Steven Marwaha

UK social firms are under-researched but are a potentially important vocational option for people with mental health problems. To describe the clinical profile, satisfaction levels and experiences of social firms employees with mental health problems. Clinical, work and service use characteristics were collected from social firms' employees with mental health problems in England and Wales. Workplace experience and satisfaction were explored qualitatively. Predominantly, social firms' employees (N = 80) report that they have a diagnosis of depression (56%) and anxiety (41%). People with schizophrenia (20%) or bipolar disorder (5%) were a minority. Respondents had low symptom and disability levels, high quality of life and job satisfaction and experienced reductions in secondary mental health service use over time. High-workplace satisfaction was related to flexibility, manager and colleague support and workplace accommodations. The clinical profile, quality of life and job sa...

Mood instability levels are high in depression, but temporal precedence and potential mechanisms are unknown. Hypotheses tested were as follows: (1) mood instability is associated with depression cross-sectionally, (2) mood instability predicts new onset and maintenance of depression prospectively and (3) the mood instability and depression link are mediated by sleep problems, alcohol abuse and life events. Data from the National Psychiatric Morbidity Survey 2000 at baseline (N = 8580) and 18-month follow-up (N = 2413) were used. Regression modeling controlling for socio-demographic factors, anxiety and hypomanic mood was conducted. Multiple mediational analyses were used to test our conceptual path model. Mood instability was associated with depression cross-sectionally (odds ratio: 5.28; 95% confidence interval: [3.67, 7.59]; p < 0.001) and predicted depression inception (odds ratio: 2.43; 95% confidence interval: [1.03-5.76]; p = 0.042) after controlling for important confound...

ABSTRACT I would like to thank Professor Parker for his erudite editorial on whether borderline personality disorder (BPD) is a mood disorder. Professor Parker examines this question by asking if BPD is a bipolar or unipolar mood condition and concludes by suggesting that it is probably neither. I would like to offer a supplementary interpretation of the literature; that is BPD is in large part a mood disorder but isn’t necessarily a bipolar or unipolar mood variant. BPD is highly comorbid with bipolar disorder1 and depression2 and those who develop bipolar disorder have early temperamental markers of emotional dysregulation3. Support that BPD is a mood disorder is also aligned with the fact that affective instability is a core feature of the syndrome. Whilst under investigated there is emerging evidence that affect or mood instability as opposed to mood episodes may be the core feature of bipolar disorders4. The majority of patients with established bipolar, even after symptomatic control continue to experience daily or weekly mood swings5. Further, the prevalence of mood instability and cyclothymic temperament is increased in unaffected bipolar probands6 and it predicts functioning in those with bipolar4. Mood instability is highly prevalent in unipolar depression7 and independently links to suicidality and health service use. Furthermore in BPD, affective instability is the least stable of the “trait like” features of the syndrome over two years8. Thus all three disorders share mood instability as a clinical component and this all points to BPD, at least in part, being a disorder of mood. However BPD doesn’t exactly fit into the bipolar or depressive affect rubric given the affective shifts don’t last long enough for either mood disorder diagnosis. Detailed studies of the nature of affective instability in mood disorders and BPD using the same measurement methods are limited. However as Professor Parker states there are differences. Those with bipolar disorder have greater levels of euthymia-elation and affect intensity. In BPD there are more shifts between anxiety, depression and euthymia-anger9. Negative emotionality is a critical feature of BPD but it is changeable, as is obvious to clinicians who have been charged with the care of people with BPD on inpatient wards. Affect can be studied on the basis of intensity, frequency of shift, rapidity of rise-times and return to baseline, reactivity to psychosocial cues or whether endogenously driven and the extent to which there is overdramatic expression10. To this could be added valence. Using this framework BPD could be conceptualised as a disorder of mood in which affect changes are intense, frequent, rapid to occur and slow to dissipate and in which the valence of the mood state is typically negative incorporating depression, anxiety and anger. This pattern of difficulties whilst related to mood, do not appear to overlap to a significant extent with how depression or bipolar disorder might be described using the same affective framework. Though it is clear terms such as intensity, frequency, rapidity of rise etc need to be better specified, experience sampling methods analyzing affective patterns in the three disorders may further illuminate this area and indeed the debate. 1. Mantere, O., Melartin, T. K., Suominen, K., Rytsälä, H. J., Valtonen, H. M., Arvilommi, P., ... & Isometsä, E. T. (2006). Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder. The Journal of clinical psychiatry, 67(4), 584-593. 2. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., ... & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 69(4), 533. 3. Luby, J. L., & Navsaria, N. (2010). Pediatric bipolar disorder: evidence for prodromal states and early markers. Journal of Child Psychology and Psychiatry, 51(4), 459-471. 4. Strejilevich, S., Martino, D., Murru, A., Teitelbaum, J., Fassi, G., Marengo, E., Igoa, A. & Colom, F. (2013). Mood instability and functional recovery in bipolar disorders. Acta Psychiatrica Scandinavica. 5. Bonsall, M. B., Wallace-Hadrill, S. M., Geddes, J. R., Goodwin, G. M. & Holmes, E. A. (2012). Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder. Proceedings of the Royal Society B: Biological Sciences 279, 916-924. 6. Diler, R. S., Birmaher, B., Axelson, D., Obreja, M., Monk, K., Hickey, M. B., Goldstein, B., Goldstein, T., Sakolsky, D. & Iyengar, S. (2011). Dimensional psychopathology in offspring of parents with bipolar disorder. Bipolar disorders 13, 670-678. 7. Marwaha, S., Parsons, N., Flanagan, S., & Broome, M. (2013). The prevalence and clinical associations of mood instability in adults living…

