse is common after discontinuation of antipsychotic medication following recovery from a FEP. It is important that patients who wish to discontinue their medication are informed of the high relapse rates and the associated risks. Furthermore, male patients, patients with NEET status and those who have had previous hospital admissions may require closer monitoring.

Neurotrophins, cytokines, oxidative stress mediators and mood state in bipolar disorder: systematic review and meta-analyses

BACKGROUND

A reliable biomarker signature for bipolar disorder sensitive to illness phase would be of considerable clinical benefit. Among circulating blood-derived markers there has been a significant amount of research into inflammatory markers, neurotrophins and oxidative stress markers.AimsTo synthesise and interpret existing evidence of inflammatory markers, neurotrophins and oxidative stress markers in bipolar disorder focusing on the mood phase of illness.

METHOD

Following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines, a systematic review was conducted for studies investigating peripheral biomarkers in bipolar disorder compared with healthy controls. We searched Medline, Embase, PsycINFO, SciELO and Web of Science, and separated studies by bipolar mood phase (mania, depression and euthymia). Extracted data on each biomarker in separate mood phases were synthesised using random-effects model meta-analyses.

RESULTS

In total, 53 studies were included, comprising 2467 cases and 2360 controls. Fourteen biomarkers were identified from meta-analyses of three or more studies. No biomarker differentiated mood phase in bipolar disorder individually. Biomarker meta-analyses suggest a combination of high-sensitivity C-reactive protein/interleukin-6, brain derived neurotrophic factor/tumour necrosis factor (TNF)-α and soluble TNF-α receptor 1 can differentiate specific mood phase in bipolar disorder. Several other biomarkers of interest were identified.

CONCLUSIONS

Combining biomarker results could differentiate individuals with bipolar disorder from healthy controls and indicate a specific mood-phase signature. Future research should seek to test these combinations of biomarkers in longitudinal studies.Declaration of interestNone.

The views of early intervention service staff on the treatment of first episode bipolar disorder

OBJECTIVE

Little is known about how first episode bipolar disorder (BD) is managed in early intervention for psychosis services (EIS). We aimed to investigate the knowledge and views of EIS staff on the assessment and treatment of BD.

METHODS

A 27-item anonymised online questionnaire was distributed to EIS mental health professionals in England. Descriptive data analysis was undertaken.

RESULTS

Responses were received from 117 EIS staff. Most were 'fairly confident' in their knowledge about causes, presentations and relapse indicators of BD, but less confident on pharmacological and psychological treatments. Eighty five percent expressed the view that more BD training was necessary in this area with 78% reporting no clear care packages within the service. Seventy two percent believe early BD should be treated within EIS only if patients have psychosis.

CONCLUSIONS

Clearer care packages and staff training are needed for EIS staff to optimise care for BD.

The impact of psychotic experiences in the early stages of mental health problems in young people

BACKGROUND

Anxiety and depressive symptoms and psychotic experiences constitute common features of emerging mental disorders in young people. Psychotic experiences and the ultra-high risk (UHR) state for psychosis appear to have a particular importance for clinical presentation, progression of symptomatology, quality of life and functioning, but the impact of psychotic experiences in individuals seeking help at non-UHR services, compared to UHR services, is under-researched.

METHODS

Sixty-nine young people (M_age ± SD at baseline = 20.8 ± 2.6, range 16-26 years, 48 females) presenting to mental health services were grouped according to UHR and non-UHR status. They were assessed at baseline for anxiety and depressive symptoms, psychological distress, psychosocial functioning and quality of life. They were followed up at three, six, and 12 months. Data were analysed using mixed linear modelling.

RESULTS

UHR individuals reported higher levels of depressive symptoms and psychological distress, and lower levels of role functioning and quality of life compared to non-UHR individuals. No differences were reported for anxiety symptoms or social functioning. Decline in psychosocial functioning was not associated with clinical deterioration or reduction of quality of life.

