Hot off the presses! Aug 22 Lancet

The Aug 22 issue of the Lancet is now up on Pubget (About Lancet): if you're at a subscribing institution, just click the link in the latest link at the home page. (Note you'll only be able to get all the PDFs in the issue if your institution subscribes to Pubget.)

Latest Articles Include:

• Movement for global mental health gains momentum
  - Lancet 374(9690):587 (2009)
  
• NICE set to revise Quality and Outcomes Framework indicators
  - Lancet 374(9690):588 (2009)
  
• Ramadan: health effects of fasting
  - Lancet 374(9690):588 (2009)
  
• Are general practitioners really unable to diagnose depression?
  Tyrer P - Lancet 374(9690):589-590 (2009)
  
• The unchanging mortality gap for people with schizophrenia
  - Lancet 374(9690):590-592 (2009)
  
• Mentally ill patients dying in social shelters in Indonesia
  - Lancet 374(9690):592-593 (2009)
  
• It's time for disruptive innovation in psychotherapy
  - Lancet 374(9690):594-595 (2009)
  
• Health-care worker burnout and the mental health imperative
  - Lancet 374(9690):595-597 (2009)
  
• Chile: an ongoing mental health revolution
  - Lancet 374(9690):597-598 (2009)
  
• European Commission takes on Big Pharma
  - Lancet 374(9690):599-600 (2009)
  
• Taking the spice out of legal smoking mixtures
  - Lancet 374(9690):600 (2009)
  
• US faces crisis in mental health care for juvenile offenders
  - Lancet 374(9690):601 (2009)
  
• Mexico fights rise in dengue fever
  - Lancet 374(9690):602 (2009)
  
• Global mental health: a failure of humanity
  - Lancet 374(9690):603-604 (2009)
  
• Clinical characteristics of paediatric H1N1 admissions in Birmingham, UK
  - Lancet 374(9690):605 (2009)
  
• Swine-origin influenza virus H1N1, seasonal influenza virus, and critical illness in children
  - Lancet 374(9690):605-607 (2009)
  
• The science and ethics of primate research
  - Lancet 374(9690):607-608 (2009)
  
• Removal of user fees and universal health-care coverage
  - Lancet 374(9690):608 (2009)
  
• Department of Error
  - Lancet 374(9690):608 (2009)
  
• Clinical diagnosis of depression in primary care: a meta-analysis
  Mitchell AJ Vaze A Rao S - Lancet 374(9690):609-619 (2009)
  Background Depression is a major burden for the health-care system worldwide. Most care for depression is delivered by general practitioners (GPs). We assessed the rate of true positives and negatives, and false positives and negatives in primary care when GPs make routine diagnoses of depression. Methods We undertook a meta-analysis of 118 studies that assessed the accuracy of unassisted diagnoses of depression by GPs. 41 of these studies were included because they had a robust outcome standard of a structured or semi-structured interview. Findings 50 371 patients were pooled across 41 studies and examined. GPs correctly identified depression in 47·3% (95% CI 41·7% to 53·0%) of cases and recorded depression in their notes in 33·6% (22·4% to 45·7%). 19 studies assessed both rule-in and rule-out accuracy; from these studies, the weighted sensitivity was 50·1% (41·3% to 59·0%) and specificity was 81·3% (74·5% to 87·3%). At a rate of 21·9%, the positive predictive value was 42·0% (39·6% to 44·3%) and the negative predictive value was 85·8% (84·8% to 86·7%). This finding suggests that for every 100 unselected cases seen in primary care, there are more false positives (n=15) than either missed (n=10) or identified cases (n=10). Accuracy was improved with prospective examination over an extended period (3–12 months) rather than relying on a one-off assessment or case-note records. Interpretation GPs can rule out depression in most people who are not depressed; however, the modest prevalence of depression in primary care means that misidentifications outnumber missed cases. Diagnosis could be improved by re-assessment of individuals who might have depression. Funding None.
• 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study)
  - Lancet 374(9690):620-627 (2009)
  Background The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients. Methods Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5·2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use. Findings Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22·5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1·41, 95% CI 1·09–1·82), and the lowest risk for clozapine (0·74, 0·60–0·91; p=0·0045 for the difference between clozapine vs perphenazine, and p<0·0001 for all other antipsychotic drugs). Long-term cumulative exposure (7–11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0·81, 0·77–0·84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0·991; 0·985–0·997). Interpretation Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed. Funding Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).
• Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial
  - Lancet 374(9690):628-634 (2009)
  Background Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care. Methods In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578. Findings 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2·39, 95% CI 1·23–4·67; p=0·011), and 46 (42%) versus 26 (26%) at 8 months (2·07, 1·11–3·87; p=0·023). Interpretation CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT. Funding BUPA Foundation.
• Schizophrenia
  - Lancet 374(9690):635-645 (2009)
  Schizophrenia is still one of the most mysterious and costliest mental disorders in terms of human suffering and societal expenditure. Here, we focus on the key developments in biology, epidemiology, and pharmacology of schizophrenia and provide a syndromal framework in which these aspects can be understood together. Symptoms typically emerge in adolescence and early adulthood. The incidence of the disorder varies greatly across places and migrant groups, as do symptoms, course, and treatment response across individuals. Genetic vulnerability is shared in part with bipolar disorder and recent molecular genetic findings also indicate an overlap with developmental disorders such as autism. The diagnosis of schizophrenia is associated with demonstrable alterations in brain structure and changes in dopamine neurotransmission, the latter being directly related to hallucinations and delusions. Pharmacological treatments, which block the dopamine system, are effective for del! usions and hallucinations but less so for disabling cognitive and motivational impairments. Specific vocational and psychological interventions, in combination with antipsychotic medication in a context of community-case management, can improve functional outcome but are not widely available. 100 years after being so named, research is beginning to understand the biological mechanisms underlying the symptoms of schizophrenia and the psychosocial factors that moderate their expression. Although current treatments provide control rather than cure, long-term hospitalisation is not required and prognosis is better than traditionally assumed.
• Paternal psychiatric disorders and children's psychosocial development
  - Lancet 374(9690):646-653 (2009)
  Psychiatric disorders of parents are associated with an increased risk of psychological and developmental difficulties in their children. Most research has focused on mothers, neglecting psychiatric disorders affecting fathers. We review findings on paternal psychiatric disorders and their effect on children's psychosocial development. Most psychiatric disorders that affect fathers are associated with an increased risk of behavioural and emotional difficulties in their children, similar in magnitude to that due to maternal psychiatric disorders. Some findings indicate that boys are at greater risk than girls, and that paternal disorders, compared with maternal disorders, might be associated with an increased risk of behavioural rather than emotional problems. Improved paternal mental health is likely to improve children's wellbeing and life course.
• Severe mental disorders in complex emergencies
  - Lancet 374(9690):654-661 (2009)
  People with severe mental disorders are a neglected and vulnerable group in complex emergencies. Here, we describe field experiences in establishing mental health services in five humanitarian settings. We show data to quantify the issue, and suggest reasons for this neglect. We then outline the actions needed to establish services in these settings, including the provision of practical training, medication, psychosocial supports, and, when appropriate, work with traditional healers. We have identified some persisting problems locally, nationally, and internationally, and suggest some solutions. Protection and care of people with severe mental disorders in complex emergencies is a humanitarian responsibility.
• Mutational analysis for Wilson's disease
  - Lancet 374(9690):662 (2009)
  
• Global responsibilities for global health rights
  - Lancet 374(9690):607 (2009)