ABSTRACT Introduction: Several studies have explored comparative effectiveness of first prescribed antipsychotics for FEP using time to treatment discontinuation as a proxy measure. Consistent differences are not demonstrated. We explored this in a large clinical sample across different services. We present an interim data analysis. Method: A retrospective cohort study examined the naturalistic treatment of all patients accepted by FEP services across 6 sites in Sussex and Warwickshire over 3 years. Case notes were examined to the point of any-cause discontinuation up to 1 year. Median and mean survival times and rate of discontinuation at 1 year were compared using survival analysis. Results: Of 579 patients prescribed antipsychotic treatment, data were available for 451. Aripiprazole was prescribed in 59 cases, Olanzapine 184, Quetiapine 114 and Risperidone 80 cases. Greatest risk of treatment discontinuation was in the fi rst 3 months for all medications. Risperidone had the longest median time-to-discontinuation (175 days, 95%CI 47.90– 302.09), followed by Aripiprazole (162 days, 95%CI 43.72–280.27), Quetiapine (154 days, 95%CI 81.68–226.32) and Olanzapine (112 days, 95%CI 85.90–138.10). Patients prescribed Olanzapine had highest rates of discontinuation by 1 year (76.4%), followed by Aripiprazole (69.5%), Quetiapine (67.9%) and Risperidone (65.8%). Discontinuation rates for patients prescribed Risperidone versus Olanzapine were signifi cantly different (%, = 3.125; p = 0.0386). Conclusions: Risperidone appears more effective than Olanzapine in the treatment of FEP, where time to all-cause treatment discontinuation is considered. In the light of the greater metabolic infl uence of Olanzapine, its use as a first line antipsychotic in FEP patients needs further consideration.

Objectives: To evaluate the neurobiological, psychophysical and behavioural measures of affective instability in clinical populations.

Data sources: A range of medical and psychological science electronic databases were searched (including MEDLINE, EMBASE, and PsycINFO). Hand searching and reference checking are also included.

Review methods: Reviews, systematic reviews, experimental and cross-sectional studies, providing affective instability in neurobiological and behavioural measurements in clinical populations. Studies were selected, data was extracted and quality was appraised.

Results: Twenty-nine studies were included, 6 of which were review studies (one a meta-analysis) and 23 of which were primary studies, across a wide variety of disorders including ADHD, bipolar affective disorder, schizophrenia, severe mood dysregulation, major depression, and borderline personality disorder.

Conclusions:  The bulk of the studies converge on the role of the amygdala, particularly in borderline personality disorders, and how it connects with other areas of the brain.  Future research needs to extend these findings across diagnoses and development.

