General practitioner contacts with patients before and after deliberate self harm.

BACKGROUND: Deliberate self harm (DSH) is an increasingly common problem. Although much attention is focused on suicide prevention by psychiatric services, the role of the general practitioner (GP) in the prevention of suicidal behaviour and in the aftercare of DSH patients is also important. AIM: To examine the nature and timing of GP contacts with DSH patients before and after an episode of DSH, and patients' satisfaction with these contacts. DESIGN OF STUDY: Structured interviews with patients shortly after an episode of DSH and again approximately one year later. SETTING: A representative sample of 139 DSH patients presenting to a district general hospital. METHOD: Patients were interviewed shortly after DSH and at follow-up about GP contacts, prescribed medication and psychiatric symptoms. RESULTS: At the time of DSH, 91.4% of patients were diagnosed with a psychiatric disorder (depression 69.8%), with 28% receiving treatment from psychiatric services. Two-thirds of patients had been in contact with their GP in the month before DSH, but only 13.3% reported expressing suicidal thoughts. Patients consulted their GP in the week following DSH in 40.6% of cases. Over half (57.9%) the patients discussed the reasons for their DSH at the first consultation and 69.5% reported that this was helpful. Overall, 64.3% of patients were satisfied with the follow-up consultations. CONCLUSIONS: The major role of the GP in the prevention of suicidal behaviour is in the detection and treatment of depression, and in the aftercare of DSH patients.     

Use of health services for major depressive episode in Finland

BACKGROUND: A universal finding in psychiatric epidemiology is that only a minority of currently depressed people seek or receive treatment. AIMS: To investigate the predictors of use of health care services for depression. METHODS: A representative random sample of 5993 non-institutionalised Finnish individuals aged 15-75 years was interviewed in 1996. Major depressive episode during the last 12 months was assessed using the Short Form of the University of Michigan version of the Composite International Diagnostic Interview (the UM-CIDI Short Form). Characteristics and health service use of the 557 depressed individuals were assessed. RESULTS: The proportion of people classified as having a major depressive episode who used any health services for their depression during the past 12 months was only 31% for men and 25% for women. Use of services was not predicted by sociodemographic factors. Longer duration, and greater severity and perceived disability predicted overall health service use for depression, but not significantly whether treatment was sought from primary or psychiatric care. CONCLUSIONS: The probability of use of health services for major depression increases with duration, severity and perceived disability related to depression. Only 59% of those suffering from even the most severe major depressive episodes use health services for depression. Use appears to be unrelated to sociodemographic factors in Finland.     

Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses

BACKGROUND: The purpose of this study was to investigate the prevalence and comorbidity of affective disorders, especially current major depressive episode and bipolar disorder among suicide attempters in Hungary. METHODS: Using a structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 100 consecutive suicide attempters, aged 18-65. RESULTS: Eighty-eight percent of the attempters had one or more current diagnoses on Axis I. In 69% it was major depressive episode and 60% of them were suffering their first episode. Thirty-five percent of the patients with current major depressive episode had had hypomanic (n=19) or manic (n=5) episodes in the past. Seventy percent of the individuals received two or more current diagnoses on Axis I. Eighty-six percent of all current Axis I disorders (except major depressive episode) were diagnosed together with a current major depressive episode. The diagnosis of current major depressive episode and the number of current psychiatric disorders was significantly and positively related to the number of suicide attempts, but the diagnosis of past major depressive episode was not. LIMITATIONS: This study included suicide attempters who had presented selfpoisoning, but not individuals with very high risk of fatality. CONCLUSIONS: In suicide attempters there is a very high prevalence of affective disorders, especially major depression, first episode of major depression and bipolar II disorder. This study underlines the importance of early detection and treatment of psychiatric disorders for the prevention of suicidal behavior.     

