No accepted intervention exists for borderline personality disorder presenting in adolescence.

To compare the effectiveness of up to 24 sessions of cognitive analytic therapy (CAT) or manualised good clinical care (GCC) in addition to a comprehensive service model of care.

In a randomised controlled trial, CAT and GCC were compared in out-patients aged 15–18 years who fulfilled two to nine of the DSM–IV criteria for borderline personality disorder. We predicted that, compared with the GCC group, the CAT group would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months.

Eighty-six patients were randomised and 78 (CAT n=41; GCC n=37) provided follow-up data. There was no significant difference between the outcomes of the treatment groups at 24 months on the pre-chosen measures but there was some evidence that patients allocated to CAT improved more rapidly. No adverse effect was shown with either treatment.

Both CAT and GCC are effective in reducing externalising psychopathology in teenagers with sub-syndromal or full-syndrome bipolar personality disorder. Larger studies are required to determine the specific value of CAT in this population.

Previous studies have reported the association between advanced paternal age at birth and the risk of autistic-spectrum disorder in offspring, including offspring with intellectual disability.

To test whether an association between advanced paternal age at birth is found in offspring with high-functioning autistic-spectrum disorder (i.e. offspring without intellectual disability).

A case–control study was conducted in Japan. The participants consisted of individuals with full-scale IQ ⩾ 70, with a DSM–IV autistic disorder or related diagnosis. Unrelated healthy volunteers were recruited as controls. Parental ages were divided into tertiles (i.e. three age classes). Odds ratios and 95% confidence intervals were estimated using logistic regression analyses, with an adjustment for age, gender and birth order.

Eighty-four individuals with autistic-spectrum disorder but without intellectual disability and 208 healthy controls were enrolled. Increased paternal, but not maternal, age was associated with an elevated risk of high-functioning autistic-spectrum disorder. A one-level advance in paternal age class corresponded to a 1.8-fold increase in risk, after adjustment for covariates.

Advanced paternal age is associated with an increased risk for high-functioning autistic-spectrum disorder.

Depersonalisation disorder is characterised by emotion suppression, but the cerebral mechanisms of this symptom are not yet fully understood.

To compare brain activation and autonomic responses of individuals with the disorder and healthy controls.

Happy and sad emotion expressions in increasing intensities (neutral to intense) were presented in an implicit event-related functional magnetic resonance imaging (fMRI) design with simultaneous measurement of autonomic responses.

Participants with depersonalisation disorder showed fMRI signal decreases, whereas the control group showed signal increases in response to emotion intensity increases in both happy and sad expressions. The analysis of evoked haemodynamic responses from regions exhibiting functional connectivity between central and autonomic nervous systems indicated that in depersonalisation disorder initial modulations of haemodynamic response occurred significantly earlier (2s post-stimulus) than in the control group (4–6s post-stimulus).

The results suggest that fMRI signal decreases are possible correlates of emotion suppression in depersonalisation disorder.

A pilot trial in Sri Lanka among patients with medically unexplained symptoms revealed that cognitive-behavioural therapy (CBT) administered by a psychiatrist was efficacious

To evaluate CBT provided by primary care physicians in a comparison with structured care

A randomised control trial (n=75 in each arm) offered six 30 min sessions of structured care or therapy. The outcomes of the two interventions were compared at 3 months, 6 months, 9 months and 12 months

In each arm, 64 patients (85%) completed the three mandatory sessions. No difference was observed between groups in mean scores on the General Health Questionnaire or the Bradford Somatic Inventory, or in number of complaints or patient-initiated consultations at 3 months. For both groups, all outcome measures improved at 3 months, and remained constant in the follow-up assessments

Cognitive–behavioural therapy given by primary care physicians after a short course of training is no more efficacious than structured care. Natural remission is an unlikely explanation for improvements in people with chronic medically unexplained symptoms, but lack of a ‘treatment as usual’ arm limits further conclusions. Further research on enhanced structured care, medical assessment and structured care incorporating simple elements of CBT principles is worthy of consideration

Convergent evidence implicates white matter abnormalities in bipolar disorder. The cingulum is an important candidate structure for study in bipolar disorder as it provides substantial white matter connections within the corticolimbic neural system that subserves emotional regulation involved in the disorder.

To test the hypothesis that bipolar disorder is associated with abnormal white matter integrity in the cingulum.

