Progressing MoodSwings. The upgrade and evaluation of MoodSwings 2.0: An online intervention for bipolar disorder

MoodSwings 2.0 is a self-guided online intervention for bipolar disorder. The intervention incorporates technological improvements on an earlier validated version of the intervention (MoodSwings 1.0). The previous MoodSwings trial provides this study with a unique opportunity to progress previous work, whilst being able to take into consideration lesson learnt, and technological enhancements. The structure and technology of MoodSwings 2.0 are described and the relevance to other online health interventions is highlighted. An international team from Australia and the US updated and improved the programs content pursuant to changes in DSM-5, added multimedia components and included larger numbers of participants in the group discussion boards. Greater methodological rigour in this trial includes an attention control condition, quarterly telephone assessments, and red flag alerts for significant clinical change. This paper outlines these improvements, including additional security and safety measures. A 3 arm RCT is currently evaluating the enhanced program to assess the efficacy of MS 2.0; the primary outcome is change in depressive and manic symptoms. To our knowledge this is the first randomized controlled online bipolar study with a discussion board attention control and meets the key methodological criteria for online interventions.

Correlates of physical activity in people living with psychotic illness

OBJECTIVE

In the light of the high prevalence of physical comorbidities in people with psychotic illness, there is a need to explore modifiable risk factors that may contribute to this disease burden. The benefits of physical activity to both physical and mental health have been well established. We aimed to examine the prevalence and correlates of physical activity in a national sample of adults living with psychotic illness.

METHODS

Physical activity was assessed in 1801 people using the International Physical Activity Questionnaire. Participants were dichotomised into low and moderate-high physical activity groups and associations between physical activity and a range of sociodemographic, clinical and physical comorbidity variables were examined using logistic regression.

RESULTS

More than half the participants were categorised in the moderate-high physical activity group with nearly half of the sample engaged in physical activity every day. There were significant associations between low physical activity and older age, unemployment, educational non-participation, antipsychotic medication use, social dysfunction, self-reported loneliness and obesity. However, there was no significant association between physical activity and sex, psychosis type, illness duration, physical comorbidity or negative symptoms.

CONCLUSION

The findings from this study may inform future interventions designed to increase physical activity in people with psychotic illness.

Metabolic syndrome in people with a psychotic illness: is cannabis protective?

BACKGROUND

Rates of the metabolic syndrome in people with psychotic illness are high. Emerging evidence suggests that cannabis use may have a positive impact on cardiometabolic risk factors in the general population, but little is known about its impact for people with psychotic illness. Our aim was to investigate whether the rate of the metabolic syndrome in people with psychotic illness was associated with frequency of cannabis use.

METHOD

The 2010 Australian psychosis survey used a two-phase design to randomly select a nationally representative sample of 1825 adults with psychotic illness for interview and physical assessment. This study is based on 1813 participants who provided data on cannabis use. Multiple logistic regression was used to model the influence of frequency of cannabis use on the metabolic syndrome, adjusting for potential covariates including antipsychotic medication use, smoking, alcohol use and cognitive function.

RESULTS

One-third (33.0%) of participants had used cannabis in the past year. The proportion of non-users, occasional users and frequent users with the metabolic syndrome was 63.0, 51.7 and 43.5%, respectively (p < 0.001). In unadjusted analyses, both occasional use and frequent cannabis use were associated with significantly lower odds of the metabolic syndrome. In the adjusted analyses, the association between the metabolic syndrome and frequent cannabis use remained significant [odds ratio = 0.56, 95% confidence interval (CI) 0.39-0.80], but not the association with occasional use (odds ratio = 0.75, 95% CI 0.49-1.13).

CONCLUSIONS

While cannabis use may be detrimental for mental health, these data suggest that it may also have a cardiometabolic protective effect. Further investigation is required to understand the mechanism underlying this paradoxical finding.

Reasons for cannabis use in first-episode psychosis: does strength of endorsement change over 12 months?

BACKGROUND

Why patients with psychosis use cannabis remains debated. The self-medication hypothesis has received some support but other evidence points towards an alleviation of dysphoria model. This study investigated the reasons for cannabis use in first-episode psychosis (FEP) and whether strength in their endorsement changed over time.

METHODS

FEP inpatients and outpatients at the South London and Maudsley, Oxleas and Sussex NHS Trusts UK, who used cannabis, rated their motives at baseline (n=69), 3 months (n=29) and 12 months (n=36). A random intercept model was used to test the change in strength of endorsement over the 12 months. Paired-sample t-tests assessed the differences in mean scores between the five subscales on the Reasons for Use Scale (enhancement, social motive, coping with unpleasant affect, conformity and acceptance and relief of positive symptoms and side effects), at each time-point.

RESULTS

Time had a significant effect on scores when controlling for reason; average scores on each subscale were higher at baseline than at 3 months and 12 months. At each time-point, patients endorsed 'enhancement' followed by 'coping with unpleasant affect' and 'social motive' more highly for their cannabis use than any other reason. 'Conformity and acceptance' followed closely. 'Relief of positive symptoms and side effects' was the least endorsed motive.

CONCLUSIONS

Patients endorsed their reasons for use at 3 months and 12 months less strongly than at baseline. Little support for the self-medication or alleviation of dysphoria models was found. Rather, patients rated 'enhancement' most highly for their cannabis use.

