Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10–24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA.

To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania.

In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes.

Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context.

Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

The approach taken to support individuals during the coronavirus disease 2019 (COVID-19) pandemic needs to take into account the requirements of people with intellectual disabilities and/or autism, who represent a major vulnerable group, with higher rates of co-occurring health conditions and a greater risk of dying prematurely. To date, little evidence on COVID-related concerns have been produced and no report has provided structured feedback from the point of view of people with intellectual disabilities and/or autism or of their family/carers.

To provide systemised evidence-based information of the priority concerns for people with intellectual disabilities and/or autism regarding the COVID-19 pandemic.

Senior representatives of major UK-based professional and service-user representative organisations with a stake in the care of people with intellectual disabilities and/or autism were contacted to provide a list of concerns across three domains: ‘mental health and challenging behaviour’, ‘physical health and epilepsy’ and ‘social circumstances and support’. The feedback was developed into statements on frequently reported priorities. These statements were then rated independently by expert clinicians. A video-conference meeting to reconcile outliers and to generate a consensus statement list was held.

Thirty-two organisations were contacted, of which 26 (81%) replied. From the respondent's data, 30 draft consensus statements were generated. Following expert clinician review, there was initially strong consensus for seven statements (23%), increasing to 27 statements (90%) following video conferencing.

These recommendations highlight the expectations of people with intellectual disabilities and/or autism in the current pandemic. This could support policymakers and professionals’ deliver and evidence person-centred care.

People with substance use disorders have a well-known increased risk for taking their own life. Previous research has mainly focused on suicide in mental health services, whereas there is limited knowledge regarding suicide after contact with substance misuse services.

The aim of the current study was to describe the utilisation of both mental health services and substance misuse services among people who have died by suicide within a year of contact with substance misuse services.

We used an explanatory observational design, where all suicide deaths in the period from 2009 to 2016 were retrieved from the Norwegian Cause of Death Registry and linked with the Norwegian Patient Registry. The people who had been in contact with substance misuse services within a year before their death were included in the sample (n = 419). The analysis was stratified by gender, and variables with significant differences between men and women were entered into a multivariate logistic regression model.

More women (73.5%) than men (60.6%) had contact with mental health services in their last year (P = 0.01). In the adjusted logistic regression model, poisoning was more common among women (adjusted odds ratio (AOR) = 1.81, 95% CI 1.09–3.02) and women were more likely to be diagnosed with a sedative, hypnotic or anxiolytic use disorder (F14) in their last year (AOR = 2.77, 95% CI 1.37–5.68).

This study highlights gender differences for suicide in substance misuse services, and the importance of collaboration and cooperation between substance misuse services and mental health services.

Although there is growing interest in mental health problems in university students there is limited understanding of the scope of need and determinants to inform intervention efforts.

To longitudinally examine the extent and persistence of mental health symptoms and the importance of psychosocial and lifestyle factors for student mental health and academic outcomes.

Undergraduates at a Canadian university were invited to complete electronic surveys at entry and completion of their first year. The baseline survey measured important distal and proximal risk factors and the follow-up assessed mental health and well-being. Surveys were linked to academic grades. Multivariable models of risk factors and mental health and academic outcomes were fit and adjusted for confounders.

In 1530 students surveyed at entry to university 28% and 33% screened positive for clinically significant depressive and anxiety symptoms respectively, which increased to 36% and 39% at the completion of first year. Over the academic year, 14% of students reported suicidal thoughts and 1.6% suicide attempts. Moreover, there was persistence and overlap in these mental health outcomes. Modifiable psychosocial and lifestyle factors at entry were associated with positive screens for mental health outcomes at completion of first year, while anxiety and depressive symptoms were associated with lower grades and university well-being.

Clinically significant mental health symptoms are common and persistent among first-year university students and have a negative impact on academic performance and well-being. A comprehensive mental health strategy that includes a whole university approach to prevention and targeted early-intervention measures and associated research is justified.

