Euthanasia review committees (Regionale Toetsingscommissies Euthanasie, RTE) scrutinise all Dutch cases of euthanasia and physician-assisted suicide (EAS) to review whether six legal ‘due care’ criteria are met, including ‘unbearable suffering without prospect of improvement’. There are significant complexities and ethical dilemmas if EAS requests are made by people with intellectual disabilities or autism spectrum disorders (ASD).

To describe the characteristics and circumstances of people with intellectual disabilities and/or ASD who were granted their EAS request; investigate the main causes of suffering that led to the EAS request; and examine physicians’ response to the request.

The online RTE database of 927 EAS case reports (2012–2021) was searched for patients with intellectual disabilities and/or ASD (n = 39). Inductive thematic content analysis was performed on these case reports, using the framework method.

Factors directly associated with intellectual disability and/or ASD were the sole cause of suffering described in 21% of cases and a major contributing factor in a further 42% of cases. Reasons for the EAS request included social isolation and loneliness (77%), lack of resilience or coping strategies (56%), lack of flexibility (rigid thinking or difficulty adapting to change) (44%) and oversensitivity to stimuli (26%). In one-third of cases, physicians noted there was ‘no prospect of improvement’ as ASD and intellectual disability are not treatable.

Examination of societal support for suffering associated with lifelong disability, and debates around the acceptability of these factors as reasons for granting EAS, are of international importance.

There is increasing evidence that assessing outcomes in terms of capability provides information beyond that of health-related quality of life (HRQoL) for outcome evaluation in mental health research and clinical practice.

To assess similarities and differences in the measurement properties of the ICECAP-A capability measure and Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) in people with schizophrenia experiencing depression, and compare these measurement properties with those of (a) the EuroQol EQ-5D-5L and EuroQol Visual Analogue Scale (EQ-VAS) and (b) mental health-specific (disease-specific) measures.

Using data for 100 patients from the UK, measurement properties were compared using correlation analyses, Bland–Altman plots and exploratory factor analysis. Responsiveness was assessed by defining groups who worsened, improved or remained unchanged, based on whether there was a clinically meaningful change in the instrument scores between baseline and 9-month follow-up assessments.

The two capability instruments had stronger convergent validity with each other (Spearman's rho = 0.677) than with the HRQoL (rho = 0.354–0.431) or the mental health-specific (rho = 0.481–0.718) instruments. The OxCAP-MH tended to have stronger correlations with mental health-specific instruments than the ICECAP-A, whereas the ICECAP-A had slightly stronger correlation with the EQ-VAS. Change scores on the capability instruments correlated weakly with change scores on the HRQoL scales (rho = 0.131–0.269), but moderately with those on mental health-specific instruments for the ICECAP-A (rho = 0.355–0.451) and moderately/strongly on the OxCAP-MH (rho = 0.437–0.557).

Assessing outcomes in terms of capabilities for people with schizophrenia and depression provided more relevant, mental health-specific information than the EQ-5D-5L or the EQ-VAS. The ICECAP-A and the OxCAP-MH demonstrated similar psychometric properties, but the OxCAP-MH was more correlated with disease-specific instruments.

Prevalence of self-harm in the UK was reported as 6.4% in 2014. Despite sparse evidence for effectiveness, guidelines recommend harm minimisation; a strategy in which people who self-harm are supported to do so safely.

To determine the prevalence, sociodemographic and clinical characteristics of those who self-harm and practise harm minimisation within a London mental health trust.

We included electronic health records for patients treated by South London and Maudsley NHS Trust. Using an iterative search strategy, we identified patients who practise harm minimisation, then classified the approaches using a content analysis. We compared the sociodemographic characteristics with that of a control group of patients who self-harm and do not use harm minimisation.