Personalized medicine and genome-based treatments: Why personalized medicine ≠ individualized treatments

The sequencing of the human genome and decreasing costs of sequencing technology have led to the notion of ‘personalized medicine’. This has been taken by some authors to indicate that personalized medicine will provide individualized treatments solely based on one’s DNA sequence. We argue this is overly optimistic and misconstrues the notion of personalization. Such interpretations fail to account for economic, policy and structural constraints on the delivery of healthcare. Furthermore, notions of individualization based on genomic data potentially take us down the road of genetic reductionism obscuring the role of environmental factors in disease and ill health. We propose that one should see personalized medicine as a way of using personal genomic information to stratify individuals into subpopulations and suggest that personalized medicine be seen within a broader idea of personalized healthcare, reflecting healthcare that integrates personal genomic data into cultural, environmental and personal contexts.

Group music therapy for severe mental illness: a randomized embedded-experimental mixed methods study

OBJECTIVE

Music therapy is an innovative approach to support people with severe mental illness (SMI). The aim of the study was to determine whether group music therapy (GMT) positively impacted on quality of life (QoL), social enrichment, self-esteem, spirituality and psychiatric symptoms of participants with SMI and how they experienced the intervention.

METHOD

The primary outcome was QoL; secondary measures assessed social enrichment, self-esteem, spirituality and psychiatric symptoms. The 13-week intervention comprised singing familiar songs and composing original songs recorded in a professional studio. Qualitative data were generated from focus group interviews and song lyric analysis.

RESULTS

Ninety-nine adults (57 female) were recruited, with an initial cohort (n = 75) randomized to either: weekly GMT followed by standard care (SC) or SC followed by GMT. Crossover occurred after 13 weeks. Measures were conducted at baseline, 13, 26 and 39 weeks. A second cohort (n = 24) could not be randomized and were assigned to GMT followed by SC. Intention-to-treat analysis showed a significant difference between GMT and SC on QoL and spirituality. This was robust to different assumptions about missing data (listwise deletion, last observation carried forward or multiple imputation). Per-protocol analysis suggested greater benefit for those receiving more sessions. Focus group interview and song lyric analyses suggested that GMT was enjoyable; self-esteem was enhanced; participants appreciated therapists and peers; and although challenges were experienced, the programme was recommended to others.

CONCLUSION

Group music therapy may enhance QoL and spirituality of persons with SMI.

Psychosis prevalence and physical, metabolic and cognitive co-morbidity: data from the second Australian national survey of psychosis

BACKGROUND

There are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities.

METHOD

The 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18-64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants.

RESULTS

The 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18-64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence.

CONCLUSIONS

Our findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.

Anxiety symptoms in psychotic disorders

BackgroundThe prevalence of anxiety symptoms among Australians with psychotic disorders was examined as part of the Survey of High Impact Psychosis (SHIP).MethodsA two-phase design was used. Of 7,955 people who were screen positive for psychosis and eligible, 1825 participants (18-34 years and 35-64 years) were interviewed. Data were collected on symptomatology, substance use, cognitive ability, functioning, disability, physical health, mental health service utilisation, medication use, education, employment and housing. Anxiety symptomatology was divided into generalized anxiety, panic, phobic, social anxiety and obsessive-compulsive symptoms.ResultsThe most common ICD-10 diagnoses were schizophrenia or schizoaffective disorder (63.0%) and bipolar (mania) disorder (17.5%). Overall, 59.8% (n = 1092) of participants reported experiencing anxiety symptoms in the previous 12 months. Female gender was highly associated with all domains of anxiety. Smoking was significantly associated with all domains of anxiety, except generalized anxiety. The presence of any depressive symptoms in the previous 12 months was significantly associated with all anxiety symptoms. Medication side-effects were associated with phobic and obsessive-compulsive symptoms. Social dysfunction was associated with social anxiety, and less so for obsessive-compulsive symptoms.ConclusionsAnxiety symptoms are common in people with psychotic disorders. Appropriate screening and treatment should be a clinical priority.

A whole-of-population study of the prevalence and patterns of criminal offending in people with schizophrenia and other mental illness

BACKGROUND

Large epidemiological studies are needed to better understand the prevalence and profile of offending by people with mental illness. This study used a whole-of-population design to examine the prevalence, type and pattern of offending across all psychiatric diagnoses, including schizophrenia, compared to the general population. Method We used whole-of-population longitudinal record-linked data for a cohort of all Western Australians born 1955-1969 to determine arrest history over the period 1985-1996 and to ascertain recorded history of psychiatric illness. Of the cohort, 116 656 had been arrested and 40 478 were on the psychiatric case register.

RESULTS

The period prevalence of arrest for people with any psychiatric illness was 32.1%. The highest arrest prevalence, by diagnostic category, was for substance use disorders (59.4%); the prevalence for schizophrenia was 38.7%. Co-morbid substance use disorders significantly increased risk of arrest in people with schizophrenia. The prevalence of mental illness among offenders was 11.1%: 6.5% of offenders had substance use disorders and 1.7% had schizophrenia. For the majority of offenders with a psychiatric illness, first arrest preceded first contact with mental health services; for schizophrenia only, this proportion was increasing over time. The mean percentage annual change in the number of arrests during 1985-1996 rose significantly for offenders with a psychiatric illness other than schizophrenia and dropped significantly for those with no mental illness. Compared to non-psychiatric offenders, offenders with schizophrenia were more likely to offend alone, to offend in open places and to target strangers.