OBJECTIVE:

Mood instability levels are high in depression, but temporal precedence and potential mechanisms are unknown. Hypotheses tested were as follows: (1) mood instability is associated with depression cross-sectionally, (2) mood instability predicts new onset and maintenance of depression prospectively and (3) the mood instability and depression link are mediated by sleep problems, alcohol abuse and life events.
METHOD:

Data from the National Psychiatric Morbidity Survey 2000 at baseline (N = 8580) and 18-month follow-up (N = 2413) were used. Regression modeling controlling for socio-demographic factors, anxiety and hypomanic mood was conducted. Multiple mediational analyses were used to test our conceptual path model.
RESULTS:

Mood instability was associated with depression cross-sectionally (odds ratio: 5.28; 95% confidence interval: [3.67, 7.59]; p < 0.001) and predicted depression inception (odds ratio: 2.43; 95% confidence interval: [1.03-5.76]; p = 0.042) after controlling for important confounders. Mood instability did not predict maintenance of depression. Sleep difficulties and severe problems with close friends and family significantly mediated the link between mood instability and new onset depression (23.05% and 6.19% of the link, respectively). Alcohol abuse and divorce were not important mediators in the model.
CONCLUSION:

Mood instability is a precursor of a depressive episode, predicting its onset. Difficulties in sleep are a significant part of the pathway. Interventions targeting mood instability and sleep problems have the potential to reduce the risk of depression.

The significance of affective changes in psychosis is increasingly acknowledged, as is the role of early traumatic events. In a previous paper, using data from the English Adult Psychiatric Morbidity Survey 2007 (APMS2007), strong associations between child sexual abuse (CSA) and psychosis were demonstrated, with some evidence of mediation by affect. In the current paper, we subjected the same dataset to formal tests of mediation. For CSA involving sexual intercourse, 38.5 % of the link was mediated, 30.0 % by depression and 8.5 % by anxiety. For all forms of contact abuse, 38.2 % was mediated, 29.1 % by depression and 9.1 % by anxiety.

I would like to thank Professor Parker for his erudite editorial on whether borderline personality disorder (BPD) is a mood disorder. Professor Parker examines this question by asking if BPD is a bipolar or unipolar mood condition and concludes by suggesting that it is probably neither. I would like to offer a supplementary interpretation of the literature; that is BPD is in large part a mood disorder but isn’t necessarily a bipolar or unipolar mood variant.

BPD is highly comorbid with bipolar disorder1 and depression2 and those who develop bipolar disorder have early temperamental markers of emotional dysregulation3. Support that BPD is a mood disorder is also aligned with the fact that affective instability is a core feature of the syndrome. Whilst under investigated there is emerging evidence that affect or mood instability as opposed to mood episodes may be the core feature of bipolar disorders4. The majority of patients with established bipolar, even after symptomatic control continue to experience daily or weekly mood swings5. Further, the prevalence of mood instability and cyclothymic temperament is increased in unaffected bipolar probands6 and it predicts functioning in those with bipolar4. Mood instability is highly prevalent in unipolar depression7 and independently links to suicidality and health service use. Furthermore in BPD, affective instability is the least stable of the “trait like” features of the syndrome over two years8. Thus all three disorders share mood instability as a clinical component and this all points to BPD, at least in part, being a disorder of mood.

However BPD doesn’t exactly fit into the bipolar or depressive affect rubric given the affective shifts don’t last long enough for either mood disorder diagnosis. Detailed studies of the nature of affective instability in mood disorders and BPD using the same measurement methods are limited. However as Professor Parker states there are differences. Those with bipolar disorder have greater levels of euthymia-elation and affect intensity. In BPD there are more shifts between anxiety, depression and euthymia-anger9. Negative emotionality is a critical feature of BPD but it is changeable, as is obvious to clinicians who have been charged with the care of people with BPD on inpatient wards.

Affect can be studied on the basis of intensity, frequency of shift, rapidity of rise-times and return to baseline, reactivity to psychosocial cues or whether endogenously driven and the extent to which there is overdramatic expression10. To this could be added valence. Using this framework BPD could be conceptualised as a disorder of mood in which affect changes are intense, frequent, rapid to occur and slow to dissipate and in which the valence of the mood state is typically negative incorporating depression, anxiety and anger. This pattern of difficulties whilst related to mood, do not appear to overlap to a significant extent with how depression or bipolar disorder might be described using the same affective framework. Though it is clear terms such as intensity, frequency, rapidity of rise etc need to be better specified, experience sampling methods analyzing affective patterns in the three disorders may further illuminate this area and indeed the debate.

1. Mantere, O., Melartin, T. K., Suominen, K., Rytsälä, H. J., Valtonen, H. M., Arvilommi, P., ... & Isometsä, E. T. (2006). Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder. The Journal of clinical psychiatry, 67(4), 584-593.

2. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., ... & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 69(4), 533.