Early identification of patients with mental health problems in need of highly specialised care could enhance the timely provision of appropriate care and improve the clinical and cost-effectiveness of treatment strategies. Recent research on the development and psychometric evaluation of diagnosis-specific decision-support algorithms suggested that the treatment allocation of patients to highly specialised mental healthcare settings may be guided by a core set of transdiagnostic patient factors.

To develop and psychometrically evaluate a transdiagnostic decision tool to facilitate the uniform assessment of highly specialised mental healthcare need in heterogeneous patient groups.

The Transdiagnostic Decision Tool was developed based on an analysis of transdiagnostic items of earlier developed diagnosis-specific decision tools. The Transdiagnostic Decision Tool was psychometrically evaluated in 505 patients with a somatic symptom disorder or post-traumatic stress disorder. Feasibility, interrater reliability, convergent validity and criterion validity were assessed. In order to evaluate convergent validity, the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the ICEpop CAPability measure for Adults (ICECAP-A) were administered.

The six-item clinician-administered Transdiagnostic Decision Tool demonstrated excellent feasibility and acceptable interrater reliability. Spearman's rank correlations between the Transdiagnostic Decision Tool and ICECAP-A (−0.335), EQ-5D-5L index (−0.386) and EQ-5D-visual analogue scale (−0.348) supported convergent validity. The area under the curve was 0.81 and a cut-off value of ≥3 was found to represent the optimal cut-off value.

The Transdiagnostic Decision Tool demonstrated solid psychometric properties and showed promise as a measure for the early detection of patients in need of highly specialised mental healthcare.

The number of refugees is at its highest since the Second World War and on the rise. Many refugees suffer from anxiety, depression and post-traumatic stress disorder (PTSD), but exact and up-to-date prevalence estimates are not available.

To report the pooled prevalence of anxiety and mood disorders and PTSD in general refugee populations residing in high-income countries and to detect sources of heterogeneity therein.

Systematic review with meta-analyses and meta-regression.

Systematic searches (final search date 3 August 2019) yielded 66 eligible publications that reported 150 prevalence estimates (total sample N = 14 882). Prevalence rates were 13 and 42% (95% CI 8–52%) for diagnosed and self-reported anxiety, 30 and 40% (95% CI 23–48%) for diagnosed and self-reported depression, and 29 and 37% (95% CI 22–45%) for diagnosed and self-reported PTSD. These estimates are substantially higher relative to those reported in non-refugee populations over the globe and to populations living in conflict or war settings, both for child/adolescent and adult refugees. Estimates were similar over different home and resettlement areas and independent of length of residence.

Our data indicate a challenging and persisting disease burden in refugees due to anxiety, mood disorders and PTSD. Knowing this is relevant for the development of public health policies of host countries. Scalable interventions, tailored for refugees, should become more readily available.

Training based on the Mental Health Gap Action Programme (mhGAP) is being increasingly adopted by countries to enhance non-specialists’ mental health capacities. However, the influence of these enhanced capacities on referral rates to specialised mental health services remains unknown.

We rely on findings from a longitudinal pilot trial to assess the influence of mental health knowledge, attitudes and self-efficacy on self-reported referrals from primary to specialised mental health services before, immediately after and 18 months after primary care physicians (PCPs) participated in an mhGAP-based training in the Greater Tunis area of Tunisia.

Participants included PCPs who completed questionnaires before (n = 112), immediately after (n = 88) and 18 months after (n = 59) training. Multivariable analyses with linear mixed models accounting for the correlation among participants were performed with the SAS version 9.4 PROC MIXED procedure. The significance level was α < 0.05.

Data show a significant interaction between time and mental health attitudes on referrals to specialised mental health services per week. Higher scores on the attitude scale were associated with more referrals to specialised services before and 18 months after training, compared with immediately after training.

