Depression is frequently seen in patients with medical illnesses yet the link between medical illnesses and depression remains unclear. There is increasing data to suggest that the array of depressive symptoms experienced by the medically-ill may involve inflammation. The activation of the immune system and the subsequent release of innate immune products such as cytokines can have important effects on behaviour. The treatment of choice for chronic viral hepatitis C, interferon-alpha IFN-α, acutely induces the production and release of other innate immune cytokines, and has been indicated to cause clinically significant depression in 30% of patients receiving treatment. This in turn can impair quality of life and affect treatment compliance. We and others use IFN-α induced depression as a model to identify alterations in psychological and biological pathways that predispose to depression in the medically-ill, and thus provide an explanatory link between inflammation and the subsequent behavioural changes. In this editorial, we aim to describe the main biological pathways involved in IFN-induced depression and to discuss psychological, clinical and biological factors that have been found to predict those who will develop more severe psychiatric symptoms during treatment with IFN-α. Among these, particular attention would be given to psychological traits, genetic polymorphisms regulating inflammation and serotonergic function, and changes in plasma levels of pro-inflammatory cytokines.

This article reviews common sources of suffering in patients with advanced illness, identifies challenges in appropriately diagnosing and treating depression in this setting, and examines the relationship between depression and other key clinical outcomes in the setting of advanced disease. A systematic literature review was conducted. Most of the existing research on patients with advanced illness has been conducted with cancer patients. Approximately 18 percent of patients with advanced illness meet criteria for major or minor depression; multiple psychiatric co-morbidities occur frequently. Prevalence rates increase as patients become sicker. However, depression is frequently underdiagnosed and undertreated in the setting of advanced illness. One of the key clinical challenges is differentiating depression from grief. Both psychosocial and psychopharmacologic interventions have been shown to be effective in treating depression in patients with advanced cancer. In conclusion, depression is a regular complication of advanced illness, reduces quality of life, compromises family member function, interferes with treatment decisions, and may shorten survival. However, numerous effective treatment approaches, including both medications and psychotherapy, exist and can be used to alleviate depression.

Research has found that depression is more common among individuals with diabetes and is associated with worse diabetes outcomes including treatment nonadherence, worse glycemic control, higher risk of diabetes complications, greater functional impairment, and increased risk of mortality. These patterns of association have led to an increase in research investigating the relationship between diabetes and depression. There remain important questions about the relationship between depression and diabetes and an unmet need for treatment approaches that are successful in ameliorating depression and improving diabetes outcomes. The current commentary discusses several conceptual issues related to the measurement of depression in diabetes, argues for the importance of health behavior and treatment adherence in approaching the problem of depression in diabetes, and provides an example of a treatment approach that incorporates the treatment of depression with strategies aimed at improving treatment adherence in order to maximize effects on diabetes outcomes.

Trial protocols are documents that describe the objectives, design, methodology, statistical considerations and aspects related to the organization of clinical trials. Trial protocols provide the background and rationale for conducting a study, highlighting specific research questions that are addressed, and taking into consideration ethical issues. Trial protocols must meet a standard that adheres to the principles of Good Clinical Practice, and are used to obtain ethics approval by local Ethics Committees or Institutional Review Boards.

Although the anatomy of the parietal lobe has been under-investigated in schizophrenia, some magnetic resonance imaging studies have shown decreased volumes, suggesting its possible implication for the pathophysiology of the disease.

Aims – Impulsivity is a multifaceted aspect of behavior that is prominent in psychiatric disorders and has serious behavioral consequences. This paper reviews studies integrating behavioral and physiological mechanisms in impulsivity and their role in severity and course of bipolar and related disorders. Methods – This is a review of work that used questionnaire, human behavioral laboratory, and neurophysiological measurements of impulsivity or related aspects of behavior. Subjects included individuals with bipolar disorder, substance-use disorders, antisocial personality disorder, and healthy controls. Results – Models of impulsivity include rapid-response impulsivity, with inability to reflect or to evaluate a stimulus adequately before responding, and reward-based impulsivity, with inability to delay response for a reward. In normal subjects, rapid-response impulsivity is increased by yohimbine, which increases norepinephrine release. Impulsivity is increased in bipolar disorder, whether measured by questionnaire, by measures of rapid-response impulsivity, or by measures of ability to delay reward. While affective state has differential effects on impulsivity, impulsivity is increased in bipolar disorder regardless of affective state or treatment. Impulsivity, especially rapid-response, is more severe with a highly recurrent course of illness or with comorbid substance-use disorder, and with history of medically severe suicide attempt. In antisocial personality disorder, rapid-response impulsivity is increased, but rewardbased impulsivity is not. In general, impulsivity is increased more in bipolar disorder than in antisocial personality disorder. In combined bipolar disorder and antisocial personality disorder, increased impulsivity is associated with substance-use disorders and suicide attempts. Conclusions – Impulsivity is associated with severe behavioral complications of bipolar disorder, antisocial personality disorder, and substance-use disorders.