In total 22 736 patients reported self-harm, of these 693 (3%) had records reporting the use of harm-minimisation techniques. We coded the approaches into categories: (a) ‘substitution’ (>50% of those using harm minimisation), such as using rubber bands or using ice; (b) ‘simulation’ (9%) such as using red pens; (c) ‘defer or avoid’ (7%) such as an alternative self-injury location; (d) ‘damage limitation’ (9%) such as using antiseptic techniques; the remainder were unclassifiable (24%). The majority of people using harm minimisation described it as helpful (>90%). Those practising harm minimisation were younger, female, of White ethnicity, had previous admissions and were less likely to have self-harmed with suicidal intent.

A small minority of patients who self-harm report using harm minimisation, primarily substitution techniques, and the large majority find harm minimisation helpful. More research is required to determine the acceptability and effectiveness of harm-minimisation techniques and update national clinical guidelines.

Electronic health records (EHRs) are a significant contributor to physicians’ low satisfaction, reduced engagement and increased burnout. Yet the majority of evidence around EHR and physician harms is based on self-reported screen time, which may both over- and underreport actual exposure.

The purpose of this study was to examine how objective EHR use correlates with physician well-being and to develop preliminary recommendations for well-being-based EHR interventions.

Prior to the onset of COVID-19, psychiatry residents and attending physicians working in an out-patient clinic at an academic medical centre provided consent for access to EHR-usage logs and completed a well-being assessment made up of three scales: the Maslach Burnout Inventory, the Urecht Work Engagement Scale and the Professional Quality of Life Measure. Survey responses and objective EHR data were analysed with descriptive statistics.

Responses were obtained from 20 psychiatry residents (total eligible residents n = 27; 74% participation) and 16 clinical faculty members (total eligible faculty n = 24; 67% participation) with an overall response rate of 71% (total eligible residents and faculty n = 51 and total residents and faculty who completed survey n = 36). Moderate correlations for multiple well-being domains emerged in analysis for all participants, especially around the time spent per note and patient visits closed the same day.

EHR-usage logs represent an objective tool in the evaluation and enhancement of physician well-being. Results from our pilot study suggest that metrics for note writing efficiency and closing patient visits the same day are associated with physician well-being. These metrics will be important to study in ongoing efforts involving well-being-based EHR interventions.

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a generic measure of functional impairment and disability but to date no studies have reported its applicability in a population of Syrian refugees.

The aim of this study was to explore the psychometric properties and factor structure of the Arabic version of the WHODAS 2.0 among a population of Syrian refugees in a Jordanian refugee camp setting. The tool was used as part of a screening procedure for a randomised controlled trial assessing the effectiveness of a low-intensity psychological intervention.

A representative sample of Syrian refugees (n = 650) were screened to assess levels of functional impairment and psychological distress. The screening results were used to explore the internal consistency and dimensionality of the WHODAS 2.0. We assessed level of convergence with the validated Kessler 10-item Psychological Distress Scale (K10), which assesses psychological distress. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to explore the construct validity and factor structure of the WHODAS 2.0.

The mean baseline WHODAS 2.0 score was 20.5 (s.d. = 7.6). The internal consistency was acceptable (Cronbach's alpha 0.74), with all 12-items appearing to be related to the same construct. The WHODAS 2.0 was positively correlated with the K10 (r = 0.57, P < 0.001). The results of the EFA identified a three-factor solution accounting for 51% of variation, corresponding with factors related to self-activities, external activities and self-care. CFA results indicated good fit of the three-factor solution.

The results indicated that the WHODAS 2.0 has a three-factor solution and is an acceptable screening tool for use among Syrian refugees.

Whether there are distinct subtypes of schizophrenia is an important issue to advance understanding and treatment of schizophrenia.

To understand and treat individuals with schizophrenia, the aim was to advance understanding of differences between individuals, whether there are discrete subtypes, and how fist-episode patients (FEP) may differ from multiple episode patients (MEP).

These issues were analysed in 687 FEP and 1880 MEP with schizophrenia using the Positive and Negative Syndrome Scale for (PANSS) schizophrenia before and after antipsychotic medication for 6 weeks.

The seven Negative Symptoms were correlated with each other and with P2 (conceptual disorganisation), G13 (disturbance of volition), and G7 (motor retardation). The main difference between individuals was in the cluster of seven negative symptoms, which had a continuous unimodal distribution. Medication decreased the PANSS scores for all the symptoms, which were similar in the FEP and MEP groups.