Findings indicate that, in parallel to mental health training, considering structural/organisational supports to bring about a sustainable change in the influence of PCPs’ mental health attitudes on referrals is important. Our results will inform the scale-up of an initiative to further integrate mental health into primary care settings across Tunisia, and potentially other countries with similar profiles interested in further developing task-sharing initiatives.

The apolipoprotein E ε4 allele (APOE*ε4) is indicated as a risk for Alzheimer's disease and other age-related diseases. The risk attributable to APOE*ε4 for depression is less clear and may be because of confounding of the relationship between dementia and depression.

We examined the risk of APOE* ε4 for incident depression and depressive symptomology over a 12-year period across the adult lifespan.

Participants were from the Personality and Total Health Through Life study, aged 20 to 24 (n = 1420), 40 to 44 (n = 1592) or 60–64 (n = 1768) at baseline, and interviewed every 4 years since 1999. Ethnicities other than White, those without genotyping and those with depression at baseline, or who reported strokes and scores on the Mini-Mental State Examination <27 at any observation, were excluded.

Over the study period, there was no evidence that APOE*ε4+ was a risk factor for depression, including any depression (odds ratio (OR) = 0.94, 95% CI 0.77–1.16, P = 0.573), major depression (OR = 0.96, 95% CI 0.60–1.53, P = 0.860), minor depression (OR = 0.94, 95% CI 0.67–1.30, P = 0.695) or depressive symptomology (incidence rate ratio (IRR) = 1.02, 95% CI 0.97–1.08, P = 0.451). APOE*ε4 was unrelated to incident depression. Findings were consistent for all age cohorts.

Among cognitively intact Australian adults who were free of depression at baseline, there was little evidence that APOE*ε4+ carriers are at increased risk for depression over a 12-year period among those who are cognitively intact.

It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments.

To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance.

National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK.

The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients.

Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

Since 2012 England has seen year-on-year reductions in people accessing specialist community alcohol treatment, and year-on-year increases in alcohol-related hospital admissions.

We examined perceived barriers to accessing specialist treatment, and perceived reasons behind hospital admission increases.

We conducted focus groups (n = 4) with service users and semi-structured interviews (n = 16) with service providers and service commissioners at four specialist community alcohol services in England, which experience either high or low rates of alcohol dependence prevalence and treatment access. Themes and subthemes were generated deductively drawing upon Rhodes’ risk environment thesis. Data were organised using the framework approach.

Data reveal a treatment sector profoundly affected at all levels by changes implemented in the Health and Social Care Act (HSCA) 2012. Substantial barriers to access exist, even in services with high access rates. Concerns regarding funding cuts and recommissioning processes are at the forefront of providers’ and commissioners’ minds. The lack of cohesion between community and hospital alcohol services, where hospital services exist, has potentially created an environment enabling the reduced numbers of people accessing specialist treatment.

Our study reveals a treatment sector struggling with a multitude of problems; these pervade despite enaction of the HSCA, and are present at the national, service provider and individual service level. Although we acknowledge the problems are varied and multifaceted, their existence is echoed by the united voices of service users, service providers and service commissioners.

Globally, nearly two-thirds of people with dementia reside in low- and middle-income countries (LMICs), yet research on how to support people with dementia in LMIC settings is sparse, particularly regarding the management of behavioural and psychological symptoms of dementia. Understanding how best to manage these symptoms of dementia with non-specialist approaches in LMICs is critical. One such approach is a non-pharmacological intervention based on the Montessori method.

To evaluate the feasibility and acceptability of a culturally adapted, group-based Montessori intervention for care home residents with dementia and their study partners, who were paid care workers in Pakistan.

This was a two-stage study: a cultural adaptation of the Montessori intervention and a single-arm, open-label, feasibility and acceptability study of 12 participant dyads. Feasibility and tolerability of the intervention and study procedures were determined through the recruitment rate, adherence to the protocol and acceptance of the intervention. Qualitative interviews were undertaken with the study partners. A pre–post exploratory analysis of ratings of behavioural and psychological symptoms of dementia, functional ability and quality of life were also conducted.