CONCLUSIONS

Our findings open the way to an informed approach to the management of offenders with mental illness.

Public attitudes towards genomic risk profiling as a component of routine population screening

Including low penetrance genomic variants in population-based screening might enable personalization of screening intensity and follow up. The application of genomics in this way requires formal evaluation. Even if clinically beneficial, uptake would still depend on the attitudes of target populations. We developed a deliberative workshop on two hypothetical applications (in colorectal cancer and newborn screening) in which we applied stepped, neutrally-framed, information sets. Data were collected using nonparticipant observation, free-text comments by individual participants, and a structured survey. Qualitative data were transcribed and analyzed using thematic content analysis. Eight workshops were conducted with 170 individuals (120 colorectal cancer screening and 50 newborn screening for type 1 diabetes). The use of information sets promoted informed deliberation. In both contexts, attitudes appeared to be heavily informed by assessments of the likely validity of the test results and its personal and health care utility. Perceived benefits included the potential for early intervention, prevention, and closer monitoring while concerns related to costs, education needs regarding the probabilistic nature of risk, the potential for worry, and control of access to personal genomic information. Differences between the colorectal cancer and newborn screening groups appeared to reflect different assessments of potential personal utility, particularly regarding prevention.

Family history tools in primary care: does one size fit all?

Family health history (FHH) has potential value in many health care settings. This review discusses the potential uses of FHH information in primary care and the need for tools to be designed accordingly. We developed a framework in which the attributes of FHH tools are mapped against these different purposes. It contains 7 attributes mapped against 5 purposes. In considering different FHH tool purposes, it is apparent that different attributes become more or less important, and that tools for different purposes require different implementation and evaluation strategies. The context in which a tool is used is also relevant to its effectiveness. For FHH tools, it is unlikely that 'one size fits all', although appreciation of different purposes, users and contexts should facilitate the development of different applications from single FHH platforms.

Early psychosis treatment in an integrated model within an adult mental health service

OBJECTIVE

To compare the treatment of patients with early psychosis, 2 years after the introduction of an integrated model of enhanced management within a public adult mental health service, with an historic cohort from the same service.

METHOD

Variables examined in the 2001 cohort were compared with 2008 patients. Computer database review and a file audit were conducted for all patients with early psychosis across the first 2 years of the program.

RESULTS

Compared to the historic cohort, patients in the current cohort were 24% less likely to have been admitted (P=0.004). There were statistically significant reductions in involuntary status and use of a locked unit. Rates of police involvement in admission and use of seclusion were also reduced, though this trend was not significant. Average length of stay was reduced. Median duration of untreated psychosis was 3 months in both 2001 and 2008 cohorts.

CONCLUSIONS

The introduction of an integrated model of management within an area mental health service for patients with early psychosis contributed to significant reductions in admissions, involuntary status and use of a locked ward. The data suggests that enhanced treatment of early psychosis patients can be offered within generic services.

The detection of mupirocin resistance and the distribution of methicillin-resistant Staphylococcus aureus at the University Hospital of the West Indies, Jamaica

OBJECTIVES

The objectives of this study were to determine the susceptibility of Methicillin Resistant Staphylococcus aureus (MRSA) isolates to Mupirocin and other antimicrobial agents and to record the prevalence and distribution of this organism at the University Hospital of the West Indies (UHWI).

METHODS

MRSA isolates collected between January 1, 2008 and December 31, 2008, were tested for low and high level resistance to Mupirocin. Susceptibility testing to other antibiotics including cotrimoxazole, minocycline, tetracycline, clindamycin, erythromycin, gentamicin and vancomycin was also done. Laboratory records for all patients from whom MRSA was recovered were reviewed and data on type and source of isolates, clinical diagnosis, history of previous hospitalization and use of mupirocin were extracted. In addition, the laboratory records for 2004 and 2005 were also reviewed to determine prevalence during these periods.

RESULTS

Seven per cent of Staphylococcus aureus isolates were resistant to methicillin (MRSA) and of these, 30% and 24% showed low level and high level resistance to mupirocin, respectively. Ninety-four per cent of MRSA strains were resistant to erythromycin while 52% showed resistance to clindamycin. Resistance to tetracycline, co-trimoxazole and minocycline was 27%, 12% and 6%, respectively, while about one-third of the isolates were resistant to gentamicin. There was no resistance to vancomycin. More than half (58%) of the isolates were from skin and soft tissue specimens while isolates from respiratory and urinary tracts and the bloodstream accounted for 19%, 13% and 4%, respectively. There has been a steady increase in prevalence from 4% in 2004 to 5% in 2007 and 7% in 2008.

CONCLUSION

Resistance of MRSA to mupirocin appears to be an emerging problem at the UHWI and must be monitored carefully. There is also significant resistance to commonly used antimicrobial agents and strict adherence to antibiotic policy is required to preserve the usefulness of these agents.