Psychiatric treatment seeking and psychosocial impairment among young adults with depression

BACKGROUND: We report data on 1-year prevalence and comorbidity of depression, related impairment, treatment need, and psychiatric treatment among young adults. METHODS: A sample of young urban adults (n=245) mean age 21.8 years was screened from a baseline population of 706 high-school students and given a semistructured clinical interview to evaluate 12-month prevalence of depression, psychosocial functioning according to DSM-IV GAF scale, need for psychiatric treatment, and use of mental health services. RESULTS: One in 10 young adults suffered from depression with associated psychosocial impairment, the female-to-male-ratio being approximately 2:1. Most depressive disorders were comorbid with other DSM-IV disorders, depression usually occurring secondary to other disorders. Comorbidity was related to impairment, treatment need, and treatment contacts. Less than half of the depressed young adults had ever contacted mental health services, and less than one-third reported treatment contacts during the index episode. Males were less likely than females to report previous treatment contacts or intention to refer to mental health services for their problems, but treatment contacts during the index episode were reported equally often by both sexes. CONCLUSIONS: A minority of the severely depressed young adults with associated impairment had sought treatment. Except for subjects with dysthymia, no gender difference emerged in treatment contact rates during the 12-month depression episode. Comorbidity showed important clinical implications by its relation to severity of depression and treatment contacts.     

The effect of the first manic episode in affective disorder: a case register study of hospitalised episodes.

BACKGROUND: It is poorly understood how the course of illness in depressive patients is affected by a manic episode. METHOD: The course of hospitalised episodes was compared for patients with depressive episodes only, patients who presented with a manic or circular first episode and patients who presented with a depressive first episode and later developed mania. The Danish psychiatric central register was used as a study base, including all hospital admissions with primary affective disorder in Denmark during 1971-1993. RESULTS: A total of 17,447 patients presented with a depressive first episode and 2903 patients with a manic or circular first episode. Among the 17,447 depressive patients, 762 patients presented with mania at later episodes (4.4%). Younger age at onset was associated with increased risk of developing mania. Patients who had a late first manic episode had the same rate of subsequent recurrence as patients with mania at first episode and this rate was higher than the rate of recurrence for patients who remained having depressive episodes only. Time since first manic episode was without importance in relation to the risk of subsequent recurrence. CONCLUSION: Patients who present with depression and later develop mania have from onset the same risk of recurrence as initially bipolar patients. LIMITATION: The data relate to admissions rather than episodes. CLINICAL RELEVANCE: Younger patients who present with depression have increased risk of developing bipolar disorder.     

Self-reported premenstrual exacerbation of depressive symptoms in patients seeking treatment for major depression

BACKGROUND: Very little research has examined the frequency with which women with major depressive disorder experience premenstrual exacerbation (PME) of depression or the characteristics of those who report such worsening. The NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study provides a unique opportunity to evaluate PME in depressed women seeking treatment in primary care or psychiatric settings. METHOD: This report presents data from the first 1500 participants enrolled in the STAR*D study. Premenopausal women with major depressive disorder were asked if they experienced a worsening of their depressive symptoms 5-10 days prior to menses. Those reporting PME were compared with those reporting no PME with regard to sociodemographic characteristics, course of illness features, symptom presentation, general medical co-morbidity, functional impairment, and quality of life. RESULTS: Of 433 premenopausal women not taking oral contraceptives, 64% reported a premenstrual worsening of their depression. Women who reported PME had a longer duration of their current major depressive episode [30.7 (S.D. = 73.7) months versus 13.5 (S.D. = 13.2) months; p=0.001], as well as greater general medical co-morbidity. Women reporting PME were also more likely to endorse symptoms of leaden paralysis, somatic complaints, gastrointestinal complaints, and psychomotor slowing, and were less likely to endorse blunted mood reactivity. CONCLUSIONS: PME is endorsed by the majority of premenopausal women with major depressive disorder and appears to be associated with a longer duration of depressive episode. PME is a common and important clinical issue deserving of further attention in both research and practice.     

