Treatment-resistant depression (TRD) is classically defined according to the number of suboptimal antidepressant responses experienced, but multidimensional assessments of TRD are emerging and may confer some advantages. Patient characteristics have been identified as risk factors for TRD but may also be associated with TRD severity. The identification of individuals at risk of severe TRD would support appropriate prioritisation of intensive and specialist treatments.

To determine whether TRD risk factors are associated with TRD severity when assessed multidimensionally using the Maudsley Staging Method (MSM), and univariately as the number of antidepressant non-responses, across three cohorts of individuals with depression.

Three cohorts of individuals without significant TRD, with established TRD and with severe TRD, were assessed (n = 528). Preselected characteristics were included in linear regressions to determine their association with each outcome.

Participants with more severe TRD according to the MSM had a lower age at onset, fewer depressive episodes and more physical comorbidities. These associations were not consistent across cohorts. The number of episodes was associated with the number of antidepressant treatment failures, but the direction of association varied across the cohorts studied.

Several risk factors for TRD were associated with the severity of resistance according to the MSM. Fewer were associated with the raw number of inadequate antidepressant responses. Multidimensional definitions may be more useful for identifying patients at risk of severe TRD. The inconsistency of associations across cohorts has potential implications for the characterisation of TRD.

Brain-derived neurotrophic factor (BDNF), which facilitates neuroplasticity and synaptogenesis, may be decreased in bipolar disorder, but has not been systematically investigated in people with newly diagnosed bipolar disorder and unaffected first-degree relatives.

To compare BDNF levels in patients with newly diagnosed bipolar disorder, their unaffected first-degree relatives and healthy controls.

The study investigated plasma BDNF levels in patients (n = 371) with newly diagnosed bipolar disorder, their unaffected first-degree relatives (n = 98) and healthy controls (n = 200) using enzyme-linked immunosorbent assay. We further investigated associations between BDNF levels and illness-related variables and medication status.

BDNF levels were found to be 22.0% (95% CI 1.107–1.343) higher in patients with bipolar disorder compared with healthy controls (P < 0.001) and 15.6% higher in unaffected first-degree relatives compared with healthy controls (95% CI 1.007–1.327, P = 0.04), when adjusting for age and gender. Further, BDNF levels were positively associated with duration of illness at a trend level (P = 0.05), age (P = 0.001) and use of anti-epileptic medication (P = 0.05).

These findings suggest that BDNF levels are not decreased in the early stages of bipolar disorder and in unaffected first-degree relatives contrasting with prior findings during later stages of the illness.

Healthcare triage for those subject to section 136 powers (MHA 1983/2007) remains challenging. Camden and Islington NHS Foundation Trust opened a dedicated Health-Based Place of Safety (HBPOS) in 2020, situated separately from an emergency department (ED). There was concern that this may lead to physical health problems going unrecognised. We aimed to design a simple, efficient algorithm to be used by non-medically-trained staff to identify those who are subject to s.136 powers who would benefit from medical clearance before being admitted to the HBPOS

We chaired a consensus meeting with nursing staff, police and emergency medicine consultants when designing the algorithm. Case notes of those presenting under s.136 to the POS over 1 calendar-month in 2019 were reviewed, and the proportion of those who the algorithm would have diverted for medical clearance was calculated. We then reviewed the proportion of cases sent for medical clearance during a single calendar month in 2020, after the HBPOS had opened, to see whether there was a significant difference.

37 patients were admitted to the ED-based POS in July 2019, of which 36 records were analysed. 9 patients (25%) were referred for medical clearance, with 2 (6%) requiring medical admission. 8.6% were identified as needing medical clearance when the algorithm was applied retrospectively (positive predictive value 66%, negative predictive value = 79%).

Review of records over 1 calendar-month after the HBPOS was established showed 30.6% of patients had been diverted for medical clearance prior to entering the HBPOS. Of the 65 patients, 1 (2%) required transfer to ED within 48 hours of entry. No statistical difference in the proportion of patients sent for medical clearance was observed since the formation of the HBPOS away from the ED (Chi-squared = 0.549, p = 0.458), suggesting the algorithm successfully identified those patients who needed medical clearance prior to admission.

We observed high rates of intoxication amongst those admitted (30–40%).

The algorithm showed high specificity and negative predictive value, allowing for a degree of confidence when admitting those deemed at low-risk of physical deterioration, though it does not eliminate the need for clinical judgement. Interpretation of the results is complicated by the COVID19 pandemic in 2020, which was not accounted for in the algorithm, which possibly led to deviations from the algorithm in real-world clinical practice.