Distribution of nosocomial organisms and their resistance patterns in the intensive care unit of the University Hospital of the West Indies, Kingston, Jamaica

OBJECTIVES

To determine the distribution and antibiotic susceptibility patterns of nosocomial pathogens in the Intensive Care Unit (ICU) at the University Hospital of the West Indies (UHWI).

METHODS

A retrospective review of the laboratory records of all ICU patients from 2002-2004 was done. All organisms isolated from blood, urine, sputum, wound swabs and CVP tips were recorded. Sensitivity reports for organisms isolated in 2004 were also obtained. Results were analysed according to source of isolates and type of infection.

RESULTS

Gram-negative organisms account for the majority oflCU isolates and show resistance to multiple antibiotics. The common Gram negative pathogens in the ICU are Pseudomonas aeruginosa, Acinetobacter spp and Stenotrophomonas maltophilia while the common Gram positive nosocomial organisms are Group D Streptococcus and coagulase negative Staphylococcus.

CONCLUSION

The organisms isolated in the ICU at the UHWI are similar to those isolated in many ICUs all over the world. Surveillance data are necessary to monitor nosocomial pathogens and their resistance patterns to guide empirical antibiotic therapy.

Protein sorting and secretion granule formation in regulated secretory cells

Formation of secretion granules in regulated secretory cells involves packaging a subject of proteins undergoing intracellular transport into specific vesicular carriers that function in stimulus-dependent exocytosis. Recent findings suggest that immature granules are a site of passive sorting, involving condensation of regulated secretory proteins. Proteins that are not condensed are stored to a lesser degree and are enriched in unstimulated, constitutive-like secretion. While these observations have helped to distinguish possible mechanisms of secretory protein sorting, there are only recent hints about the sorting processes that may be required to create the regulated secretory carrier membranes.

The emergence of Stenotrophomonas maltophilia as a significant nosocomial pathogen at the University Hospital of the West Indies

Stenotrophomonas maltophilia is emerging worldwide as a nosocomial pathogen. It is associated with certain risk factors and a wide range of infections. This study was done to document its emergence at the University Hospital of the West Indies and to determine the incidence, distribution and risk factors associated with it. A retrospective study was conducted over the period April 1997 to December 2000. Clinical records were available for 46 of the 66 patients identified over the study period. Fifty-five per cent of the cases came from the Intensive Care Unit (ICU) and the rest from other wards. There was a slight increase in the prevalence of infection with increasing age. The surgical service accounted for the largest number of isolates. Of the cases presented, 95.7% were exposed to a wide range of antibiotics and had some form of instrumentation. Underlying disease was found in 71.7% of the patients. S maltophilia was found most often in the sputum of ICU patients whereas it was most often isolated from wound swabs in the ward patients. The organism was isolated from blood more often in ICU patients (23.3%) than in ward patients (9.5%) and there was a 44% mortality rate among the cases in ICU compared with those on the wards (4.8%). Stenotrophomonas maltophilia is an important nosocomial pathogen and occurs in a wide cross-section of patients. The risk factors must be addressed and infection control measures implemented to restrict the spread of this organism.

Incidence of schizophrenia in south-east London between 1965 and 1997

BACKGROUND

There has been much debate about changes in the incidence of schizophrenia.

AIMS

To identify any changes in incidence of schizophrenia in Camberwell, south-east London, between 1965 and 1997.

METHOD

Research Diagnostic Criteria and DSM-III-R diagnoses were generated for all first contacts by the OPCRIT computer program, and incidence rates of schizophrenia in seven time periods were measured. Indirect standardisation and Poisson models were used to measure the effect of time period and to examine interactions with age and gender.

RESULTS

There was a continuous and statistically significant increase in the incidence of schizophrenia, which was greatest in people under 35 years of age and was not gender-specific.

CONCLUSIONS

The incidence of schizophrenia has doubled in south-east London over the past three decades.

Types of patients in a psychiatric intensive care unit

OBJECTIVE

This paper reports the findings of a descriptive study of a patient population over a three-month period on an eight bed psychiatric intensive care unit (PICU) in Western Australia. The report provides a quantitative insight into the profile of patients in PICUs. It provides information on patients' diagnoses, presenting signs, symptoms and/or behaviours, legal codes assigned to patients, treatment interventions and management.

METHOD

Data were collected prospectively from August to October 1999. A total of 122 patients were admitted to the PICU during the review period. Data were entered into an Access program then exported to SPSS (Version 9 for Windows) for analysis and frequency distributions were obtained.

RESULTS

The results confirmed that the majority of patients admitted to the PICU were assessed as a high level of risk or needed containment. This finding is in line with the admission criteria developed by staff working in the PICU. It also supports the view that staff working in these units require expertise and confidence to communicate with and manage potentially aggressive and highly aroused patients.

CONCLUSION

This study demonstrates the importance of ongoing evaluations of patient populations in promoting best practice initiatives in psychiatric care.

Comparison of the incidence of schizophrenia in rural Dumfries and Galloway and urban Camberwell

BACKGROUND

Being born or living in urban areas is associated with high rates of schizophrenia. However, few studies have compared the incidence in urban/rural areas using the same methodology.

AIMS

To compare service-based incidence rates for schizophrenia in rural Dumfries and Galloway in south-west Scotland with urban Camberwell in south-east London.

METHOD

Using Research Diagnostic Criteria diagnoses from the OPCRIT computer algorithm, we compared the incidence of schizophrenia over 12 years (1979-1984 and 1992-1997) using indirect standardisation techniques and Poisson regression modelling.