CONCLUSIONS

Psychotic experiences appear to be particularly associated with depressive symptoms and psychological distress, impaired role functioning and quality of life in help-seeking young people in the medium-term. It is therefore important to pay special attention to psychotic experiences in the early stages of mental health problems even if psychotic symptoms are not the main motivation for help-seeking.

Autism and psychosis: Clinical implications for depression and suicide

There is increasing recognition of the co-occurrence of autism and schizophrenia spectrum disorders. However, the clinical significance of this on outcomes such as depression and suicidal thinking has not been explored. This study examines the association of autism spectrum traits, depressive symptoms and suicidal behaviour in individuals with psychotic experiences. In two cross sectional studies, individuals from a non-help seeking university student sample and patients with first episode psychosis (FEP) service completed standardized measures of autism spectrum traits, psychotic experiences, depressive symptoms and suicidal thinking. In healthy non-help seeking students, increased autism traits and increased subclinical psychotic experiences were significantly associated with depressive symptoms; a significant interaction effect suggests their combined presence has a greater impact on depression. In FEP, high autism traits and positive symptoms were associated with increased depression, hopelessness and suicidality, however there was no significant interaction effect. In FEP a multiple mediation model revealed that the relationship between autism traits and risk for suicidality was mediated through hopelessness. Young people with subclinical psychotic experiences and all patients with FEP should be screened for autism spectrum traits, which may have significant impact on clinical outcomes. Tailored interventions for patients with high levels of autistic spectrum co-morbidities in FEP should be a priority for future research.

The relationship between negative symptoms and depression in schizophrenia: a systematic review

OBJECTIVE

To provide an update on the evidence base for the nature of the relationship between negative symptoms and depressive features in people with schizophrenia, and propose new models that reflect their complex relationship.

METHOD

A systematic review following PRISMA guidelines. A total of 2210 articles were identified from EMBASE, PsychInfo and MEDLINE, and further two articles were hand-searched from references. Twenty-seven met inclusion criteria and were included in the review.

RESULTS

In schizophrenia, primary evidence suggests symptoms of low mood, suicidal ideation and pessimism have more specificity for depression whereas alogia and blunted affect may have more specificity as negative symptoms. Anhedonia, anergia and avolition may be common to both.

CONCLUSION

It may be possible to further distinguish depressive features from negative symptoms in schizophrenia when detailed phenomenology is considered. However, in a proposed dimensional model, these two domains continue to share certain phenomena, highlighting their close relationship.

Depression during first episode psychosis and subsequent suicide risk: A systematic review and meta-analysis of longitudinal studies

BACKGROUND

Evidence suggests first episode psychosis (FEP) is associated with suicide, and the influence of depression on suicidal behaviour in cross sectional studies is clear. However the influence of depression during FEP on longer-term mortality is not certain. Existing evidence was synthesised to understand the influence of depressive symptoms during FEP on subsequent suicidal behaviour.

METHODS

Medline, Embase, PsycINFO, Cochrane Library, Web of Science, OpenGrey, and NICE Evidence were searched from inception to Jan 25, 2017. Longitudinal observational studies assessing the relationship between depressive symptoms during FEP with a measure of s at a specified follow-up time were included. Summary estimates were extracted. The Downs and Black Instrument was used to appraise study quality. Odds ratio (OR) of suicidal behaviour were calculated using random effects meta-analyses. The study protocol was registered with PROSPERO (CRD42017055881).

RESULTS

Of 4210 articles found, 23 fulfilled eligibility criteria. 13 were included in meta-analysis (n=3002). 428 participants demonstrated suicidal behaviour in the study periods. Odds of suicidal behaviour during follow-up were significantly higher among patients with depressive symptoms during FEP compared to those without (OR=1.59, 95% CI 1.14-2.21; I2=50.0%, p=0.02). Meta-regression demonstrated no evidence of influence of length of follow-up on results.

CONCLUSIONS

Depressive symptoms during FEP are associated with increased longer-term risk of suicidal behaviour. This association should be acknowledged during early management planning. Large-scale clinical trials are needed to identify efficacious management of depression during FEP.