Fractional anisotropy in the anterior and posterior cingulum was compared between 42 participants with bipolar disorder and 42 healthy participants using diffusion tensor imaging.

Fractional anisotropy was significantly decreased in the anterior cingulum in the bipolar disorder group compared with the healthy group (P=0.003); however, fractional anisotropy in the posterior cingulum did not differ significantly between groups.

Our findings demonstrate abnormalities in the structural integrity of the anterior cingulum in bipolar disorder. They extend evidence that supports involvement of the neural system comprising the anterior cingulate cortex and its corticolimbic gray matter connection sites in bipolar disorder to implicate abnormalities in the white matter connections within the system provided by the cingulum.

Pregabalin is a novel compound that has been shown to have efficacy in the treatment of generalised anxiety disorder and is licensed for the treatment of the disorder in the European Union.

The current study was designed to evaluate the safety and efficacy of pregabalin, an α2δ-ligand, in the treatment of generalised anxiety disorder in people 65 years and older.

This was a double-blind, randomised (2:1), placebo-controlled, 8-week trial of pregabalin, in flexible doses of 150–600 mg/day, in the treatment of DSM–IV generalised anxiety disorder with a baseline Hamilton Rating Scale for Anxiety (HRSA) total score ⩾20. The primary outcome was end-point (week 8 or last visit, with last observation carried forward (LOCF)) change in HRSA total score.

A total of 273 patients (women, 78%; mean age, 72 years (s.d.=6); mean baseline HRSA total score, 26 (s.d.=4.6)) were randomised and received study treatment. On the primary intent-to-treat LOCF analysis, pregabalin was associated with a 2-point greater reduction in HRSA total score than placebo (12.87 v. 10.7; P<0.05). In a post hoc repeated measures mixed-effect model analysis, pregabalin was associated with significantly greater improvement than placebo in the HRSA total score from week 2 (–9.8 (s.d.=0.6) v. −7.2 (s.d.=0.8); P=0.0052) through week 8 (–14.4 (s.d.=0.6) v. −11.6 (s.d.=0.8); P=0.0070). Significant improvement was observed in the pregabalin group on both the HRSA psychic and somatic anxiety factors. There was a significantly greater decrease from baseline in mean Hamilton Rating Scale for Depression (HRSD) score with pregabalin compared with placebo (–5.48 (s.d.=0.46) v. −4.02 (s.d.=0.59); P=0.041). Pregabalin was well-tolerated, with almost all adverse events in the mild-to-moderate range, and self-limiting (median duration of 4–16 days). Discontinuations due to adverse events were similar for pregabalin (10.7%) and placebo (9.4%).

Pregabalin, in doses of 150–600 mg/day, was a safe and effective treatment of generalised anxiety disorder in patients 65 years and older. The anxiolytic efficacy of pregabalin had an early onset (by 2 weeks) and significantly improved both psychic and somatic symptoms of anxiety.

Despite the prevalence and clinical significance of borderline personality disorder, its treatment remains understudied.

To evaluate treatment with variably dosed olanzapine in individuals with borderline personality disorder.

In this 12-week randomised, double-blind trial, individuals received olanzapine (2.5–20 mg/day; n=155) or placebo (n=159) (trial registry: NCT00091650). The primary efficacy measure was baseline to end-point change on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN–BPD) using last-observation-carried-forward methodology.

Both olanzapine and placebo groups showed significant improvements but did not differ in magnitude at end-point (76.56 v. 76.25, P=0.661). Response rates (50% reduction in ZAN–BPD) were 64.7% with olanzapine and 53.5% with placebo (P=0.062); however, time to response was significantly shorter for olanzapine (P=0.022). Weight gain was significantly greater (2.86 v. 70.35 kg, P50.001), with higher incidence of treatment-emergent abnormal high levels of prolactin for the olanzapine group.

Individuals treated with olanzapine and placebo showed significant but not statistically different improvements on overall symptoms of borderline personality disorder. The types of adverse events observed with olanzapine treatment appeared similar to those observed previously in adult populations.

It has been stated that rates of homicide due to mental disorder are constant over time.

To examine whether there were changes in the rates of homicide due to mental disorder over time, and whether changes in these rates were associated with changes in the rates of other homicides in England and Wales.

Examination of four sets of official homicide statistics from England and Wales from 1946 to 2004.

The rate of total homicide and the rate of homicide due to mental disorder rose steadily until the mid-1970s. From then there was a reversal in the rate of homicides attributed to mental disorder, which declined to historically low levels, while other homicides continued to rise.