The negative symptoms are a major source of individual differences, and there are potential implications for treatment.

Health anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable.

To investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive–behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036).

A multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6–12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome.

This trial will be the first to test the clinical outcomes and cost-effectiveness of remotely delivered CBT for the treatment of high health anxiety.

The findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care.

The World Psychiatric Association recently emphasised that the protection of human rights in mental healthcare was a ‘central concern’. This paper examines recent literature on human rights and mental healthcare.

To (a) outline how international human rights law distinguishes between the protection and promotion of human rights; and (b) explore the literature on promoting human rights in mental healthcare which avoids what has been termed the ‘Geneva impasse’ between those who argue that compulsory care and treatment can never comply with human rights law and those who argue that they can if certain conditions are met.

The following doctrinal methodology was used: (a) identification and detailed analysis of international human rights conventions and commentaries; (b) identification of key literature on human rights and mental healthcare; and (c) critical analysis of key issues emerging from the literature.

Much of the literature on human rights and mental healthcare focuses on whether restrictions on compulsory care are required to meet the requirements of United Nations Conventions. There is an emerging literature identifying measures to promote the right to the enjoyment of the highest attainable standard of mental health.

There has been a focus on protecting the rights to liberty and equality before the law for mental health patients. The nascent literature on promoting human rights in mental healthcare could mark a way forward beyond the ‘Geneva impasse’ that has dominated public debate in recent years.

Depressive disorders are common mental health problems during adolescence. Many adolescents with depression describe difficulties with sleeping. Findings of previous studies regarding changes in objective sleep quality in adolescents with depressive disorders are heterogeneous.

This study aims to investigate differences in objective and subjective sleep quality between adolescents with depressive disorders and healthy peers, and to evaluate if potential changes in sleep occur concurrently with changes in the release of cortisol and alpha-amylase after awakening.

This non-interventional parallel study examines correlations between depressive disorders, sleep quality and release of stress hormones. Sleep quality in the past 2 weeks, severity of depressive symptoms, psychiatric comorbidities and stress response of 30 adolescents with depressive disorders and 30 healthy controls (N = 60) are assessed via questionnaires. In participants’ home environments, the objective sleep quality of seven consecutive nights is measured by sleep accelerometry. After awakening, participants answer sleep questionnaires to examine the subjective sleep quality of those nights. Furthermore, salivary cortisol and alpha-amylase are measured three times after awakening (+0 min, +30 min and +45 min after awakening).

Sleep is an important factor for prognosis and well-being in adolescents with depression. The results of this study can be highly valuable to integrate a more detailed examination of sleep quality and sleeping impairments in the treatment of adolescent depressive disorders.

The number of mental health-related 999 calls to emergency services has increased in recent years. However, emergency services staff have an unfavourable reputation when it comes to supporting people experiencing mental health problems.

To assess the levels of explicit and implicit mental health stigma among accident and emergency, ambulance and police staff, and draw comparisons with the general population. Additional analyses sought to identify which variables predict mental health stigma among emergency services staff.

A cross-sectional survey of 1837 participants, comprising four independent groups (accident and emergency, ambulance and police staff, and the general population).

Levels of mental health stigma across all four groups were lower than those reported in recent surveys of the general population by the ‘Time to Change’ campaign. Within this study, explicit levels of mental health stigma were lower among the general population compared with emergency services staff. There was no difference between emergency service professions, nor were there any between-group differences in terms of implicit mental health stigma. The only consistent predictors of mental health stigma were attitudes and future behavioural intentions, whereby increased stigma was predicted by increased fear, reduced sympathy and greater intended discrimination.

Our findings suggest that levels of mental health stigma have improved over time, but there is room for improvement in emergency services staff. Interventions to improve mental health stigma may be most effective if, in line with the cognitive–behavioural model of stigma, they target attitudes and behavioural intentions.

Individuals with personality disorders often have extensive involvement with healthcare services including frequent utilisation of emergency departments.