RESULTS

The incidence was 61% higher in urban Camberwell than in rural Dumfries and Galloway (standardised incidence ratio (SIR)=1.61; 95% CI=1.42-1.81). There was no difference in incidence when we compared the White population in Camberwell with Dumfries and Galloway (SIR=1.12; 95% CI=0.86-1.43).

CONCLUSIONS

The incidence of schizophrenia in urban Camberwell was higher than that in rural Dumfries and Galloway; the high incidence of non-Whites in Camberwell largely explains the urban/rural difference.

Risk factors for the deficit syndrome of schizophrenia

Previous studies have found two risk factors associated with the deficit syndrome of schizophrenia: an increase in summer births, compared to others with schizophrenia; and a higher risk of schizophrenia in relatives. In data from the Camberwell Register Psychosis Series, a population-based sample that approximated a treated-incidence sample, the deficit/nondeficit categorization was made using a previously validated proxy method. Associations were found between the deficit syndrome and both summer birth and a family history of schizophrenia. In contrast, nondeficit schizophrenia was associated with a family history of psychiatric problems other than schizophrenia. The deficit group also had poorer insight. An early age of onset was associated with disorganization, but not with the deficit or nondeficit group. The deficit/nondeficit differences could not be attributed to confounding by demographic features or the severity of hallucinations, delusions, or formal thought disorder.

A clinical validation of the Dysmorphic Concern Questionnaire

OBJECTIVE

The current study addressed the concept of dysmorphic concern as a symptom that may exist in a number of disorders. The aims of the study were to: (i) validate a recently developed questionnaire that measures dysmorphic concern, the Dysmorphic Concern Questionnaire (DCQ); and (ii) evaluate the relationship of dysmorphic concern to depressed mood, social phobia, and obsessive-compulsive symptomatology.

METHOD

Sixty-five psychiatric inpatients were diagnosed using the computerized version of the Composite International Diagnostic Interview (CIDI-A). They then completed the DCQ, and questionnaires measuring body dysmorphic disorder (the Body Dysmorphic Disorder Examination, or BDDE), depression, social phobia, and obsessive-compulsive disorder (OCD). The factor structure and convergent validity of the DCQ were determined, and associations with mood and anxiety symptoms explored.

RESULTS

The DCQ was found to be a reliable and valid instrument that is sensitive to dysmorphic concern. Furthermore, although dysmorphic concern was associated with body dysmorphic disorder (BDD), depression, social phobia and OCD, only the score from the BDDE predicted DCQ score in a multiple regression analysis. Finally, BDD symptomatology was best defined by the presence of negative body beliefs as measured by the DCQ.

CONCLUSIONS

Negative body beliefs are the hallmark of BDD. However, the existence of dysmorphic concern does not necessarily imply a diagnosis of BDD. The DCQ is a quick and efficient means of identifying dysmorphic concern in those who present with depression, OCD, social phobia or BDD.

The use of seclusion in the year 2000: What Has Changed?

This study was undertaken to examine the perceptions of nurses working in three psychiatric settings regarding the effect and use of seclusion. It also aimed to identify current practices at these sites in the metropolitan area of Western Australia. A total of 78 nurses specialising in mental health care participated in the study by completing the 'Attitude towards seclusion survey'. The findings of this study indicate that nurses perceive seclusion as an accepted patient management strategy. The results also showed that the decision to seclude the patient was made by a senior mental health practitioner and that one hour was the average time a patient spent in seclusion. It is important to ensure that punishment, paternalistic attitudes or punitive actions are not part of clinical judgment regarding the use of seclusion. The study has provided evidence of nurses' perceptions concerning seclusion and the results highlight the need for staff to continue to explore and evaluate issues that lead to seclusion in order to facilitate the use of other management strategies that encourage a less restrictive environment.

A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia

OBJECTIVE

The objective of this study was to investigate the efficacy of group-based cognitive-behavioural therapy (CBT) for social anxiety in schizophrenia.

METHOD

Patients with schizophrenia (20) with comorbid social anxiety were randomly assigned to the group-based CBT or wait-list control condition. Pre-, post- and 6-week follow-up ratings included measures of social anxiety and avoidance, mood and quality of life.

RESULTS

The intervention group improved on all outcome measures and the control group showed no change in symptomatology.

CONCLUSIONS

Group-based CBT is effective in treating social anxiety in schizophrenia.