The reasons for the rise and fall in homicides attributed to mental disorder are not clear. The earlier increase in such homicides may have been due to the same sociological factors that caused the increase in other homicides over that time. The subsequent decline may have been due to improvements in psychiatric treatments and service organisation. Another possibility is that there has been an informal change to the legal tests for the finding of homicide due to mental disorder.

Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy.

To assess the relationship between special observation and self-harm rates, by ward, while controlling for potential confounding variables.

A multivariate cross-sectional study collecting data on self-harm, special observation, other conflict and containment, physical environment, patient and staff factors for a 6-month period on 136 acute-admission psychiatric wards.

Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities.

Certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.

Smoking is disproportionately prevalent among people with psychiatric illness.

To investigate smoking as a risk factor for major depressive disorder.

A population-based sample of women was studied using case–control and retrospective cohort study designs. Exposure to smoking was self-reported, and major depressive disorder diagnosed using the Structured Clinical Interview for DSM–IV–TR (SCID–I/NP).

Among 165 people with major depressive disorder and 806 controls, smoking was associated with increased odds for major depressive disorder (age-adjusted odds ratio (OR)=1.46, 95% CI 1.03–2.07). Compared with non-smokers, odds for major depressive disorder more than doubled for heavy smokers (>20 cigarettes/day). Among 671 women with no history of major depressive disorder at baseline, 13 of 87 smokers and 38 of 584 non-smokers developed de novo major depressive disorder during a decade of follow-up. Smoking increased major depressive disorder risk by 93% (hazard ratio (HR)=1.93, 95% CI 1.02–3.69); this was not explained by physical activity or alcohol consumption.

Evidence from cross-sectional and longitudinal data suggests that smoking increases the risk of major depressive disorder in women.

The importance of the neurotransmitter serotonin (5-HT) in the pathophysiology of anxiety is well known. A key role for postsynaptic 5-HT1A receptors has recently been suggested in studies of genetic knockout mice.

To measure 5-HT1A receptor binding in patients with panic disorder in the untreated state and after recovery on treatment with selective serotonin reuptake inhibitors (SSRIs).

Nine symptomatic untreated patients with panic disorder, seven patients recovered on SSRI medication and nineteen healthy volunteers underwent a single positron emission tomography (PET) scan using the 5-HT1A tracer [11C]WAY-100635.

In comparison with controls, both presynaptic and postsynaptic 5-HT1A receptor binding was reduced in untreated patients, with the most significant reductions being in the raphe, orbitofrontal cortex, temporal cortex and amygdala. In recovered patients presynaptic binding was reduced, but there was no significant reduction in postsynaptic binding.

Panic disorder is associated with reduced 5-HT1A receptor availability, which is also known to have a key role in depression.

Postgraduate courses on cognitive-behavioural therapy (CBT) assess various competencies using essays, case studies and audiotapes or videotapes of clinical work

To evaluate how reliably a well-established postgraduate course assesses CBT competencies

Data were collected on two cohorts of trainees (n=52). Two examiners marked trainees on: (a) two videotapes of clinical practice; (b) two case studies; and (c) three essays

Essay examinations were more reliable than case studies, which in turn were more reliable than videotaped assessments. The reliability of the latter two assessments was considerably lower than that commonly expected of high-stakes examinations. To assess reliably standard CBT competencies, postgraduate courses would need to examine about 5 essays, 12 case studies and 19 videotapes

Reliable assessment of standard competencies is complex and resource intensive. There would need to be a marked increase in the number of samples of clinical work assessed to be able to make reliable judgements about proficiency

In recent years suicide has become a major public health problem in Pakistan.

To identify major risk factors associated with suicides in Karachi, Pakistan.

A matched case–control psychological autopsy study. Interviews were conducted for 100 consecutive suicides, which were matched for age, gender and area of residence with 100 living controls.

Both univariate analysis and conditional logistic regression model results indicate that predictors of suicides in Pakistan are psychiatric disorders (especially depression), marital status (being married), unemployment, and negative and stressful life events. Only a few individuals were receiving treatment at the time of suicide. None of the victims had been in contact with a health professional in the month before suicide.

Suicide in Pakistan is strongly associated with depression, which is under-recognised and under-treated. The absence of an effective primary healthcare system in which mental health could be integrated poses unique challenges for suicide prevention in Pakistan.