The aim of this study was to identify factors associated with emergency department presentations by individuals with personality disorders.

A 12-month retrospective data analysis of all mental-health-related emergency department visits was performed. Age, gender, time and season of presentation, length of stay, mode of arrival and discharge arrangements for individuals with personality disorders were compared to individuals with other psychiatric diagnoses.

There were 336 visits by individuals with personality disorders and 5290 visits by individuals with other psychiatric diagnoses.

Individuals with personality disorders were significantly more likely to be female, young adults, brought in by police, arrive in the evening, discharged home and have a longer median length of stay.

Knowing what factors are associated with emergency department presentations by individuals with personality disorders can help ensure that appropriately trained support staff are available.

For people in mental health crisis, acute day units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to crisis resolution teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly compared with those receiving CRT care alone.

We aimed to investigate readmission rates, satisfaction and well-being outcomes for people using ADUs and CRTs.

We conducted a cohort study comparing readmission to acute mental healthcare during a 6-month period for ADU and CRT participants. Secondary outcomes included satisfaction (Client Satisfaction Questionnaire), well-being (Short Warwick–Edinburgh Mental Well-being Scale) and depression (Center for Epidemiologic Studies Depression Scale).

We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312, 42%) across four National Health Service trusts/health regions. There was no statistically significant overall difference in readmissions: 21% of ADU participants and 23% of CRT participants were readmitted over 6 months (adjusted hazard ratio 0.78, 95% CI 0.54–1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4–3.5, P < 0.001) and well-being scores (1.3, 95% CI 0.4–2.1, P = 0.004), and lower depression scores (−1.7, 95% CI −2.7 to −0.8, P < 0.001), than CRT participants.

Patients who accessed ADUs demonstrated better outcomes for satisfaction, well-being and depression, and no significant differences in risk of readmission, compared with those who only used CRTs. Given the positive outcomes for patients, and the fact that ADUs are inconsistently provided in the National Health Service, their value and place in the acute care pathway needs further consideration and research.

There is cumulative evidence of the importance of exploring the change of dynamics between symptoms over time as reflective of consolidation of psychopathology.

To explore the interactions between symptoms of ICD-11 adjustment disorder before and after the second lockdown of the COVID-19 pandemic in Israel and identify the most central symptoms and their concurrent and prospective associations with probable adjustment disorder.

This is a population-based study drawn from a probability-based internet panel. A representative sample of the adult Israeli population was assessed at two time points (T1, pre-second lockdown, n = 1029, response rate 76.17%; T2, post-second lockdown, n = 764, response rate 74.24%). Symptoms of adjustment disorder were assessed by the International Adjustment Disorder Questionnaire (IADQ).

Although the overall strength of associations at the two measurement points was similar and two same communities were found, there was a significant change in their structure, with a more consolidated network at T2. The most central item was ‘difficult to relax’ in both networks. Cross-sectionally, all symptoms of failure to adapt significantly predicted adjustment disorder. ‘Worry a lot more’ (preoccupation) and ‘difficult to adapt to life’ (failure to adapt) at T1 significantly predicted this diagnosis at T2.

Adjustment disorder symptoms consolidated during the second lockdown of the pandemic. In line with the ICD-11 conceptualisation of adjustment disorder, both preoccupation and failure-to-adapt symptoms have prognostic validity. This highlights the importance of identifying and targeting adjustment disorder symptoms during a period of stress such as the COVID-19 pandemic.

There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal.

To systematically assess the occurrence of voice content regarding appearance and identify correlates.

Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being.

Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was ‘the voices tell me that I am ugly’ (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was ‘I look as nice as other people’ (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia.

Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect – and subsequently reinforce – negative beliefs about one's appearance, low self-esteem, worry and paranoia.

None.

The Japanese Government programme ‘General Principles of Suicide Prevention Policy' (GPSPP) contributed to decreasing suicide mortality rates (SMRs) before the COVID-19 pandemic, but they increased after the pandemic.

To identify risk factors for youth suicide and the impact of GPSPP on youth suicide.