The secretory carrier membrane protein family: structure and membrane topology

Secretory carrier membrane proteins (SCAMPs) are integral membrane proteins found in secretory and endocytic carriers implicated to function in membrane trafficking. Using expressed sequence tag database and library screens and DNA sequencing, we have characterized several new SCAMPs spanning the plant and animal kingdoms and have defined a broadly conserved protein family. No obvious fungal homologue has been identified, however. We have found that SCAMPs share several structural motifs. These include NPF repeats, a leucine heptad repeat enriched in charged residues, and a proline-rich SH3-like and/or WW domain-binding site in the N-terminal domain, which is followed by a membrane core containing four putative transmembrane spans and three amphiphilic segments that are the most highly conserved structural elements. All SCAMPs are 32-38 kDa except mammalian SCAMP4, which is approximately 25 kDa and lacks most of the N-terminal hydrophilic domain of other SCAMPs. SCAMP4 is authentic as determined by Northern and Western blotting, suggesting that this portion of the larger SCAMPs encodes the functional domain. Focusing on SCAMP1, we have characterized its structure further by limited proteolysis and Western blotting with the use of isolated secretory granules as a uniformly oriented source of antigen and by topology mapping through expression of alkaline phosphatase gene fusions in Escherichia coli. Results show that SCAMP1 is degraded sequentially from the N terminus and then the C terminus, yielding an approximately 20-kDa membrane core that contains four transmembrane spans. Using synthetic peptides corresponding to the three conserved amphiphilic segments of the membrane core, we have demonstrated their binding to phospholipid membranes and shown by circular dichroism spectroscopy that the central amphiphilic segment linking transmembrane spans 2 and 3 is alpha-helical. In the intact protein, these segments are likely to reside in the cytoplasm-facing membrane interface. The current model of SCAMP1 suggests that the N and C termini form the cytoplasmic surface of the protein overlying a membrane core, which contains a functional domain located at the cytoplasmic interface with little exposure of the protein on the ectodomain.

Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders

OBJECTIVE

This paper reports on a study designed within the framework of the National Survey of Mental Health and Wellbeing to: estimate the prevalence of psychoses in urban areas of Australia; identify profiles of symptomatology, impairments and disabilities; collect information on services received and needed; and explore quality of life issues in a broadly representative sample of people with psychotic illnesses.

METHOD

The study was conducted over four areas in the Australian Capital Territory, Queensland, Victoria and Western Australia, as a two-phase survey: (i) a census and screening for psychosis of all individuals who made contacts with mental health services during a period of 1 month in 1997; and (ii) interviews with a stratified random sample (n=980) of the screen-positive individuals (n=3800) using a standardised instrument.

RESULTS

The point prevalence (1 month) of psychotic disorders in the urban population aged 18-64 is in the range of 4-7 per 1000 with a weighted mean of 4.7 per 1000. People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance-use comorbidity and frequent side effects of medication. Although the utilisation of hospital-based and community mental health services, as well as of public and non-governmental helping agencies, is high, the majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent.

CONCLUSIONS

The so-called 'low-prevalence' psychotic disorders represent a major and complex public health problem, associated with heavy personal and social costs. There is a need for a broad programmatic approach, involving various sectors of the community, to tackle the multiple dimensions of clinical disorder, personal functioning and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention.

Analyses of proteins involved in vesicular trafficking in platelets of mouse models of Hermansky Pudlak syndrome

Hermansky Pudlak syndrome (HPS) is an autosomal recessive inherited disorder characterized by defects in synthesis and/or secretion of three related subcellular organelles: melanosomes, platelet-dense granules, and lysosomes. In the mouse, mutant forms of any of 14 separate genes result in an HPS-like phenotype. The mouse pearl and mocha genes encode subunits of the AP3 adaptor protein complex, confirming that HPS mutations involve proteins regulating intracellular vesicular trafficking. Therefore, expression of several additional proteins involved in vesicular transport was examined by immunoblotting of platelet extracts from HPS mutant and control mice. Platelet levels of SCAMPS (secretory carrier membrane proteins), Rab11, Rab31, NSF (N-ethylmaleimide-sensitive fusion protein), syntaxin 2, syntaxin 4, munc18c, and p115/TAP (p115/transcytosis-associated protein) were not significantly altered in several different HPS mutants. However, gunmetal (gm/gm) platelets contained decreased amounts of SNAP-23. The Snap23 gene was mapped to mouse chromosome 5, demonstrating it cannot encode the gm gene, which maps to chromosome 14. It is likely therefore that the gm gene functions upstream of SNAP-23 in vesicular trafficking.

Differences in distribution of ages of onset in males and females with schizophrenia

An earlier age at onset of schizophrenia in men as opposed to women, has been widely reported, but hitherto, insufficient account has been taken of parameters that might confound this finding. Furthermore, few explanatory models have accounted for the differences in shape of the age-at-onset distributions in males and females with schizophrenia. A catchment area sample of 477 first contact cases with schizophrenia or related disorders was ascertained through a case register. Differences in age at onset distributions between males and females were determined, and adjustment made for potential confounding factors. The most powerful predictors of early illness-onset were poor premorbid occupational functioning, single marital status, and male sex. The earlier onset in males was robust to controlling for other parameters. The shape of the onset distribution also differed between the sexes: SKUMIX analysis revealed a two-peak distribution for males, and a three-peak distribution for females. The mean age at onset for schizophrenia is earlier in males, and the onset distribution differs between the sexes. Psychosocial variables cannot explain these findings. Possible explanations for these gender differences include males and females being differentially susceptible to subtypes of illness with different mean ages at onset; precipitating and/or ameliorating factors operating at different stages of life in males and females; and/or an X-linked susceptibility locus that determines the age at onset.