Aberrant salience network functional connectivity in auditory verbal hallucinations: a first episode psychosis sample

Auditory verbal hallucinations (AVH) often lead to distress and functional disability, and are frequently associated with psychotic illness. Previously both state and trait magnetic resonance imaging (MRI) studies of AVH have identified activity in brain regions involving auditory processing, language, memory and areas of default mode network (DMN) and salience network (SN). Current evidence is clouded by research mainly in participants on long-term medication, with chronic illness and by choice of seed regions made 'a priori'. Thus, the aim of this study was to elucidate the intrinsic functional connectivity in patients presenting with first episode psychosis (FEP). Resting state functional MRI data were available from 18 FEP patients, 9 of whom also experienced AVH of sufficient duration in the scanner and had symptom capture functional MRI (sc fMRI), together with 18 healthy controls. Symptom capture results were used to accurately identify specific brain regions active during AVH; including the superior temporal cortex, insula, precuneus, posterior cingulate and parahippocampal complex. Using these as seed regions, patients with FEP and AVH showed increased resting sb-FC between parts of the SN and the DMN and between the SN and the cerebellum, but reduced sb-FC between the claustrum and the insula, compared to healthy controls.It is possible that aberrant activity within the DMN and SN complex may be directly linked to impaired salience appraisal of internal activity and AVH generation. Furthermore, decreased intrinsic functional connectivity between the claustrum and the insula may lead to compensatory over activity in parts of the auditory network including areas involved in DMN, auditory processing, language and memory, potentially related to the complex and individual content of AVH when they occur.

The CIRCuiTS study (Implementation of cognitive remediation in early intervention services): protocol for a randomised controlled trial

Background

Cognitive problems in people with schizophrenia predict poor functional recovery even with the best possible rehabilitation opportunities and optimal medication. A psychological treatment known as cognitive remediation therapy (CRT) aims to improve cognition in neuropsychiatric disorders, with the ultimate goal of improving functional recovery. Studies suggest that intervening early in the course of the disorder will have the most benefit, so this study will be based in early intervention services, which treat individuals in the first few years following the onset of the disorder. The overall aim is to investigate different methods of CRT.

Methods

This is a multicentre, randomised, single-blinded, controlled trial based in early intervention services in National Health Service Mental Health Trusts in six English research sites. Three different methods of providing CRT (intensive, group, and independent) will be compared with treatment as usual. We will recruit 720 service users aged between 16 and 45 over 3 years who have a research diagnosis of non-affective psychosis and will be at least 3 months from the onset of the first episode of psychosis. The primary outcome measure will be the degree to which participants have achieved their stated goals using the Goal Attainment Scale. Secondary outcome measures will include improvements in cognitive function, social function, self-esteem, and clinical symptoms.

Discussion

It has already been established that cognitive remediation improves cognitive function in people with schizophrenia. Successful implementation in mental health services has the potential to change the recovery trajectory of individuals with schizophrenia-spectrum disorders. However, the best mode of implementation, in terms of efficacy, service user and team preference, and cost-effectiveness is still unclear. The CIRCuiTS trial will provide guidance for a large-scale roll-out of CRT to mental health services where cognitive difficulties impact recovery and resilience.

Trial registration

ISRCTN, ISRCTN14678860, Registered on 6 June 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2553-3) contains supplementary material, which is available to authorized users.

The effect of structured consent on recall of information pre- and post-electroconvulsive therapy: a pilot study

Aims and method

A randomised, blind comparison of a structured consent procedure against routine consent was conducted to determine whether it had any utility in improving treatment knowledge In patients receiving electroconvulsive therapy (ECT). Additionally we aimed to determine whether degree of cognitive impairment intelligence and severity of depression influenced recall of information.

Results

Thirty-two subjects were investigated. Structured consent significantly improved the number of knowledge items recalled pre-ECT (P<0.05). Knowledge scores declined significantly after completion of the treatment course in both structured consent (P<0.05) and control groups (P<0.06). There was a significant correlation between Mini-Mental State Examination (MMSE) scores and the number of knowledge items recalled both pre- (r=0.43, P<0.05) and post-ECT (r=0.53, P<0.01).