Annual suicide numbers during 2007–2022 were obtained from government databases. SMRs of student and non-student youths were analysed with a linear mixed-effects model. Interrupted time-series analysis was conducted to investigate temporal relations between three GPSPP periods and SMRs with 52 suicide motives among high school, special vocational school and university students. Multiple regression analysis was conducted to investigate the influence of grade repetition on university student SMRs.

Non-student youth SMRs were higher than student SMRs. School-related (worrying about the future/underachievement), health-related (mainly mental illness) and family-related (conflict with parent and severe verbal reprimands) motives were major motives for student SMRs. During the first GPSPP period (2007–2012), no student SMRs decreased. During the second period (2012–2017), university and special vocational school student SMRs increased, but high school student SMRs were unchanged. In contrast, during the third period (2017–2022), with the exception of male special vocational school students, all SMRs increased. Unexpectedly, long-term grade repetition was negatively associated with health-related SMRs.

These findings suggest that GPSPP-supported programmes in schools partially contributed to student suicide prevention. To suppress increasing student SMRs, social/life support specialists should participate in in-school support services to bolster the social standing and lives of students who repeat grades or experience setbacks.

Post-traumatic stress disorder (PTSD) carries a high disease burden worldwide, yet significant barriers exist to providing and accessing treatment for PTSD, particularly in refugee populations and in low- and middle-income countries. There is emerging evidence that self-administered psychological therapies, such as those accessed via online and mobile applications, are efficacious for many mental illnesses and increase access to treatment. Online and mobile applications offering self-help tools for eye movement desensitisation reprocessing (EMDR) therapy, an internationally recommended treatment for PTSD, are already widely distributed to the public.

To present a commentary evaluating the potential benefits and risks of self-administered EMDR therapy: first, by conducting a search for existing peer-reviewed evidence relating to self-administered EMDR therapy; second, by presenting existing evidence for other self-help psychotherapies and evaluating what additional insight this could provide into the potential efficacy, safety, tolerability and accessibility of self-administered EMDR therapy; and, third, by describing the conflicting views of EMDR experts on the topic.

A search was conducted for articles related to internet, mobile, book or computerised self-help EMDR therapy. The following databases were searched systematically: Medline, PsycInfo, EMBASE, AMED, CINAHL, Psychology and Behavioural Sciences, Cochrane Database and the EMDR Library.

Only one small primary research study was found relating to self-administered EMDR therapy. The results indicated significantly reduced symptoms of PTSD, depression, anxiety, distress and disability between pre-treatment and 3 month follow-up. No serious adverse events were reported. However, substantial methodological issues were discovered.

There is evidence that self-administered psychotherapies, in general, can be safe, effective and highly accessible. However, controversies persist regarding the safety and potential efficacy of self-administered EMDR therapy, and more robust research is needed. It is vital that methods are found to improve worldwide access to effective PTSD treatment, particularly given the current scale of migration to flee civil unrest.

In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs).

The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs.

This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform.

CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform.

The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04–1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94–2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32–1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41–3.57, P < 0.001).

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Efficacy of inhaled loxapine 5 or 10 mg in treating agitation was shown using the Positive and Negative Syndrome Scale – Excited Component (PANSS-EC) in two Phase III randomised, double-blind, placebo-controlled trials in 344 agitated patients with schizophrenia and 314 patients with bipolar I disorder (Clinicaltrials.gov: NCT00628589, NCT00721955).

To examine the five individual items comprising the PANSS-EC and the percentage of patients achieving a clinical response (reduction of ≥40%) in PANSS-EC (Response-40) for these two studies.

Response-40 was examined at the primary end-point (2 h) and over time.

Response-40 and each PANSS-EC item score were statistically significant v. placebo at 2 h and at each assessment time point for both doses.

Inhaled loxapine produced rapid improvement in agitated patients with schizophrenia or bipolar I disorder, achieving Response-40 at the first assessment (10 min post dose). These results highlight the effectiveness of loxapine across all components of agitation as measured by the PANSS-EC.