Suicidal behaviour among primary-care patients with depressive disorders

BACKGROUND: Most national suicide prevention strategies set improved detection and management of depression in primary health care into a central position. However, suicidal behaviour among primary-care patients with depressive disorders has been seldom investigated. METHOD: In the Vantaa Primary Care Depression Study, a total of 1119 primary-care patients in the City of Vantaa, Finland, aged 20 to 69 years, were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. Depressive disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the 137 patients with depressive disorder were included in the study. Suicidal behaviour was investigated cross-sectionally and retrospectively in three time-frames: current, current depressive episode, and lifetime. Current suicidal ideation was measured with the Scale for Suicidal Ideation (SSI), and previous ideation and suicide attempts were evaluated based on interviews plus medical and psychiatric records. RESULTS: Within their lifetimes, 37% (51/137) of the patients had seriously considered suicide and 17% (23/137) attempted it. Lifetime suicidal behaviour was independently and strongly predicted by psychiatric treatment history and co-morbid personality disorder, and suicidal behaviour within the current episode was predicted most effectively by severity of depression. CONCLUSIONS: Based on these findings and their convergence with studies of completed suicides, prevention of suicidal behaviour in primary care should probably focus more on high-risk subgroups of depressed patients, including those with moderate to severe major depressive disorder, personality disorder or a history of psychiatric care. Recognition of suicidal behaviour should be improved. The complex psychopathology of these patients in primary care needs to be considered in targeting preventive efforts.     

Bipolar depression: relationship between episode length and antidepressant treatment

BACKGROUND: The role of antidepressant medications in bipolar depression remains controversial, mainly due to a lack of research in this area. In this study the authors examined the episode length in bipolar depression and the relationship between antidepressant therapy and episode length. METHOD: A retrospective chart review of 165 subjects identified 50 (30%) with bipolar illness who experienced a major depressive episode between 1 January 1998 and 15 December 2000. Data gathered utilized a structured instrument completed by the clinician at each visit. This instrument includes modified SCID mood modules as well as continuous ratings for each associated symptom of depression and mood elevation. Survival analysis was employed to calculate the median length of the depressive episodes for the entire group. Further survival analysis compared the episode length for subjects treated with antidepressants during the depression (N = 33) with those who did not receive antidepressants (N = 17). The rate of switch into elevated mood states was compared for the two groups. RESULTS: The survival analysis for the entire sample demonstrated 25%, 50% and 75% probability of recovery at 33 (S.E. 8.7), 66 (S.E. 17.9) and 215 (S.E. 109.9) days, respectively. Comparing those who received (N = 33) and those who did not receive (N = 17) antidepressants during the episode did not reveal any difference in the length of the depressive episode. Switch rates were not significantly different between those receiving antidepressants and those not taking these medications (15.2% v. 17.6%, respectively). CONCLUSIONS: Over the past 20 years little progress has been made in reducing the length of depressive episodes in those with bipolar illness. This is despite increasing pharmacological options available for treating depression. Clinicians treating bipolar depression should discuss with their patients the likelihood that the episode will last between 2-3 months. Our results also suggest that antidepressant treatment may not reduce the length of depressive episodes, neither did it appear to contribute to affective switch in our sample.     

The community prevalence of depression in older Australians

OBJECTIVE: To estimate the prevalence of depression among older adults in Australia. METHOD: All general practitioners in Australia's five most populous states who satisfied certain eligibility criteria (e.g., sufficient weekly working hours, sufficient numbers of elderly patients) were invited to participate. Those who consented were asked to identify all of their patients aged 60+ and invite them (either directly or via the study team) to complete a questionnaire. The questionnaire identified those who had experienced 'clinically significant depression' and those who had experienced a 'major depressive episode' in the past two weeks, via the Patient Health Questionnaire (PHQ-9). Consenting patients completed the questionnaire and returned it to the study team in a reply-paid envelope. RESULTS: In total, 22,251 patients returned questionnaires. Overall, the age-adjusted rate of clinically significant depression was 8.2% (95%CI=7.8%-8.6%), with the age-adjusted rates for males being 8.6% (95%CI=7.9%-9.2%) and for females being 7.9% (95%CI=7.4%-8.4%). The overall, male and female age-adjusted rates for a major depressive episode were 1.8% (95%CI=1.6%-2.0%), 1.9% (95%CI=1.6%-2.2%) and 1.7% (95%CI=1.5%-2.0%), respectively. DISCUSSION: Our study suggests that depression among older people is a major public health problem. The above estimates provide guidance for efficient planning of services, and establish a baseline against which preventive and treatment interventions can be assessed. Armed with this information, we can progress efforts at reducing this major health problem and its consequences.     

