The potential role of psychopharmacology in suicide prevention is often minimised. This may to some extent reflect that few medication trials have specifically focussed on prevention of suicidal behaviour – indeed this outcome is often not reported in trials. However, there is reasonably strong evidence that lithium may reduce risk of suicide, the postulated mechanism being a specific effect on aggression. Evidence is lacking with regard to any protective effect of other mood stabilizers. Clozapine may reduce suicidal behaviour in patients with schizophrenia, with reduction of affective symptoms being a possible explanation. The role of antidepressants in relation to suicide risk is highly controversial, especially in children and adolescents. It is unclear whether minor tranquillizers or hypnotics can assist in suicide prevention, although they can reduce the anxiety symptoms that may occur during initial treatment with SSRI antidepressants. Itis also uncertain whether psychopharmacology has a role in preventing suicidal behaviour in people with personality disorders. Despite the limitations of the evidence we contend that suicide risk should be an important factor in deciding when and what to prescribe.

Declaration of Interest: We have no interests to declare.

We reviewed available research findings, including meta-analyses on effects of lithium-treatment associated with rates of suicidal behavior in bipolar disorder or unipolar major depressive disorder patients, and for comparisons of lithium to mood-stabilizing anticonvulsants. Data from meta-analyses consistently indicate marked reductions of suicidal behavior and mortality during long-term treatment with lithium salts in bipolar disorder patients, and possibly also in unipolar, recurrent major depressive, perhaps even more effectively than with anticonvulsants proposed as mood-stabilizers. Suicidal risk is frequently associated with dysphoric-agitated symptoms, anger, aggression, and impulsivity-all of which may respond better to treatment with lithium or other mood-stabilizing medicines than to antidepressants. In these conditions, antidepressant treatment may not provide a beneficial effect on risk of suicidal thoughts and perhaps attempts, particularly in juveniles, whereas, lithium, perhaps even more than anticonvulsants, seems to be remarkably effective in the preventing suicidal behavior. The mechanism of action is not well defined and may be associated with either a prevention of mood recurrences or a more specific “antisuicidal” activity.

Declaration of Interest: Dr. Tondo has received research support from Janssen and Eli Lilly Corporations and has served as a consultant to Glaxo-SmithKline and Merck Corporations. Dr. Baldessarini has recently been a consultant or investigator-initiated research collaborator with: AstraZeneca, Auritec, Biotrofix, Janssen, JDS-Noven, Lilly, Luitpold, NeuroHealing, Novartis, Pfizer, and SK-BioPharmaceutical Corporations. Neither author is a member of pharmaceutical speakers’ bureaus, nor do they or any family member hold equity positions in biomedical or pharmaceutical corporations.

Self-injurious and suicidal behaviours are highly prevalent in patients with borderline personality disorder (BPD) and the risk of completed suicide is high. Borderline patients often present with heterogeneous clinical pictures and widespread comor-bidity complicating clinical assessments and management. This calls for increased efforts in systematic evaluation and monitoring of self-harming and suicidal behaviours; these behaviours should be addressed actively as high priority treatment targets. Early drop-out is common for BPD patients in treatment but is possible to counteract by fostering a strong therapeutic relationship through adopting a realistic, but consistent and supportive approach carefully avoiding reinforcement of suicidal behaviours. Suicidal crises should primarily be managed in an outpatient setting giving priority to keeping the patient safe adopting a safety plan procedure, while helping the patient as quickly as possible to return emotionally to a more acceptable level of arousal and mental functioning. Pharmacological treatments should primarily be used for management of comorbid conditions, but may possibly also be helpful when used to reduce specific symptoms such as anger, hostility and impulsivity. There is currently a range of different integrated short-term and long-term psychological treatments in different stages of development and some of them have been shown to be efficacious in reducing suicidal behaviours; notably dialectical behaviour therapy and mentalization-based therapy.

Declaration of Interest: None.