Relocation of the t-SNARE SNAP-23 from lamellipodia-like cell surface projections regulates compound exocytosis in mast cells

For regulated secretion, mast cells and several other cell types utilize compound exocytosis, a combination of granule-plasma membrane and granule-granule fusions. The molecular machinery that controls this massive export process has not been identified. We report that SNAP-23, a t-SNARE related to SNAP-25, relocates in response to stimulation from plasma membrane lamellipodia-like projections to granule membranes in permeabilized mast cells. While relocation is a prerequisite for secretion, it can occur without membrane fusion and will expedite a subsequent secretory response. After relocation, SNAP-23 is required for exocytosis, implying a crucial role in promoting membrane fusion. Thus, relocation of this SNARE regulates compound exocytosis and links granule-plasma membrane and granule-granule fusions.

Sorting and storage during secretory granule biogenesis: looking backward and looking forward

Secretory granules are specialized intracellular organelles that serve as a storage pool for selected secretory products. The exocytosis of secretory granules is markedly amplified under physiologically stimulated conditions. While granules have been recognized as post-Golgi carriers for almost 40 years, the molecular mechanisms involved in their formation from the trans-Golgi network are only beginning to be defined. This review summarizes and evaluates current information about how secretory proteins are thought to be sorted for the regulated secretory pathway and how these activities are positioned with respect to other post-Golgi sorting events that must occur in parallel. In the first half of the review, the emerging role of immature secretory granules in protein sorting is highlighted. The second half of the review summarizes what is known about the composition of granule membranes. The numerous similarities and relatively limited differences identified between granule membranes and other vesicular carriers that convey products to and from the plasmalemma, serve as a basis for examining how granule membrane composition might be established and how its unique functions interface with general post-Golgi membrane traffic. Studies of granule formation in vitro offer additional new insights, but also important challenges for future efforts to understand how regulated secretory pathways are constructed and maintained.

Intracellular transport and secretion of salivary proteins

Intracellular transport and secretion of salivary proteins are major activities of salivary acinar cells. While the major intracellular pathway followed by salivary proteins following their synthesis has been described previously, there is only limited understanding of how this process is regulated at the molecular level. Studies of salivary proteins, especially proline-rich proteins, expressed in an endocrine cell line have begun to provide insight regarding intermolecular interactions during transport and the role played by structural signals during intracellular sorting. Analysis of the secretion of newly synthesized salivary proteins in parotid tissue has shown that there are multiple pathways of discharge from acinar cells. While granule exocytosis is the major pathway, at least two other pathways that export salivary proteins have been found to originate from maturing secretion granules. These pathways may contribute to other acinar cell functions, including secretion of proteins in the absence of acute stimulation and support of the secretory process for fluid and electrolytes.

Influenza epidemics and incidence of schizophrenia, affective disorders and mental retardation in Western Australia: no evidence of a major effect

In-utero exposure to influenza has been implicated as a risk factor for developmental CNS damage. This study tests the hypothesis that in-utero exposure to influenza: (1) in the second gestational trimester is associated with an increased risk of schizophrenia and affective psychoses; and (2) in the first gestational trimester is associated with an increased risk of mental retardation. Analysis was confined to 1852 cases on the Western Australian psychiatric case register with ICD-9 diagnoses of schizophrenia, affective psychoses, or neurotic depression (comparison group), and 804 cases on the Intellectual Handicap Register with mental retardation that were related to 82,963 'exposed' and 32,462 'non-exposed' births between 1950 and 1960 in the total population of Western Australia. The data were examined for effects associated with six influenza epidemics in the period 1950-1960. Using relative risk ratios for individual epidemics as well as Poisson regression and a proportional hazards model to examine systematic effects for the whole period, no major effect could be identified for maternal influenza on the incidence of schizophrenia, affective psychoses and neurotic depression, despite sufficient statistical power to detect an effect. However, a possible effect was found for mental retardation in males exposed in the first and second gestational trimester.

Evidence for a genetic association between alleles of monoamine oxidase A gene and bipolar affective disorder

We present evidence of a genetic association between bipolar disorder and alleles at 3 monoamine oxidase A (MAOA) markers, but not with alleles of a monoamine oxidase B (MAOB) polymorphism. The 3 MAOA markers, including one associated with low MAOA activity, show strong allelic association with each other but surprisingly not with MAOB. Our results are significant only for females, though the number of males in our sample is too small to draw any definite conclusions. Our data is consistent with recent reports of reduced MAOA activity in patients with abnormal behavioral phenotypes. The strength of the association is weak, but significant, which suggests that alleles at the MAOA locus contribute to susceptibility to bipolar disorder rather than being a major determinant.

Does influenza cause schizophrenia? A five year review

Over the last five years a body of literature has been generated concerning whether or not prenatal exposure to influenza results in an increased risk of developing schizophrenia in the exposed offspring. The studies are reviewed with respect to the traditional epidemiological criteria that help to define causality. There is a modest degree of consistency in support of an association between the 1957 influenza epidemic--and less so, for influenza epidemics in general--and later schizophrenia. Two cohort studies examining the 1957 epidemic do not support an association. The strength and specificity of the association remain weak. The proposed association draws coherence from the neurodevelopmental hypothesis of schizophrenia. Suggestions are made for future research that could add to our understanding of the putative association between influenza and schizophrenia.