Antidepressant medication and interpersonal psychotherapy (IPT) are both recommended interventions in depression treatment guidelines based on literature reviews and meta-analyses. However, ‘conventional’ meta-analyses comparing their efficacy are limited by their reliance on reported study-level information and a narrow focus on depression outcome measures assessed at treatment completion. Individual participant data (IPD) meta-analysis, considered the gold standard in evidence synthesis, can improve the quality of the analyses when compared with conventional meta-analysis.

We describe the protocol for a systematic review and IPD meta-analysis comparing the efficacy of antidepressants and IPT for adult acute-phase depression across a range of outcome measures, including depressive symptom severity as well as functioning and well-being, at both post-treatment and follow-up (PROSPERO: CRD42020219891).

We will conduct a systematic literature search in PubMed, PsycINFO, Embase and the Cochrane Library to identify randomised clinical trials comparing antidepressants and IPT in the acute-phase treatment of adults with depression. We will invite the authors of these studies to share the participant-level data of their trials. One-stage IPD meta-analyses will be conducted using mixed-effects models to assess treatment effects at post-treatment and follow-up for all outcome measures that are assessed in at least two studies.

This will be the first IPD meta-analysis examining antidepressants versus IPT efficacy. This study has the potential to enhance our knowledge of depression treatment by comparing the short- and long-term effects of two widely used interventions across a range of outcome measures using state-of-the-art statistical techniques.

Prior research has identified behavioural health outcomes as key sequelae to combat deployment. However, relatively little is known about differential patterns of change in depression or generalised anxiety linked to deployment to a combat zone. In this paper, we add to the existing trajectory literature and examine key predictive factors of behavioural health risk.

The primary aim is to leverage growth mixture modelling to ascertain trajectories of psychological distress, operationalised as a coherent construct combining depression and generalised anxiety, and to identify factors that differentiate adaptive and maladaptive patterns of change.

Data were collected from a brigade combat team prior to a combat deployment to Afghanistan, during deployment, at immediate re-integration and approximately 2–3 months thereafter. The main outcome was measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS).

Three latent trajectories were identified: a low–stable trajectory, a declining trajectory and a rising trajectory. Most individuals aligned with the low–stable trajectory. A conditional model using covariates measured during deployment showed that the low–stable trajectory differed consistently from the remaining trajectories on self-reported loneliness and non-combat deployment stressors.

The examination of differential patterns of adaptation, to identify individuals at higher risk, is critical for the efficient targeting of resources. Our findings further indicate that loneliness may be a useful leverage point for clinical and organisational intervention.

Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas.

This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified).

Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422).

Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%).

This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.

The Netherlands has few financial barriers to access mental healthcare. However, in 2012, a sharp rise in co-payments was introduced.

We tested whether these increased co-payments coincided with less guideline-recommended continuous out-patient psychiatric care and more crisis interventions for patients with bipolar disorder.

A retrospective longitudinal cohort study on a health insurance registry was performed to examine trends, and deviations from these trends, in the healthcare received by patients with bipolar disorder. Deviations of trends were tested by time-series analyses (autoregressive integrated moving average). Subsequently, the relationship between significant deviations of trends and rise in co-payments was examined. Outcome measures were the level of standard out-patient care (out-patient psychiatric care and/or medication), crisis psychiatric care and somatic care.

The cohort comprised 3210 patients. During follow-up, the use of psychiatric care decreased and somatic care increased. The high rise in co-payments from 2012 onward coincided with decreases in standard out-patient care and increases in medication-only treatment, crisis psychiatric care and somatic care. Crisis intervention was highest when patients received only bipolar disorder medication. Patients receiving continuous standard out-patient care (62%) had less crisis intervention compared with the other patients.

Our data suggest that the rise of co-payments decreased guideline-recommended continuous out-patient psychiatric care among patients with bipolar disorder, and increased crisis psychiatric care.

The global rise in mental health issues calls for a strong psychiatry workforce. Yet, psychiatry training worldwide is facing recruitment challenges, causing unfilled consultant posts and possibly threatening the quality of patient care. An in-depth understanding of trainees’ progression through training is warranted to explore what happens to recruited trainees during training.

To uncover current trends in psychiatry trainees’ progression through training in the UK.

This national retrospective cohort study with data from the UK Medical Education Database used discrete-time survival analysis to analyse training progression for those trainees who started their core psychiatry post in 2012–2017 (2820 trainees; 59.6% female, 67.6% UK graduates (UKGs)). The impact of sociodemographic characteristics on training progression were also investigated.