Clinical implications

Structured consent procedures may be a useful way of improving patient knowledge of ECT and merit further study. Low scores on MMSE should caution clinicians to take particular care when consenting patients to ECT.

The immune system and schizophrenia: an update for clinicians

It has long been recognised that the pathology of schizophrenia may involve the immune system, yet this has been a relatively neglected area of research. Recent advances in our understanding of the complexities and functioning of the immune system have allowed new investigation into this area from many angles, including cellular and genetic avenues. A number of prominent theories have been developed. This article gives an overview of our understanding of the immune system and highlights recent advances pertaining to schizophrenia.

LEARNING OBJECTIVES

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Depression in schizophrenia and early psychosis: implications for assessment and treatment

Depression in schizophrenia has been a neglected field for some time, but much evidence exists as to the common occurrence of affective disturbance in so-called non-affective psychosis. Depression is related to poor outcome in terms of functional recovery, relapse rate and suicide, and there is increasing evidence that it also precedes the onset of first-episode psychosis for many individuals. This article reviews recent steps forward in the evidence base for depression in schizophrenia in terms of prevalence, importance, assessment and treatment implications, with the aim of providing useful information for practising psychiatrists.

Self-harm in first-episode psychosis

Aims and Method

Suicide in schizophrenia remains frequent. One of the best predictors of suicide, previous self-harm, is increasing in young people. the aim of this case-note review was to investigate the frequency of a history of self-harm for individuals presenting to psychiatric services with a first episode of psychosis in our local area and study their demographic characteristics.

Results

A history of self-harm was found in 32% of the cohort. the predominant method of self-harm was self-laceration. In univariate analyses, age and gender were significant predictors of self-harming behaviour.

Clinical Implications

The rate of self-harm among those with first-episode psychosis is high. Efforts to reduce the rate of completed suicide in psychotic illness need to focus on this risk, which often predates contact with psychiatric services. This emphasises again the need for early detection and intervention in psychotic illness.

Treatment of depression in schizophrenia: systematic review and meta-analysis

BackgroundDepression in schizophrenia predicts poor outcomes, including suicide, yet the effectiveness of antidepressants for its treatment remains uncertain.AimsTo synthesise the evidence of the effectiveness of antidepressants for the treatment of depression in schizophrenia.MethodMultiple databases were searched and inclusion criteria included participants aged over 18 years with schizophrenia or related psychosis with a depressive episode. Papers were quality assessed used the Cochrane risk bias tool. Meta-analyses were performed for risk difference and standardised mean difference of all antidepressants, antidepressant class and individual antidepressant where sufficient studies allowed.ResultsA total of 26 moderate- to low-quality trials met inclusion criteria. In meta-analysis a significant risk difference was found in favour of antidepressant treatment, with a number needed to treat of 5 (95% CI 4-9). Studies using tools specifically designed to assess depression in schizophrenia showed a larger effect size. However, after sensitivity analysis standardised mean difference of all antidepressants did not show a statistically significant improvement in depression score at end-point, neither did any individual antidepressant class.ConclusionsAntidepressants may be effective for the treatment of depression in schizophrenia, however, the evidence is mixed and conclusions must be qualified by the small number of low- or moderate-quality studies. Further sufficiently powered, high-quality studies are needed.

Suicidality in Autistic Spectrum Disorders

Abstract. Background: It is suggested that people with autistic spectrum disorders (ASD) may be at increased risk of suicide; however, research on this topic has been minimal and there are conflicting reports in existing studies. Aim: To bring together research investigating the prevalence, risk factors, and comorbid factors of suicidality in ASD. Method: A systematic search was performed of Medline, Psych Info, Embase, and the Web of Science following PRISMA guidelines. After exclusion criteria were applied, 70 full-text articles were screened. The final review contained 12 papers with a total sample size of 2,651. Results: Prevalence of suicide attempts varied between 7% and 47%, while suicidal ideation was reported in up to 72% of cases. Being male and having a history of self-harm and depression were cited as significant risk factors. Limitations: Papers were cross sectional and contained a number of limitations. Only one paper used the gold standard for diagnosis of ASD and one a standardized measure of suicidal behavior. Conclusion: Suicidal attempts and ideation are increased in ASD; however, the extent of the increase and the risk factors identified within this group remain under-investigated. There is a lack of research on protective factors. The correlation between ASD and suicidality needs further examination with longitudinal research.