抑郁症躯体症状及其相关因素分析

目的 :探讨以躯体症状为主诉的和以情感症状为主诉的抑郁症病人的差异。方法 :采用自编“抑郁症病人深入访谈提纲”和HAMD、HAMA对 6 2例抑郁症病人进行访谈和评定。结果 :抑郁症病人最常见的躯体症状主诉为食欲下降 ( 6 7 7% )、入睡困难 ( 6 6 1% )、胸闷 ( 5 8 1% )、心慌 ( 5 4 8% )和肢体乏力 ( 4 5 4% ) ,并且躯体化组病人在教育程度与个性特征、求医方式、接受诊断标签等方面与情感症状为主的抑郁症病人比较有显著差异 ;88 7%的抑郁症病人较病前工作能力下降 (平均下降 5 1 5 % )。结论 :以躯体症状为主诉的和以情感症状为主诉的抑郁症病人在文化教育程度、性格、自身对抑郁症的认识以及求医方式上存在差异     

Neuroticism in familial depression

This study examined the relationship between personality factors and depression in subjects who may have a familial vulnerability to depression (i.e. first-degree relatives of depressed patients). Four groups comprised our study sample: relatives who had never experienced a psychiatric episode of depression; relatives who had experienced a psychiatric episode of depression but were currently well; relatives who had never experienced a psychiatric episode of depression but were currently depressed; and relatives who had experienced a past history of depression and were currently depressed. Of the four personality characteristics measured (Psychoticism, Extraversion, Neuroticism and Lie), the only significant effects between groups appeared to be attributable to Neuroticism (N). The strongest association was between current illness and N. There was also a tendency for subjects with a past history of depression to have an inflated N score. However, this appeared to be associated with the presence of current depressive symptomatology. Our findings indicate that when current symptomatology is taken into account Neuroticism does not seem to reflect the trait of liability to depression, but is strongly associated with the state of being depressed.     

The risk factors for depression in first myocardial infarction patients

BACKGROUND: Depression affects outcome following myocardial infarction but the risk factors for such depression have been little studied. This study considered whether the causes of depression occurring before and after myocardial infarction were similar to those of depression in the general population. METHOD: Consecutive patients admitted to hospital following their first myocardial infarction were interviewed with the Schedule for Clinical Assessment in Neuropsychiatry to detect psychiatric disorders and the Life Events and Difficulties Schedule to assess recent stress. Participants completed the Hospital Anxiety and Depression Scale (HADS) at entry to the study and 1 year later and the risk factors associated with a high score at both times were assessed. RESULTS: Of 314 (88% of eligible) patients who were recruited, 199 (63%) were male and 63 (20%) had depressive disorders. Logistic regression identified the following as independently associated with depressive disorder that had been present for at least I month before the myocardial infarction: younger age, female sex, past psychiatric history, social isolation, having marked non-health difficulties and lack of a close confidant. At follow-up 269/298 (90%) responded; of 189 participants not depressed at first assessment, 39 (21%) became depressed by the 1 year follow-up. Logistic regression identified frequent angina as the only significant predictor of raised HADS scores at 12 months. CONCLUSIONS: Depression developing during the year following myocardial infarction does not have the same risk factors as that which precedes myocardial infarction. Further clarification of the mechanisms linking depression to poor outcome may require separation consideration of pre- and post-myocardial infarction depression, and its risk factors.     

"Near-fatal" deliberate self-harm: characteristics, prevention and implications for the prevention of suicide

BACKGROUND: There have been few studies of the most serious cases of deliberate self-harm (DSH). These cases represent an important clinical problem. They may also be suitable as a "proxy" for suicide in research studies. METHODS: We developed a definition of "near-fatal" deliberate self-harm (NFDSH) and identified all cases attending accident and emergency departments in an urban area during an 18-month period. We compared them to less severe DSH on social and clinical characteristics, and examined their initial clinical management. We compared their age and gender profile with that of completed suicides. NFDSH cases who agreed to be interviewed were asked about their experiences of seeking help and their views on prevention of suicide. RESULTS: 158 cases were identified, 8% of all DSH. The most common method of self-harm was self-poisoning. The most common psychiatric diagnosis was depression. Compared to less severe DSH, near-fatal cases had higher rates of several social and clinical risk factors for suicide and showed evidence of greater suicidal intent. Forty-one percent were allowed home following assessment. Most admissions lasted 2 days or less. The age and gender profile was closer to that of suicide than in DSH generally. Few subjects agreed to be interviewed; those who did described poor previous experiences of services. LIMITATIONS: We did not assess each case of DSH individually but applied a workable definition of NFDSH. Firm conclusions cannot be drawn from the qualitative part of the study because of the low rate of agreement to interview. CONCLUSIONS: NFDSH is an important clinical phenomenon associated with indicators of high suicide risk. This high risk is frequently not reflected in clinical management. Further studies of NFDSH could contribute to what is known about suicide prevention but the reluctance of NFDSH subjects to be interviewed may be a difficulty for future research.     

