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Abstract Antidepressant response in adolescents As evidence accrues of the efficacy of fluoxetine in treating depression in adolescents, US investigators report the impact of drug therapy with or without cognitive behavioural therapy (CBT) for continuation and maintenance treatment (Arch Gen Psychiatry 2008 65:44755). Originally, 439 adolescents aged 12–17 years were randomised in a trial of 12 weeks' treatment with fluoxetine, CBT, combination therapy or placebo. For this study, those who had initially received placebo were excluded and, of the 327 initially assigned to active treatment, 270 completed the 12week trial. Of this group, 242 continued their assigned treatment for a further six weeks before an additional 18 weeks' maintenance treatment with CBT and/or fluoxetine. Over the first 12 weeks, response rates were 42 per cent with CBT, 68 per cent with fluoxetine and 71 per cent with combined treatment. Eighty‐two per cent of those with an initial response continued and maintained their response for 36 weeks; success rates were 97 per cent (CBT), 74 per cent (fluoxetine) and 88 per cent (combination). Of those who did not attain a response initially, 62–80 per cent did so by week 36 with no significant differences between treatments. The authors conclude that most adolescents will achieve a sustained response eventually and highlight the finding that CBT may help others to maintain their early response. Drug treatment and pregnancy Three studies have reported new findings on the safety of psychotropic drugs during pregnancy. Canadian epidemiologists describe a case‐control study to explore the effects of duration of antidepressant therapy during the first trimester (Br J Psychiatry 2008;192:344–50). They identified 2329 women who had been pregnant between 1998 and 2002 with a psychiatric disorder who were prescribed an antidepressant for at least 30 days in the year before pregnancy; 189 infants (8 per cent) were born with a major malformation. Paroxetine (36 per cent, sertraline (15 per cent) and venlafaxine (13 per cent) were the most frequently prescribed antidepressants in the first trimester. Compared with controls, antidepressant use during the first trimester was not associated with a higher risk of malformations and longer duration of treatment (more than 60 days) did not increase the risk. A second observational study from Canada examined the effect of timing and duration of treatment with SSRIs during pregnancy (Br J Psychiatry 2008;192:383–43). A total of 1575 women treated during early (<185 days) pregnancy and 1925 treated in late pregnancy were identified by record linkage. After adjusting for duration of exposure and maternal illness, outcomes did not differ significantly between early and late exposure. However, increased duration of exposure (after adjusting for maternal illness severity and regardless of the timing of exposure) was associated with increased risks of reduced gestational age, lower birth weight, low weight for gestational age and respiratory distress. The third study, this time from the National Teratology Service in Newcastle upon Tyne, compared outcomes in 45 full‐term infants exposed to typical antipsychotics during pregnancy and 25 exposed to atypical antipsychotics with 38 non‐exposed infants (Br J Psychiatry 2008;192:333–7). Exposure to a typical antipsychotic was associated with significantly shorter median gestational age (273 vs 280 days) among boys and lower mean birth weight among girls. By contrast, atypical antipsychotics were associated with a higher incidence of children large for gestational age (20 per cent vs 2 per cent with typical agents and 3 per cent in controls). The authors suggest that the risk of weight gain with atypicals may also apply to infants exposed in utero, but further study is needed. More on memantine Two pooled analyses of trials involving patients with moderate to severe Alzheimer's disease cover similar territory. An analysis of six trials involved a total of 1826 patients (MMSE <20, mean 12) randomised to placebo or memantine 20mg per day (Int J Geriatr Psychiatry 2008;23:537–45); in two of these trials, memantine was added to established anticholinesterase therapy. After 24 or 28 weeks, memantine was associated with superior total Neuropsychiatric Inventory score and significant improvements in individual scores for delusions, agitation/aggression and irritability/lability. Memantine also improved specific symptoms among patients who were symptomatic at baseline, though the absolute differences were modest, and reduced the emergence of symptoms among asymptomatic patients. The most consistent improvement occurred with agitation/aggression. The second analysis (J Clin Psychiatry 2008;69:341–8) was of three trials included in the first. This subgroup had lower mean MMSE score (nine) and included one trial in which memantine was added to donepezil therapy. This analysis also found a significantly higher rate of improvement in a cluster of symptoms (agitation/ aggression, delusions and hallucinations) with memantine (58 vs 45 per cent with placebo at six months). This study showed a greater rate of decline among patients with behavioural disturbances compared with others with Alzheimer's disease and a lower rate of emergence of new behavioural symptoms with memantine compared with placebo (24 vs 37 per cent). A study from Finland has compared memantine with escitalopram in the treatment of depression associated with alcohol dependence (J Clin Psychiatry 2008;69:392–9). Eighty people attending a treatment clinic were randomised to either drug (at a dosage of 20mg daily); just over 40 per cent were currently drinking and 40 per cent reported abstinence for one to three months. The rest had been abstinent for up to one year. About three‐quarters of participants completed the trial; after six months, baseline scores of anxiety and depression decreased in both groups with no significant differences between them. Quality of life outcomes improved equally in both groups, and cognitive function scores were unchanged. Olanzapine not effective for pathological gambling Drugs that have been evaluated as treatments for pathological gambling include the SSRIs, opiate antagonists and lithium. Citing possible links between this disorder and bipolar disorder and dopaminergic dysfunction, US psychiatrists now report a trial of olanzapine (J Clin Psychiatry 2008;69:433–40). They randomised 42 people meeting DSM‐IV criteria for pathological gambling to placebo or olanzapine 2.5–15mg daily (mean final dose 5mg daily). Over half of those assigned to olanzapine and over a quarter taking placebo did not complete the trial. After 12 weeks there was no difference in scores of gambling behaviour or response rates among the remaining 25 participants. Patient beliefs and prescribing The GMC says doctors should take into account patients' beliefs when providing information about treatment, so that patients can make decisions that are truly informed. This is relevant to prescribing medicines that contain animal products such as beef or pork gelatine or stearic acid. A survey of psychiatrists' in parts of Yorkshire with diverse ethnic communities suggests that many take little account of faith when considering treatment (Psychiatric Bull 2008;32:179–82). Only 40 per cent of the 95 surveys posted were returned. Most respondents were from non‐white ethnic groups (68 per cent) and trained overseas (58 per cent); over a third were consultants. Although 71 per cent said they were aware that some medicines contained animal products only 53 per cent believed it was necessary to discuss this with patients. About 80 per cent did not know that selected psychotropic drugs contain animal products and did not inform patients of the possibility. Encouragingly, 75 per cent who had not discussed this information in the past said they would now do so, though half said they would wait for the patient to raise the question – many believing that compliance would be adversely affected. Long‐term intervention improves prescribing It can be difficult to improve the quality of prescribing and to sustain any gains over time but, say researchers in the Republic of Ireland, repeated intervention makes a difference (Psychiatric Bull 2008;32:183–6). They identified six indicators (polypharmacy, use of thioridazine, high‐dose antipsychotics, maintenance use of a benzodiazepine or hypnotic, and routine use of anticholinergic agents) and assigned a score of one point to each indicator identified per patient. The scores were audited to produce an assessment of prescribing practice quality (PPQ). The authors previously reported that providing a programme of education, clear guidelines and non‐pharmacological therapies had successfully reduced PPQ scores after one and two years. Five years later, they report that a continued emphasis on prescribing protocols and education during each new doctor's induction, combined with annual audit

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