Background – People suffering from schizophrenia have markedly increased physical morbidity and mortality. A poor diet and sedentary lifestyle make a significant contribution to this ill health. Healthcare professionals need to include assessments of diet and to promote a ‘healthy living’ lifestyle. Aims – To describe the dietary habits and cardiovascular risk factors of people with chronic schizophrenia living in supported accommodation and to audit the provision of cardiovascular health screening in this population. Method – The dietary habits of 69 people with chronic schizophrenia living in community settings were assessed. Tobacco smoking, body mass indices and waist circumference were also measured. The dietary behaviour of patients living in high care settings with care staff present every day was compared with those in low care settings. Results – Residents in both levels of care made poor dietary choices. Patients in high care were consuming more fast food than those in low care. The dietary habits of men and women in both levels of care were worse than reported by surveys of the general population in England. All patients had seen their GP in the previous year though only 3 had received diabetes screening and fewer than half had lipid profiles. Conclusions – People with schizophrenia do not improve their diet just by the provision of healthy food as was the case in high care settings. Secondary care services must address physical health monitoring as well as mental health if the increased mortality of patients with schizophrenia is to be addressed effectively. More effective interventions are necessary to improve and sustain a healthy diet.

Declaration of Interest: Nothing to declare.

Aim – The high economic and social costs associated with the ‘common mental disorders’, and the need to scale up appropriate care services, are now widely recognized, but responses vary from country to country. In Britain, a current government initiative to promote psychological therapy is driven both by economic pressures and by research on the factors of happiness, or life-satisfaction. This article provides a short critical review of the project. Method – A health policy analysis, with regard to problem definition; objectives; sources of information; criteria for evaluation; impact on existing services, and comparison with alternative strategies. Results – The new programme, Improving Access to Psychological Therapies (IAPT), aims to expand treatment services by training 3,600 ‘psychological therapists’ in cognitive behavioural therapy (CBT), which they will then apply in the wider community. This service, with an initial budget of £173 million, will provide treatment for depression and chronic anxiety from local centres across the country. The programme is intended to pay for itself by reducing incapacity costs. Closer examination, however, raises questions concerning the project’s theoretical basis, logistics and research methodology, and casts doubt on its advantages over alternative approaches. Conclusions – The IAPT project is ill-designed to achieve its objectives and unsuitable as a model for treatment and care of the common mental disorders in other countries. An alternative strategy, based on closer integration of community mental health and primary health care, should be tested and on previous experience seems likely to prove more cost-effective.

Declaration of Interest: None.

Aims – Postnatal depression, the most frequent complication occurring after pregnancy, is often not recognized. The prevalence of postnatal depression is currently considered to be 10–15% in western countries. A wide range of risk factors related to postnatal depression were researched in international studies. Our aim was to evaluate the risk factors and their frequency in a women population of Bergamo Province and compare the results with findings of international literature. Methods – 595 women taking part to antenatal courses in three hospitals in Bergamo Province were screened for Postnatal Depression using EPDS and clinical interview. Prevalence and possible psychosocial risk factors data were collected and subsequently analysed and compared with literature findings. Results – Thirty six (7.1%) women of our sample had postnatal depression. Depressed mood and depression during pregnancy, anxiety during pregnancy, poor social support, recent life events, a history of depression or other psychiatric history, presence of maternity blues were the strongest predictors of postnatal depression in our sample. Conclusions – The Psychosocial risk factors emerged from our study are substantially the same indicated by international studies, on the contrary prevalence is a little lower. This result may be explained considering that our women sample wasn't completely representative of general population.

Declaration of Interest: Results of this study are part of a project, “Identification and early treatment of post partum depression”, approved and financially supported by Regione Lombardia. This study didn't receive grants or support from drug companies. There are no conflicts of interest.

Aim – To test the hypothesis that stressful life events, in particular intrusive events, would cluster before the first onset of psychosis. Method – Forty-one patients with first episode psychosis were interviewed with the Life Events and Difficulties Schedule to assess events in the year before the onset of illness. Events were rated contextually on timing, independence, threat, and intrusiveness. Within-patient group clustering was evaluated, and the patient group was compared with two general population surveys from London. Results – Events were very frequent in the year before the onset of psychosis. Stressful and intrusive events were more common in the three months before onset compared with the previous nine months, although few analyses reached conventional statistical significance. Threatening and intrusive events were much more frequent in patients than in the comparison groups. First episode psychosis patients were strikingly more likely to report an intrusive event in the three months before onset (OR=17.1, 34% v 3%), and also showed an excess between three months and one year before onset (OR=8.1, 11% v 3%). Conclusions – Events may trigger many cases of first episode psychosis. The effect emerges several months before onset, particularly if the events are intrusive. This has both theoretical and clinical implications.