Mindfulness‐based cognitive therapy for residual depressive symptoms

Objectives. Mindfulness‐based cognitive therapy (MBCT) is a new group‐based intervention for prevention of relapse in recurrent depression which has not been scientifically evaluated regarding its clinical effectiveness for ameliorating residual depressive symptoms following a depressive episode. The aim of this study was to assess the efficacy of MBCT in reducing residual depressive symptoms in psychiatric outpatients with recurrent depression, and to particularly explore the effects of mindfulness techniques on rumination. Design. The design of this study was a mixed model complex design. Design 1 consisted of a consecutive series of patients. They were assigned to either MBCT or TAU. The independent variables were time and group allocation, and dependent variables were Beck Depression Inventory (BDI) and Rumination Scale. In Design 2, the TAU group proceeded to complete an MBCT group, and the BDI and Rumination Scale results of the two groups were collapsed. Method. Nineteen patients with residual depressive symptoms following a depressive episode, and who were attending outpatient clinic, were assigned to either MBCT or treatment as usual (TAU), with the TAU group then proceeding to complete an MBCT group. Depressive and ruminative symptoms were assessed before, during, and after treatment, and at one‐month follow‐up. Results. A significant reduction in depressive symptoms was found at the end of MBCT, with a further reduction at one‐month follow‐up. A trend towards a reduction in rumination scores was also observed. Conclusions. Group MBCT has a marked effect on residual depressive symptoms, which may be mediated through the mindfulness‐based cognitive approach towards excessive negative ruminations in patients with residual depressive symptoms following a depressive episode.     

The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems

BACKGROUND: Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems. METHOD: Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures. RESULTS: At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference = -0.36; 95% CI -0.61 to -0.11) and hopelessness (weighted mean difference =-3.2; 95% CI -4.0 to -2.41), and significantly more reported improvement in their problems (odds ratio = 2.31; 95% CI 1.29 to 4.13), than patients who were in the control treatment groups. CONCLUSIONS: Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH.     

Suicide in young people aged 15-24: a psychological autopsy study

BACKGROUND: The suicide rate in young people in the United Kingdom has increased over the last decade. As there is a paucity of information about the characteristics of young suicides we have undertaken a detailed investigation of suicides in people aged 15-24 years by means of the psychological autopsy approach. METHODS: The sample consisted of 27 subjects (25 males, two females) whose deaths received a verdict of suicide (N=24) or undetermined cause (N=3). Information was collected from informant interviews, coroners' inquest notes, medical records and psychiatric case notes. A sub-sample of 22 male subjects was compared with an age-matched sample of male deliberate self-harm (DSH) patients. RESULTS: Psychiatric disorders were diagnosed in 19 (70.4%) subjects. These were most commonly depressive disorders (55.5%). Very few individuals were receiving treatment for their disorders. Substance abuse disorders were uncommon but a substantial proportion of individuals had problems with alcohol or drug misuse. Personality disorders were present in 29.6% of subjects and disorders or personality trait accentuation in 55.6%. Comorbidity of psychiatric disorders was found in a third of subjects. The suicides were often the end-point of long-term difficulties extending back to childhood or early adolescence. In addition to mental disorders, relationship and legal difficulties were identified as relatively common contributory factors to the suicides. In comparison to deliberate self-harm patients, male suicides were more likely to use dangerous methods and live alone. LIMITATIONS: Several potential informants could not be interviewed and there was no general population control sample. CONCLUSIONS: The process leading to suicide in young people is often long term, with untreated depression in the context of personality and/or relationship difficulties being a common picture at the time of death. The prevention of suicide in the young clearly requires multiple strategies.     