The overall probability of completing training in 6 years (minimum years required to complete psychiatry training in the UK) was 17.2% (ranging from 4.8% for non-UKG females to 29% for UKG males). The probability to not progress was highest (57.1%) from core to specialty training. For UKGs, trainees from ethnicities other than White, trainees with a disability, and trainees who had experienced childhood social deprivation (measured as entitlement to free school meals) had a significantly (P ≤ 0.02) lower probability of completing training in 6 years.

Less than one in five psychiatry trainees are likely to complete training in 6 years and this probability varies across groups of doctors. Completing psychiatry training in 6 years is, therefore, the exception rather than the norm and this has important implications for trainees, those planning psychiatry workforces or responsible for psychiatry training.

We sought to develop a teaching pilot to help year 2 medical students meet the following learning outcomes: Develop a better understanding of patient and carer experiences of mental illness; Recognise and challenge unhelpful attitudes towards people with mental illness; Promote a broader understanding of cultural issues surrounding mental illness, including stigma and discrimination.

337 medical students were invited to attend a lecture by author LQ, a documentary photographer who presented a narrative of his brother Justin's lived experience of schizophrenia (louisquail.com/big-brother-introduction). 197 students attended the session, which was recorded and made available online. Students were invited to enter a competition to win a signed copy of LQ's book, ‘Big Brother’ and asked to submit either a 500-word written reflective piece, or a creative work accompanied by a 200-word statement. 13 submissions were received, including paintings, drawings, collage, photography, and poetry, all of which were blind rated by authors SR and GB, based on originality and quality of reflection. Of the six shortlisted, three winning entries were chosen by author LQ.

All reflections moved away from a technical understanding of schizophrenia, towards person-centred interpretations, with dominant themes of ‘stigma’, ‘disempowerment’, ‘understanding people as individuals’, ‘subjective experience of mental illness’, ‘inclusion’ and ‘healing power of nature’.

The three prize winners (authors GY, AK and KT) used different mediums: GY painted an osprey over a chaotic collage of disordered and stigmatizing words (the osprey representing empowerment and the “reservoir for wellbeing in nature”); AK's sonnet began as an ode to the chaos of Justin's experience, but the concluding lines reframed this struggle, conveying feelings of hope and beauty; and KT's self-portrait, produced with a slow shutter-speed photograph, powerfully conveyed a sense of disorientation and disturbance. She reflected on how the stigma of mental illness affects self-perception. The talk was well-attended, and reflections were of high quality. A limitation of this pilot was that only a small proportion of students completed the reflective assignment.

Innovative teaching strategies are needed to address negative attitudes towards mental illness and psychiatry, which are prevalent amongst the medical profession. This pilot provides a model for combining carer-led, reflective, and creative elements in undergraduate psychiatry teaching, with the aim of challenging stigma. This model will be evaluated in a further study involving fifth year medical students, which will use a validated scale to measure change in students’ attitudes towards mental illness and psychiatry.

Aggressive behaviour is a prevalent and harmful phenomenon in patients with borderline personality disorder (BPD). However, no short-term, low-cost programme exists that specifically focuses on aggression.

Attuning therapy modules to pathogenetic mechanisms that underlie reactive aggression in BPD, we composed a 6 week mechanism-based anti-aggression psychotherapy (MAAP) approach for the group setting, which we tested against a non-specific supportive psychotherapy (NSSP).

A cluster-randomised two-arm parallel-group phase II trial of N = 59 patients with BPD and overt aggressive behaviour was performed (German Registry for Clinical Trials, DRKS00009445). The primary outcome was the externally directed overt aggression score of the Modified Overt Aggression Scale (M-OAS) post-treatment (adjusted for pre-treatment overt aggression). Secondary outcomes were M-OAS irritability, M-OAS response rate and ecological momentary assessment of anger post-treatment and at 6 month follow-up, as well as M-OAS overt aggression score at follow-up.

Although no significant difference in M-OAS overt aggression between treatments was found post-treatment (adjusted difference in mean 3.49 (95% CI −5.32 to 12.31, P = 0.22), the MAAP group showed a clinically relevant decrease in aggressive behaviour of 65% on average (versus 33% in the NSSP group), with particularly strong improvement among those with the highest baseline aggression. Most notably, significant differences in reduction in overt aggression between MAAP and NSSP were found at follow-up.

Patients with BPD and aggressive behaviour benefited from a short group psychotherapy, with improvements particularly visible at 6 month follow-up. Further studies are required to show whether these effects are specific to MAAP.