3. Luby, J. L., & Navsaria, N. (2010). Pediatric bipolar disorder: evidence for prodromal states and early markers. Journal of Child Psychology and Psychiatry, 51(4), 459-471.


4. Strejilevich, S., Martino, D., Murru, A., Teitelbaum, J., Fassi, G., Marengo, E., Igoa, A. & Colom, F. (2013). Mood instability and functional recovery in bipolar disorders. Acta Psychiatrica Scandinavica.

5. Bonsall, M. B., Wallace-Hadrill, S. M., Geddes, J. R., Goodwin, G. M. & Holmes, E. A. (2012). Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder. Proceedings of the Royal Society B: Biological Sciences 279, 916-924.

6. Diler, R. S., Birmaher, B., Axelson, D., Obreja, M., Monk, K., Hickey, M. B., Goldstein, B., Goldstein, T., Sakolsky, D. & Iyengar, S. (2011). Dimensional psychopathology in offspring of parents with bipolar disorder. Bipolar disorders 13, 670-678.

7. Marwaha, S., Parsons, N., Flanagan, S., & Broome, M. (2013). The prevalence and clinical associations of mood instability in adults living in England: results from the Adult Psychiatric Morbidity Survey 2007. Psychiatry research, 205(3), 262-268.

8. Chanen, A. M., Jackson, H. J., McGorry, P. D., Allot, K. A., Clarkson, V. & Yuen, H. P. (2004). Two-year stability of personality disorder in older adolescent outpatients. Journal of Personality Disorders 18, 526-541

9. Reich, D. B., Zanarini, M. C., & Fitzmaurice, G. (2012). Affective lability in bipolar disorder and borderline personality disorder. Comprehensive psychiatry, 53(3), 230-237.

10. Koenigsberg, H. W. (2010). Affective instability: toward an integration of neuroscience and psychological perspectives. Journal of personality disorders, 24(1), 60-82.

Background: In the UK, the severely mentally ill have high rates of unemployment. Aims: To (1) evaluate implementation of an employment intervention and (2) test the effectiveness of training an existing staff member in providing the employment intervention (Model A) against the provision of a dedicated employment specialist to a team (Model B). Methods: An employment service was implemented in five mental health teams, with three teams having an existing team member trained and two teams receiving an additional member of staff to carry out the employment intervention. Work outcomes for the two groups were compared at 1 year. Results: Competitive employment was obtained by 17.7% receiving an employment intervention (10.3%, Model A versus 22.8% Model B). Rates of employment or training obtained were 25.6% (10/39) in Model A versus 35.1% (20/57) in Model B, but the difference was not statistically different. Type of employment service model was not significantly associated with working. Conclusion: An employment service can be introduced effectively into mental health teams in the UK and positive employment outcomes achieved in a short space of time. Providing an additional resource is more effective compared to asking existing staff to deliver the intervention alongside other roles.

IMPORTANCE Although many studies have explored the correlates of violence during first-episode psychosis (FEP), most have simply compared violent psychotic individuals with nonviolent psychotic individuals. Accumulating evidence suggests there may be subgroups within psychosis, differing in terms of developmental processes and proximal factors associated with violent behavior. OBJECTIVE To determine whether there are subgroups of psychotic individuals characterized by different developmental trajectories to violent behavior. DESIGN, SETTING, AND PARTICIPANTS The National EDEN (Evaluating the Development and Impact of Early Intervention Services in the West Midlands) Study longitudinal cohort assessed premorbid delinquency (premorbid adjustment adaptation subscale across childhood and adolescence), age at illness onset, duration of untreated psychosis, past drug use, positive symptoms, and violent behavior. Group trajectories of premorbid delinquency were estimated using latent class growth analysis, and associations with violent behavior were quantified. This study included 6 early intervention services in 5 geographical locations across England, with violent behavior information available for 670 first-episode psychosis cases. MAIN OUTCOMES AND MEASURES Violent behavior at 6 or 12 months following early intervention services entry. RESULTS Four groups of premorbid delinquency were identified: stable low, adolescent-onset high to moderate, stable moderate, and stable high. Logistic regression analysis, with stable low delinquency as the reference group, demonstrated that moderate (odds ratio, 1.97; 95% CI, 1.12-3.46) and high (odds ratio, 3.53; 95% CI, 1.85-6.73) premorbid delinquency trajectories increased the risk for violent behavior during FEP. After controlling for confounders, path analysis demonstrated that the increased risk for violence in the moderate delinquency group was indirect (ie, partially mediated by positive symptoms) (probit coefficient [β] = 0.12; P = .002); while stable high delinquency directly increased the risk for violence (β = 0.38; P = .05). CONCLUSIONS AND RELEVANCE There appear to be diverse pathways to violent behavior during FEP. Stable high premorbid delinquency from childhood onwards appears to directly increase the risk for violent behavior, independent of psychosis-related risk factors. In addition to tackling illness-related risks, treatments should directly address antisocial traits as a potent risk for violence during FEP.