Genetic association between alleles of pancreatic phospholipase A2 gene and bipolar affective disorder

Chromosome 12q is a region of interest for the genetics of bipolar affective disorder because of reports of apparent cosegregation between this disorder and Darier's disease in a small number of families. Findings from a recent linkage study suggest that this chromosomal region may contain a susceptibility gene for bipolar affective disorder. We have found evidence of an allelic association between bipolar disorder and a marker at the pancreatic phospholipase A2 gene (PLA2A) in this region (p < or = 0.01). These results are consistent with the linkage study, and warrant additional investigations.

No evidence of association between dopamine D4 receptor variants and bipolar affective disorder

Disturbance in the dopamine neurotransmitter system has been implicated in the pathogenesis of affective disorder. In this study, we examine the possibility that functional variants of the recently cloned dopamine D4 receptor gene contribute to the genetic component of manic depression. The polymorphism, a 48 bp tandem repeat coding for part of the third cytoplasmic loop, was detected using a PCR based method. In a first sample of 57 patients and 59 controls, we found allele 7 to be in excess in the patients. In contrast, allele 3 was less frequent in patients. A second, larger sample of 90 patients and 91 controls was utilized to test these hypotheses. Data from the two samples were then pooled together for further analyses. We calculated the power of our samples, and if the frequency of 7 repeat allele obtained from sample 1 is true, i.e., 25% (28/114) for patients and 14% (16/118) for controls, then the power of the combined sample is 62% at 5% (two-tailed) significance level. However, both observations were not replicated; we therefore conclude that variations in this repeat at the DRD4 gene do not contribute to the genetic component of manic depression.

The criminal careers of incident cases of schizophrenia

We present a population-based, longitudinal study of all incident cases (N = 538) of schizophrenia in the London Borough of Camberwell between 1964 and 1984. Cases were selected from the Camberwell Cumulative Psychiatric Case Register. Case-notes were obtained, and further classified using a computerized operational check list for rating psychotic illness. Cases are not restricted to hospital discharges, as in previous studies, and account is taken of time at liberty to offend. In order to test the hypothesis that schizophrenia makes an independent contribution to criminality over other mental disorders, controls were chosen to be representative of nonschizophrenic mental disorders matched for age, sex and period. The rate of conviction is increased in women with schizophrenia compared to other mental disorders for most offence categories (rate ratio = 3.3). In men overall rates do not differ (rate ratio = 1.03), although there is an interaction between gender, schizophrenia and ethnicity, with young black men with schizophrenia being most at risk. The rate ratio for violent offences in men with schizophrenia is 3.8, confirming recent studies from Sweden. Subjects with schizophrenia were more likely to acquire any criminal record than those with other mental disorders. The rate of lifetime conviction was greater in those with schizophrenia than either a sample of working-class boys from the same area followed by Farrington & West, or National data. The risk of first conviction is increased by schizophrenia, unemployment, ethnic group, substance abuse and low social class, and decreased by being employed, married, female and older age of onset. Adjustment using survival analysis showed that schizophrenia made a small independent contribution to the risk of acquiring a criminal record (hazard ratio = 1.4) but gender, substance abuse, ethnicity and age of onset were more substantial. Previous criminality was the strongest independent association of post-illness conviction, with schizophrenia only a trend. Although subjects with schizophrenia were more likely to acquire a criminal record, criminal careers began later and were shorter than those of the controls. The risk of criminality increased throughout the study period, but suggestions of a specific increase in those with schizophrenia as a result of changes in community care were not confirmed. These results confirm that women with schizophrenia are at increased risk of acquiring a criminal record, but the effect in men is for violent convictions only. The strongest associations of criminal conviction remain those recognized in non-schizophrenic subjects.

Association and haplotype analysis at the tyrosine hydroxylase locus in a combined German-British sample of manic depressive patients and controls

Tyrosine hydroxylase (TH) is the key enzyme in the synthesis of catecholamines and may therefore be of aetiological relevance in the development of psychiatric illness. Hipolar affective disorder association studies, with restriction fragment length polymorphisms located in flanking regions of the TH gene, have shown conflicting results. Alleles of a tetranucleotide repeat polymorphism (TH4) located in intron 1 of the gene were tested for association with bipolar affective disorder in a combined German and British sample of 183 bipolar patients and 209 healthy control probands. No differences in TH4 allele frequencies were found in the two groups. A subset of patients and controls was typed with the flanking markers Ty7/BglII and pJ4.7/TaqI and frequencies of two-locus haplotypes were estimated. Linkage disequilibrium was found between TH4-Ty7 and TH4-pJ4.7. Haplotype frequencies did not differ between patients and controls.

A comparative study of 470 cases of early-onset and late-onset schizophrenia

The presence or absence of 22 schizophrenic symptoms was recorded with the age at onset of illness in 470 patients with non-affective, non-organic psychoses. Positive and negative formal thought disorder, affective symptoms, inappropriate affect, delusions of grandiosity or passivity, primary delusions other than delusional perception, and thought insertion and withdrawal were all more common in early-onset cases (age at onset 44 years or less; n = 336). Persecutory delusions with and without hallucinations, organised delusions, and third-person, running commentary and accusatory or abusive auditory hallucinations were all more common in late-onset cases (age at onset 45 years or more; n = 134). There was no difference between cases of early and late onset in the prevalence of delusions of reference, bizarre delusions, delusional perception, or lack of insight. We conclude that although there are clinical similarities between cases of schizophrenia with early and late onset, there are sufficient differences between them to suggest that they are not phenotypically homogeneous.