Aims – This paper seeks to provide a methodology to assess the cost-effectiveness of anti-stigma campaigns for people with mental health problems. Methods – The costs of running a national campaign in Scotland were obtained and combined with the number of adults in the Scottish population and the estimated number of people with improved attitudes towards people with mental health problems. A decision model was constructed to estimate the economic impact of a campaign in terms of increased use of services by people with depression and increased work time. Results – If the campaign caused 10% of changed attitudes then it was estimated to cost £35 per one less person who felt that people with mental health problems were dangerous and £186 per one less person who felt the public needs protection from people with mental health problems. The decision model suggested extra economic benefits (employment gains minus service costs) as a result of an anti-stigma campaign compared to the absence of a campaign. Conclusions – Data on the economic impact of anti-stigma campaigns are scarce and evaluation is intrinsically difficult. We have demonstrated a method to conduct such analyses. The model proposed here should be tested further as data become available.

Aim – to provide a conceptual and practical analysis of the impacts of mental health diagnoses on consumers and to consider how service users might contribute to the new psychiatric classifications currently being drawn up. Methods – A search was carried out revealing a very sparse literature on this topic. Consultations with service users were conducted and the views of experts sought. Results – Diagnosis is important as it marks the formal status of psychiatric patient being conferred. Consumers react differently, and often, negatively to this. Stigma can follow from a diagnosis. The process of giving a diagnosis can range from one of negotiation and taking the person's strengths into account to the blunt allocation of an unwanted label. Consumers can be reduced to their diagnosis so it becomes their whole personhood and this can have an effect on their sense of self. However, consumers are not passive victims and have their own strategies for dealing with these issues. Conclusion – Consumers can use these experiences to make contributions to the new diagnostic classification systems and to future research.

Aim – Delinquency among adolescents and antecedent conduct disorder among children has been recognized as a growing public mental health problem in contemporary societies. The contribution of the neighbourhood environment to delinquent behaviour was examined in a cohort of Dutch adolescents (aged approximately 11 years at baseline; n=394). Methods – Multilevel regression analyses estimated associations between baseline neighbourhood socioeconomic status and social capital, and delinquent behaviour two years later controlling for individual-level variables. Results – A significant interaction effect was found between neighbourhood environment variables and gender in models of delinquency, indicating that associations between neighbourhood environment variables and delinquency were apparent, for the most part, in girls only. However, higher level of neighbourhood informal social control was associated with increased delinquency rates in boys. Conclusion – In girls there is a longitudinal association between neighbourhood characteristics and delinquency, suggesting complex gender differences in the way the wider social environment impacts on behavioural outcomes.

Aim – The aim of the study was to determine how carer need for closure relates to expressed emotion. It also examined the links between carer need for closure and patient functioning including patient need for closure. Methods – In a cross-sectional study, 70 caregivers of patients with psychosis completed the Need for Closure Scale (NFCS), the Camberwell Family Interview (CFI) and measures of distress, burden, coping and social network. The NFCS was assessed in terms of its two primary dimensions: a need for simple structure (NFSS) and Decisiveness. Patients also completed measures of psychotic symptoms and affect, and in 50 matched caregiver patient dyads, direct comparisons were undertaken between caregiver and patient NFCS scores. Results – No links were found between caregiver NFC and EE in this predominately low EE sample. More decisive carers had higher levels of self esteem, were less distressed, and resorted less to avoidant coping. The need for simple structure was greater in carers who lacked a confidante. As predicted, patients reported significantly higher NFSS and lower Decisiveness scores than carers, but no relationship was observed between caregiver NFC and patient symptoms of psychosis. Conclusions – Carers reporting confident decision making were also more likely to report adaptive functioning in terms of having lower levels of avoidant coping and distress, and higher levels of self esteem. The results suggest that this style of thinking might be a helpful way of coping with some of the difficulties involved in caring for someone with psychosis.

Aim – To develop predictive models to allocate patients into frequent and low service users groups within the Italian Community-based Mental Health Services (CMHSs). To allocate frequent users to different packages of care, identifing the costs of these packages. Methods – Socio-demographic and clinical data and GAF scores at baseline were collected for 1250 users attending five CMHSs. All psychiatric contacts made by these patients during six months were recorded. A logistic regression identified frequent service users predictive variables. Multinomial logistic regression identified variables able to predict the most appropriate package of care. A cost function was utilised to estimate costs. Results – Frequent service users were 49%, using nearly 90% of all contacts. The model classified correctly 80% of users in the frequent and low users groups. Three packages of care were identified: Basic Community Treatment (4,133 Euro per six months); Intensive Community Treatment (6,180 Euro) and Rehabilitative Community Treatment (11,984 Euro) for 83%, 6% and 11% of frequent service users respectively. The model was found to be accurate for 85% of users. Conclusion – It is possible to develop predictive models to identify frequent service users and to assign them to pre-defined packages of care, and to use these models to inform the funding of psychiatric care.