Background

Employment is associated with better quality of life and wellbeing in people with mental illness. Unemployment is associated with greater levels of psychological illness and is viewed as a core part of the social exclusion faced by people with mental illness. Social Firms offer paid employment to people with mental illness but are under-investigated in the UK. The aims of this phase of the Social Firms A Route to Recovery (SoFARR) project were to describe the availability and spread of Social Firms across the UK, to outline the range of opportunities Social Firms offer people with severe mental illness and to understand the extent to which they are employed within these firms.
Method

A UK national survey of Social Firms, other social enterprises and supported businesses was completed to understand the extent to which they provide paid employment for the mentally ill. A study-specific questionnaire was developed. It covered two broad areas asking employers about the nature of the Social Firm itself and about the employees with mental illness working there.
Results

We obtained returns from 76 Social Firms and social enterprises / supported businesses employing 692 people with mental illness. Forty per cent of Social Firms were in the south of England, 24% in the North and the Midlands, 18% in Scotland and 18% in Wales. Other social enterprises/supported businesses were similarly distributed. Trading activities were confined mainly to manufacturing, service industry, recycling, horticulture and catering. The number of employees with mental illness working in Social Firms and other social enterprises/supported businesses was small (median of 3 and 6.5 respectively). Over 50% employed people with schizophrenia or bipolar disorder, though the greatest proportion of employees with mental illness had depression or anxiety. Over two thirds of Social Firms liaised with mental health services and over a quarter received funding from the NHS or a mental health charity. Most workers with mental illness in Social Firms had been employed for over 2 years.
Conclusions

Social Firms have significant potential to be a viable addition to Individual Placement and Support (IPS), supporting recovery orientated services for people with the full range of mental disorders. They are currently an underdeveloped sector in the UK.

Objective

The First Episode of Psychosis (FEP) represents a period of heightened risk for aggression. However, it is not known whether this risk is significantly altered following contact with mental health services.
Method

Meta-analytic methods were used to estimate pooled prevalence of ‘any’ and ‘serious’ aggression during FEP, while meta-regression analyses were conducted to explore reasons for heterogeneity between studies.
Results

Fifteen studies comprising 3, 294 FEP subjects were analysed. Pooled prevalence of ‘any aggression’ before service contact was 28% (95% CI: 22–34) and following contact 31% (95% CI: 20–42). Pooled prevalence of ‘serious aggression’ was 16% (95% CI: 11–20) before service contact and 13% (95% CI: 6–20) following contact. Four studies reporting repeated assessments within the same cohort revealed that aggression rates did not significantly differ post and pre service contact: Odds Ratios for any aggression: 1.18 (95% CI: 0.46–2.99) and serious aggression: 0.61 (95% CI: 0.31–1.21).
Conclusion

Rates of aggression are high during FEP, both before and following initial service contact, and seem not to alter following contact. This conclusion remains tentative due to considerable heterogeneity between studies and a lack of prospective cohort studies.

"Background

Severe work impairment can be present for a considerable proportion of the course of bipolar disorder (BD) and is costly for governments, services and individuals. Understanding predictors of employment in BD is therefore crucial as some may be susceptible to interventions. We conducted a systematic review of prospective studies in order to identify predictors of employment in people with BD.
Methods

We searched Medline, PsychInfo, EMBASE and Web of Science databases, hand searched 3 journals and used predetermined criteria to select papers for full text inclusion. Sixty seven papers were identified. Nine met inclusion criteria, with a total sample of 3184.
Results

Studies included in this review identified cognitive deficits (67%, n=4), depression (43%, n=3) and level of education (33%, n=2) as predictors of employment in BD patients. Bipolar depression not only affects whether someone is employed but also time off work. Even sub-syndromal depression appears to damage employment prospects. Verbal memory and executive functioning appear to be predictors of work functioning.
Limitations

Conclusions are based on a relatively small number of studies and are therefore subject to change with the addition of further studies. A formal meta-regression was not possible due to differences between measures of employment and work functioning.
Conclusions

Better assessment and management of depression and cognitive difficulties could improve the occupational functioning of BD patients. There is a need for high quality longitudinal studies specifically designed to investigate predictors of employment in large bipolar disorder samples."