Electroconvulsive therapy is associated with superior symptomatic and functional change in depressed patients after psychiatric hospitalization

BACKGROUND: Major depressive episode is associated with quality of life (QOL) deficits, and QOL improves following remission of depression. We conducted an observational study of the relationship between depressive symptoms and QOL for 1 year after psychiatric hospitalization, and compared QOL in patients who received ECT against those who did not. METHODS: We examined 88 patients with major depressive disorder (53.4+/-15.4 years old; 69 women) upon admission, with repeated measurements at discharge, 1, 3, 6, and 12 months after discharge. Depression severity was measured with the Beck Depression Inventory. QOL measurements encompassed ADLs, IADLs, performance in major roles, and satisfaction with relationships. Treatment for depression was at the discretion of the respective physicians. RESULTS: Depression severity dropped dramatically by discharge, and changed little thereafter. QOL measures showed improvement at the first month, with additional improvement at the third month. Improvement in QOL was closely tied to improvement in depression severity. ECT during the index hospitalization was associated with greater improvement in depressive symptoms and in most measures of QOL. LIMITATIONS: The results of this study may not apply to the treatment of outpatients, and the large number of statistical comparisons may have resulted in some spurious associations. CONCLUSIONS: Inpatient treatment of depression is followed by improvement in QOL. Novel findings in this study include evidence that maximum improvement in QOL does not occur until an average of 3 months after discharge, and that ECT-treated patients had superior outcomes.     

Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy

BACKGROUND: The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions. METHOD: A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up. RESULTS: Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9.6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2.07 (95% confidence interval (CI) 1.13-3.00) and 1.62 (95% CI 0.70-2.55) respectively] and PEP patients [2.37 (95% CI 1.35-3.39) and 1.93 (95% CI 0.92-2.94) respectively]. CONCLUSIONS: The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.     

Variations in time of hospital presentation for deliberate self-harm and their implications for clinical services

BACKGROUND: Variation in number, characteristics and management of deliberate self-harm (DSH) patients presenting to hospital during the 24-h cycle and day of the week may have implications for patient services. We have investigated how patient characteristics and clinical management of DSH episodes vary according to hour and day of presentation. METHODS: Time of presentation was studied in 5348 DSH patients who presented to a general hospital following 9101 episodes during a 6-year period. Patient characteristics were identified through routine clinical monitoring. RESULTS: Presentations varied markedly during the 24-h cycle, ranging from a peak between 8 pm and 3 am (average hourly rate of 6.6% of all episodes) to a low between 4 am and 10 am (1.4%). The majority (72.0%) occurred outside office hours. DSH associated with alcohol use and interpersonal problems was more frequent during the late evening or night, and at the weekend. A greater proportion of daytime presentations involved high suicide intent (although a larger number of high intent acts presented at other times), and more were admitted and assessed. LIMITATIONS: This study was based on DSH presentations to one hospital. Time and date of presentation and of psychosocial assessment, not time of DSH, were available for analysis. CONCLUSIONS: Peak times for DSH presentations are at night and the weekend, suggesting that specialist DSH services in general hospitals should be available 24 h a day, 7 days a week. Time of presentation should not be used as a proxy measure of suicide intent.     

Readmission rates for adjustment disorders: comparison with other mood disorders

BACKGROUND: The diagnostic category of adjustment disorders continues to receive little attention in the research literature despite its estimated incidence of 5-21% in psychiatric consultation services for adults and 7.1% in inpatient admissions. METHODS: Ten years of readmission data were reviewed for six diagnostic categories: adjustment disorders, major depressive disorder (single episode and recurrent), dysthymia, any anxiety disorder and depression NOS. Cox regression analysis was used. RESULTS: Admission diagnosis was a significant predictor of readmission, with adjustment disorders resulting in significantly fewer readmissions than the group as a whole, and major depression recurrent resulting in significantly more readmissions. LIMITATIONS: Structured interviews were not used for the establishment of admission diagnoses. CONCLUSIONS: Readmission rates in this sample support the construct validity of the adjustment disorders category. The category includes a significant minority of patients admitted to psychiatric hospitalization.