Self-harm and suicidal behaviour are recognised as public health concerns. Prolonged social withdrawal behaviour, or hikikomori, is reported as a risk factor for suicidal behaviour.

To examine the occurrence and additional risk of prolonged social withdrawal behaviour on self-harm and suicidal behaviour among Chinese university students.

A cross-sectional online survey was conducted with three universities in southern China. A two-stage random sampling was adopted for recruitment, with students in different years of study, in different departments of each participating university. Hierarchical logistic regression analyses were conducted to investigate the sociodemographic and psychological correlates of self-harm and suicidal behaviours among male and female participants with hikikomori status.

Of the students who completed the online survey, 1735 (72.23%) were included in the analysis; 11.5% (n = 200) reported self-harm behaviour and 11.8% (n = 204) reported suicidal behaviours in the past 12 months. Men showed a higher prevalence rate of self-harm than women (14.7% v. 10.8%, P = 0.048), but a similar rate of suicidal behaviours (11.9% v. 11.3%, P = 0.78). The overall prevalence rate of social withdrawal behaviour was 3.2% (7.0% for men and 2.3% for women, P < 0.001). Prolonged social withdrawal behaviour status was significantly associated with self-harm (odds ratio 2.00, 95% CI 1.22–3.29) and suicidal behaviour (odds ratio 2.35, 95% CI 1.45–3.81). However, the associations became statistically insignificant after adjustment for psychological factors in the final models in the logistic regression analyses.

Prolonged social withdrawal behaviour appears to be associated with self-harm and suicidal behaviour, but psychological factors have stronger links with suicidality.

We aimed to investigate the adherence to the Mental Health Act Code of Practice and the adequate documentation of consent to treatment across three forensic low secure inpatient units.

Our sample included all inpatients detained on three forensic wards at The Newsam Centre. This included a total of 31 patients with an age range of 25 to 59 years. The Mental Health Act Code of Practice was used as criteria for audit standards. Data were collected using Microsoft Excel and analysed using descriptive methods.

We found that 28 patients out of 31 had been admitted for over three months and of these patients 12 were subject to a T2 and 16 subject to a T3. A total of 24 patients had their CTT medication list documented on the online drug chart; with a remaining seven patients who did not. As per guidelines, 27 patients had the appropriate medications prescribed as per their CTT, however one patient did not. The audit revealed a total of two patients currently on a Section 62. Of the qualifying T3 forms, four patients had this reviewed every two years whilst there was one patient who had not.

We found that the adherence to Mental Health Act Code of Practice was overall positive with the majority of service users being reviewed appropriately and documented as per guidance. However, areas identified for improvement included the recording of CTT on online drug charts as well as reviewing T3 every two years. This audit highlights the need for easy access to guidance, appropriate documentation as well as frequent checking of adherence. A leaflet has been created outlining the guidelines and will be distributed to all staff working within the forensic settings and placed in easily accessible locations. As further recommendations from this audit we advise all wards to plan weekly checks during team meetings to ensure information is up to date and that all staff are aware of any discrepencies. A re-audit is planned in the coming months to re-assess adherance after implementation of the interventions.

During the first wave of the COVID-19 pandemic, distancing measures were enforced to reduce virus spread, which likely had an impact on the overall mental health of the population.

To investigate the prevalence of mental health outcomes (depression, anxiety and insomnia), and associated risk factors, during a physical distancing period imposed in the first wave of COVID-19.

During the first month of Portugal's state of emergency, an online survey was created and disseminated through social media channels. Sociodemographic and clinical variables were assessed via self-reported questionnaires. Univariate linear regressions were used to identify associations between the collected variables and mental health outcomes. Multivariate regression analyses were performed to identify independent risk factors for clinical outcomes, with adjustment for potential confounders.

We analysed data from 1626 participants: a significant proportion showed depression (30.2%), anxiety (53.1%) and insomnia (36.3%) symptoms. Multivariate regression models showed that being male and working from home were protective for all mental health outcomes analysed, whereas the perception of infection, being under psychiatric care and taking medication were risk factors (P < 0.05). Days in isolation and being unemployed were risk factors for depression and insomnia (P < 0.05). Younger age and being a student were risk factors for depression, whereas being a healthcare professional was protective (P < 0.05). Indirect contact with COVID-19 was a risk factor for anxiety (P < 0.05).

COVID-19-related distancing measures were associated with high levels of adverse mental health symptoms. Several risk factors were associated with these symptoms, which highlight the importance of identifying vulnerable groups during physical distancing periods.