The Objective Structured Clinical Examination (OSCE), originally developed in the 1970's, has been hailed as the "gold standard" of clinical assessments for medical students and is used within medical schools throughout the world. The Clinical assessment of Skills and Competencies (CASC) is an OSCE used as a clinical examination gateway, granting access to becoming a senior Psychiatrist in the UK. Discussion: Van der Vleuten's utility model is used to examine the CASC from the viewpoint of a senior psychiatrist. Reliability may be equivalent to more traditional examinations. Whilst the CASC is likely to have content validity, other forms of validity are untested and authenticity is poor. Educational impact has the potential to change facets of psychiatric professionalism and influence future patient care. There are doubts about acceptability from candidates and more senior psychiatrists. Summary: Whilst OSCEs may be the best choice for medical student examinations, their use in post graduate psychiatric examination in the UK is subject to challenge on the grounds of validity, authenticity and educational impact.

OBJECTIVE: This analysis used data from the large (n = 1208) European Schizophrenia Cohort to examine the association between subjective side-effects of antipsychotic medication and the Mental and Physical Composite Scores (MCS; PCS) of the SF-36 scale.

METHOD: Relationships between the subjective evaluation of side-effects identified from the Subjective Side-Effects Scale and the adjusted mean score on the PCS and MCS were examined. Where appropriate, these associations of subjective side-effects were compared with those of the same side-effects measured objectively.

RESULTS: In this study, subjective side-effects of antipsychotic medication were linked either to both the PCS and the MCS or, in a few instances, to neither. Subjective evaluations of sexual side-effects were associated only with the MCS, those of sialorrhoea only with the PCS. Objective ratings of extrapyramidal side-effects were related neither to PCS nor to MCS.

CONCLUSION: These data suggest that side-effects, whether subjective or objective, may need to be considered individually in relation to their impact on quality of life.

"SUMMARY. Aim – To examine the associations of job acquisition and loss in a representative, prospective community sample of people with schizophrenia living in the UK, France and Germany. Method – A representative sample of twelve hundred and eight people with schizophrenia were recruited from selected secondary mental health services in the U.K, France and Germany and followed up for 2 years. Information on demographic details, psychotic symptoms and work status was collected. Results –  The odds of getting jobs were increased by being resident in Marseille, Leipzig, Hemer and Heilbronn and by a higher regional general population employment rate. The odds were reduced by living in Lyon, a later illness onset, a longer length of illness, a continuous illness course and more severe negative psychotic symptoms. Previous vocational training reduced the odds of losing employment, whilst living in Lyon or Leipzig, harmful use of alcohol and more positive psychotic symptoms at baseline all increased the odds. Conclusions – In addition to illness related factors, area of residence and local labour market conditions appear to be important in explaining employment status change in people with schizophrenia.
Declaration of Interest: All authors declare there are no conflicts of interest. This study was funded by grants from Lundbeck A/S and from the German Federal Ministry of Education and Research. "

Background Little is known about international variations in employment rates among people with schizophrenia or about the factors associated with employment in this disorder.

Aims To describe employment patterns and the variables associated with working in an international sample of people with schizophrenia.

Method An analysis was made of baseline data from the European Schizophrenia Cohort study, a 2-year investigation of people with schizophrenia in contact with secondary services and living in France, Germany and the UK (n=1208).

Results Participants were working in all sections of the job market. People who had a degree, were living with their families or had experienced only a single episode of illness were more likely to be working. A continuous illness course, more severe non-psychotic symptoms and drug misuse reduced the odds of employment. There were large variations between centres in employment rates, which were highest in the three German study sites. These differences persisted after adjustment for individual characteristics.

Conclusions Local social contexts may be as important as individual or illness-related factors in explaining employment status.