Auditory verbal hallucinations in first episode psychosis – an fMRI symptom capture study

Introduction

Neurobiological models of auditory verbal hallucination (AVH) have been advanced by symptom capture functional magnetic resonance imaging (fMRI), where participants self-report hallucinations during scanning. To date, regions implicated are those involved with language, memory and emotion. However, previous studies focus on chronic schizophrenia, thus are limited by factors, such as medication use and illness duration. Studies also lack detailed phenomenological descriptions of AVHs. This study investigated the neural correlates of AVHs in patients with first episode psychosis (FEP) using symptom capture fMRI with a rich description of AVHs. We hypothesised that intrusive AVHs would be associated with dysfunctional salience network activity.

Methods

Sixteen FEP patients with frequent AVH completed four psychometrically validated tools to provide an objective measure of the nature of their AVHs. They then underwent fMRI symptom capture, utilising general linear models analysis to compare activity during AVH to the resting brain.

Results

Symptom capture of AVH was achieved in nine patients who reported intrusive, malevolent and uncontrollable AVHs. Significant activity in the right insula and superior temporal gyrus (cluster size 141 mm3), and the left parahippocampal and lingual gyri (cluster size 121 mm3), P < 0.05 FDR corrected, were recorded during the experience of AVHs.

Conclusions

These results suggest salience network dysfunction (in the right insula) together with memory and language processing area activation in intrusive, malevolent AVHs in FEP. This finding concurs with others from chronic schizophrenia, suggesting these processes are intrinsic to psychosis itself and not related to length of illness or prolonged exposure to antipsychotic medication.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Depression and Schizophrenia: Cause, Consequence, or Trans-diagnostic Issue?

The presence of depression in schizophrenia has been a challenge to the Kraepelinian dichotomy, with various attempts to save the fundamental distinction including evoking and refining diagnoses such as schizoaffective disorder. But the tectonic plates are shifting. Here we put forward a summary of recent evidence regarding the prevalence, importance, possible aetiological pathways and treatment challenges that recognizing depression in schizophrenia bring. Taken together we propose that depression is more than comorbidity and that increased effective therapeutic attention to mood symptoms will be needed to improve outcomes and to support prevention.

Fifteen years on - early intervention for a new generation

Early intervention for psychosis (EIP) is a model of service delivery that aims to support young people with first-episode psychosis by providing the best available treatments, supporting recovery and preventing relapse. In this editorial, we review the evidence for EIP, how the model has developed since its inclusion in the NHS policy implementation guideline for mental health in 2001, challenges and areas of ongoing debate, and future development.

What bridges the gap between self-harm and suicidality? The role of forgiveness, resilience and attachment

Self-harm is the most robust risk for completed suicide. There is a lack of understanding of why some people who self-harm escalate to suicidal behaviour when others do not. Psychological factors such as attachment, self-forgiveness and self-appraisal may be important. To determine whether factors from the Interpersonal Theory and Schematic Appraisals models are useful to identify suicidal behaviour in populations that self-harm. Specifically we investigate whether resilience factors of secure attachment, self-forgiveness and positive self-appraisals significantly influence suicidality in people who self-harm. A cross-sectional online study of 323 participants recruited from self-harm support forum. Validated self-report measures were used to assess appraisals, relationships, self-forgiveness, attachment style, suicidality and self-harm. Emotion coping and support seeking self-appraisals and self-forgiveness were negatively associated with suicidality in participants with a history of self-harm. Dismissing attachment was positively associated with suicidality. The perceived ability to cope with emotions, the perceived ability to gain support and self-forgiveness may protect against suicide in people who self-harm. Conversely the presence of dismissing attachment may increase the risk of suicidality. Findings provide therapeutic targets to reduce risk of suicidality in this high risk group.