Schizophrenia is a severe and complex psychiatric disorder that needs treatment based on extensive experience. Antipsychotic drugs have already become the cornerstone of the treatment for schizophrenia; however, the therapeutic effect is of significant variability among patients, and only around a third of patients with schizophrenia show good efficacy. Meanwhile, drug-induced metabolic syndrome and other side-effects significantly affect treatment adherence and prognosis. Therefore, strategies for drug selection are desperately needed. In this study, we will perform pharmacogenomics research and set up an individualised preferred treatment prediction model.

We aim to create a standard clinical cohort, with multidimensional index assessment of antipsychotic treatment for patients with schizophrenia.

This trial is designed as a randomised clinical trial comparing treatment with different kinds of antipsychotics. A total sample of 2000 patients with schizophrenia will be recruited from in-patient units from five clinical research centres. Using a computer-generated program, the participants will be randomly assigned to four treatment groups: aripiprazole, olanzapine, quetiapine and risperidone. The primary outcomes will be measured as changes in the Positive and Negative Syndrome Scale of schizophrenia, which reflects the efficacy. Secondary outcomes include the measure of side-effects, such as metabolic syndromes. The efficacy evaluation and side-effects assessment will be performed at baseline, 2 weeks, 6 weeks and 3 months.

This trial will assess the efficacy and side effects of antipsychotics and create a standard clinical cohort with a multi-dimensional index assessment of antipsychotic treatment for schizophrenia patients.

This study aims to set up an individualized preferred treatment prediction model through the genetic analysis of patients using different kinds of antipsychotics.

Satisfaction with the medical interview has been rarely explored in primary care outside the UK, despite evidence suggesting that a trustful doctor–patient relationship is a key ingredient to facilitate treatment adherence and relief from illness-related distress.

The aims of this study are to analyse the construct validity of the Italian version of the Medical Interview Satisfaction Scale (MISS-21) and its correlations with two outcome measures, the Inventory of Depressive Symptomatology – Self-Report and World Health Organization Quality Of Life Brief Version, in patients with mild-to-moderate depression, recruited in primary care practices.

The factor structure underlying the MISS-21 was investigated with principal component analysis, and the internal consistency of the factors was evaluated with Cronbach's alpha. Network analysis was used to investigate the interrelationships among items. The importance of individual items in the network structure was determined with centrality analyses. Correlations of MISS-21 scores with changes in depression and quality of life were analysed with Spearman's correlation coefficient.

The MISS-21 proved to have a robust four-dimensional factor structure. Cronbach's alpha for the factors ranged from 0.77 to 0.93, suggesting good to excellent internal consistency. The four factors identified were positively correlated with improvement in depressive symptoms and three quality-of-life domains.

The MISS-21 has sound psychometric properties, and comprises four factors related to clinical outcomes, which makes it suitable for clinical and research applications. The central items in the network should be considered as possible targets for quality improvement interventions in primary care.

The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety.

This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety.

Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically.

The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally.

The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.

Countries worldwide are experiencing a third wave of the coronavirus disease 2019 (COVID-19) pandemic. Government-imposed restrictive measures continue with undetermined effects on physical and mental health.

To compare child and adolescent mental health services (CAMHS) referrals over 11 months (January–November) in 2020, 2019 and 2018 and examine any impact the different phases of the COVID-19 restrictions might have on referral rates.

Monthly CAMHS Health Service Executive data were examined, covering a catchment population of 260 560 or 12.7% of all youth (age group 0–18 years) in Ireland. The total number of urgent and routine referrals, appointments offered, rates of non-attendances and discharge outcome are presented.

There was a significant drop in referrals in 2020, compared with prior years (χ2 = 10.3, d.f. = 2, P = 0.006). Referrals in 2020 dropped from March to May by 11% and from June to August by 10.3%. From September, both routine and urgent referrals increased by 50% compared with previous years (2018/2019), with the highest increase in November 2020 (180%). Clinic activity also increased from September, with double the number of out-patient appointments offered, compared with previous years (χ2 = 5171.72, d.f. = 3, P < 0.001) and lower (6.6%) rates of non-attendance (χ2 = 868.35, d.f. = 3, P < 0.001).

In 2020, following an initial decline, referrals to CAMHS increased consistently from September. Such unprecedented increase in referrals places further strain on services that are already underresourced and underfunded, with the likelihood of increased waiting lists post COVID-19. It is envisaged that once the pandemic is over, resources will be even more constrained, and CAMHS will be urgently in need of additional ring-fenced funding.