Background:
Little is known about the extent to which work contributes to the recovery of people with schizophrenia. There is increasing interest in the subject because of new service models and the economic cost of unemployment in people with severe mental illness.
Methods:
A literature search was carried out with the aim of investigating: a) employment rates in schizophrenia and first-episode psychosis and the extent to which they have changed over time; b) the barriers to work; c) the factors associated with being employed among people with schizophrenia; and d) whether employment influences other outcomes in schizophrenia.
Results:
There are wide variations in reported employment rates in schizophrenia. Most recent European studies report rates between 10 % and 20%, while the rate in the US is less clear. There is a higher level of employment among first-episode patients. The employment rate in schizophrenia appears to have declined over the last 50 years in the UK. Barriers to getting employment include stigma,discrimination, fear of loss of benefits and a lack of appropriate professional help. The most consistent predictor of employment is previous work history. Working is correlated with positive outcomes in social functioning, symptom levels, quality of life and self esteem, but a clear causal relationship has not been established.
Conclusions:
Very low employment rates are not intrinsic to schizophrenia, but appear to reflect an interplay between the social and economic pressures that patients face, the labour market and psychological and social barriers to working.

Background: Knowledge of mental health service users views is important in service planning, to ensure access for everyone and in particular for those in minority groups. Depression is common in older people and it has been suggested that ethnic elders may be more vulnerable to mental illness. This study therefore explored and compared the views of White British (WB) and Black African–Caribbean (BC) older people on depression as an illness, avenues of help and the place of mental health services. Methods: A qualitative analysis of semi-structured interviews using vignettes describing an older man with depression and a woman with psychosis. The purposive sample consisted of 40 WB and BC older people half of who had been depressed. Results: 21 WB (10 depressed and 11 not depressed) and 19 BC (10 depressed and 9 not depressed) were interviewed. Most people irrespective of ethnicity or depression recognised that there was something wrong with the man with depression. Most did not consider it an illness. Ethnicity but not depression effected the interpretation of the aetiology of the symptoms. A minority thought that consulting the GP would help but some BC specified that it would be inappropriate. BC who had not been depressed thought that spiritual help was appropriate. Both ethnic groups suggested that mental health services were for care, incarceration or dealing with violence. None of those who had been depressed thought that the mental health services were for dealing with violence. Limitations: We interviewed established BC immigrants and our results might not apply to new BC immigrants or other immigrant groups. Descriptions within the vignettes of depression and psychosis were defined by us. Conclusions: Most older people do not view depression as a mental illness. Older people, particularly BC therefore often do not see psychiatric services as appropriate and believe they are primarily for psychosis and violence. These views are amenable to change. Doctors should be explicit that services are for people with depression.

BACKGROUND: Work is important for mental health but we are only just beginning to understand why so few people with psychosis in the UK work.

AIMS: To identify the opinions of a purposive sample of patients with psychosis on themes related to employment.

METHOD: A thematic analysis of 15 semi-structured interviews with people with schizophrenia or bipolar affective disorder.

RESULTS: Participants identified a range of advantages to working but also expressed substantial doubts. Symptoms, medication and potential damage to health are the problems that people believe affect their ability to work. Most people would not tell their employers about their illness because they feared discrimination during the selection process, but believed it could help their chances of retaining a job if employers knew. A number reported a lack of encouragement to work from mental health professionals and not enough helpful employment services.

CONCLUSIONS: Although most people want to work, given the pressures they face some may choose not to. Barriers that people face are both internal and external and these interact.

Quality of life (QOL) is an important outcome for people with schizophrenia, but most previous studies of its correlates have had small sample sizes or explored a limited number of variables. We conducted an analysis of the baseline data from the European Schizophrenia Cohort (EuroSC) study, a naturalistic investigation of people with schizophrenia living in France, Germany, and the United Kingdom (N = 1208). German participants had the highest subjective QOL. Country of residence, depression, accommodation status, and employment were the most important factors in explaining subjective QOL. Many correlates of subjective QOL in people with schizophrenia were similar to those in the general population. Many of the factors important in explaining subjective QOL in people with schizophrenia are not readily amenable to change. Differences in mental health service provision in the United Kingdom and Germany may in part explain variations in the QOL of people with schizophrenia resident there.

BACKGROUND: Negative staff attitudes have been cited as a factor in explaining the low rates of employment in people with psychosis. We aimed to conduct the first systematic survey of staff attitudes in UK community mental health teams.

METHODS: A questionnaire survey of clinicians working in community mental health teams in North London, UK.

RESULTS: Clinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients.

CONCLUSIONS: In this London catchment area, clinicians believed the majority of people with psychosis to be capable of some kind of work, albeit not always open market, but they had few resources available to them to facilitate this. They give priority to the development of place and support vocational services.