Declaration of Interest: DR was supported by a UK Medical Research Council studentship. The authors have no conflicts of interest in writing this paper.

Aim – To assess the relationship between mental health and health-related quality of life (HRQL) in the general population, and to map GHQ-12 as a screening test for population psychological distress to a generic health state measure (EQ-5D) in order to estimate health state values and allow deriving quality-adjusted life years. Methods – Relationship between mental health and HRQL was examined from the 2004 Canary Islands’ Health Survey. Participants were classified as probable psychiatric cases according to GHQ-12. HRQL was measured by the EQ-5D index. Multivariate lineal regression analysis was used to examine the association between mental health and HRQL adjusting by socio-demographic variables and comorbidities. A multivariate regression model was built from EQ-5D to estimate health states values using GHQ-12 as exposure. Results – EQ-5D index scores decreased as the GHQ-12 scores increased. Clinical and socio-demographic factors influenced HRQL without changing the overall trend for this negative relationship. The regression equation explained 43% of the variance. For estimation of utility scores, the model showed a high predictive capacity, with a mean forecast errors of 16%. Conclusions – HRQL progressively decreased when the probability of being a psychiatric case increased. Findings enable health state values to be derived from GHQ-12 scores for populations where utilities has not or cannot be measured directly.

Declaration of Interest: Authors declare no conflicts of interest. This work was supported by the Quality Plan for the National Health Service (Spanish Ministry of Health and Social Policy).

Aim – To review studies conducted to establish the risk of spontaneous abortion (SA) in women exposed to anti-depressant drugs (ADs) during early pregnancy. Methods – By using different search terms, PubMed, Toxline, EMBASE, PsychINFO, and the Cochrane library databases were searched from January 1980 to March 2008, to identify studies assessing the risk of SA in women exposed to different classes of ADs during the first trimester of pregnancy. Results – Ten studies over 21 identified were selected for the analysis. All were performed prospectively and included as control group unexposed women, or exposed to non-teratogenic drugs or to placebo. In seven studies a depressive episode was specified as the reason for which the drug was prescribed, while the time of exposure was in nine. Conclusions – Only three studies over ten selected reported a significant association between an increased rate of SAs and early pregnancy exposure to some ADs. Many methodological flaws in the study design were found in all studies considered. Given this background and a lack of strong evidence on this issue, further prospective and better designed studies are needed to assess the risk of SA in pregnant women exposed to ADs against the risk of an untreated maternal depression.

Declaration of Interest: None.

Aim – The objective of this study was to identify clinical and demographic factors that may be associated with benzodiazepine treatment, to describe the reported reasons for use of these medications and to appraise the pattern of use in relation to standard guidelines in a general population sample. Methods – Telephone survey methods were employed to select a sample of 3345 people between the ages of 18 and 64. A computer assisted telephone interview, including the Mini Neuropsychiatric Diagnostic Interview (MINI), was administered. Estimates were weighted for design features and population demographics. Results – The overall prevalence of benzodiazepines use was 3.3% (95% confidence interval [CI] 2.6 to 4.1%). There was a higher frequency of medication use in women than men, among respondents who were widowed, separated or divorced, and those with lower levels of education. In relation to MINI diagnosis, diagnoses of Panic Disorder and Major Depression increased the probability of taking benzodiazepines. The reported main reason for use was “Sleep disorders” (68.9%), “Anxiety” (35.8%), “Depression” (27.8%) and “Pain management” (21.2%). More than 80% of subjects were taking benzodiazepines for more than one year. Conclusions – When compared to previous estimates, the lower frequency of benzodiazepines use suggests that there has been improvement in their evidence-based use at a population level. However our results once more confirm the difficulty stopping the use of these medications once they have been started. Further randomized control studies may help clinicians in having a better practical approach to rational benzodiazepine use.

Declaration of Interest: None.