The recruitment and retention rates of people with dementia were acceptable, and the intervention was well tolerated by participant dyads. Findings show a reduction in agitation levels and improvement in mood and interest for the activities.

Feasibility studies of low-cost, easy-to-deliver and culturally adapted interventions are essential in laying the groundwork for subsequent definitive effectiveness and/or implementation trials for dementia in LMICs, where awareness and resources for dementia are limited.

Cognitive impairment is a core feature of depression and has a negative effect on a person's functioning, in psychosocial and interpersonal areas, and on workforce performance. Cognitive impairment often persists, even with the remittance of mood symptoms. One potential way of improving treatment of cognitive impairment would be to identify variables that predict cognitive change in patients with depression.

To systematically examine findings from studies that investigate baseline variables and how they predict, or correlate with, cognitive change in mood disorders, and to examine methodological issues from these studies.

Studies that directly measured associations between at least one baseline variable and change in cognitive outcome in patients with current major depressive episode were identified using PubMed and Web of Science databases. Narrative review technique was used because of the heterogeneity of patient samples, outcome measures and study procedures. The review was registered on PROSPERO with registration number CRD42020150975.

Twenty-four studies met the inclusion criteria. Evidence from the present review for prediction of cognitive change from baseline variables was limited for demographic factors, with some preliminary evidence for depression, cognitive and biological factors. Identification of patterns across studies was difficult because of methodological variability across studies.

Findings from the present review suggest there may be some baseline variables that are useful in predicting cognitive change in mood disorders. This is an area warranting further research focus.

People with a personality disorder have a higher mortality and reduced life expectancy than the general population. Childbearing is thought to have a protective effect on morbidity and mortality. Yet, there are no studies on whether childbearing is related to a lower mortality among women with personality disorder.

This study examined associations between childbearing and mortality among women with personality disorder. Our hypothesis was that parity would be associated with lower mortality.

This register-based cohort study included 27 412 women treated for personality disorder in in-patient or specialised out-patient care between 1990 and 2015. We used nationwide population-based registers to obtain information on sociodemographics, child delivery, healthcare use and mortality. Mortality risk estimates were calculated as hazard ratios (HRs) with 95% CIs using Cox regression. Adjustments were made for year of birth, educational level, age at diagnosis, comorbidity and severity of personality disorder.

Nulliparous women had a nearly twofold increased mortality risk (adjusted HR = 1.78, 95% CI 1.50–2.12) compared with parous women and over twofold mortality risk (adjusted HR = 2.29, 95% CI 1.72–3.04) compared with those giving birth after their first personality disorder diagnosis. Those giving birth before their first personality disorder diagnosis had a 1.5-fold higher risk of mortality than those giving birth after their first personality disorder diagnosis (adjusted HR = 1.48, 95% CI 1.06–2.07). There was a threefold risk of suicide in nulliparous women compared with those giving birth after their first personality disorder diagnosis (adjusted HR = 2.90, 95% CI 1.97–4.26).

Childbearing history should be an integral part of the clinical evaluation of women with personality disorder.

The Health of the Nation Outcomes Scales (HoNOS) has been widely used as an outcome measure in UK mental health settings for the past decade. The data-set gathered provides a unique opportunity to evaluate the effectiveness of the totality of mental healthcare in ‘real-world’ conditions; much of our clinical evidence currently comes from highly parameterised clinical trials investigating single interventions in highly selected patients.

To examine all outcomes measured by HoNOS for a range of diagnostic groups, evaluate the influence of patient demographics on those outcomes, and observe changes in patient groups over time.

Here we show the data from 6813 adult patients treated in Cambridgeshire between 2012 and 2017. Patients were split into three diagnostic groups: psychosis, non-psychosis and organic. Changes in HoNOS scores from initial assessment to discharge were tested and regressions were used to evaluate the influence of age, gender and ethnicity on the changes, as well as to model changes in the severity of initial presenting symptoms with time.

HoNOS scores significantly improve after treatment for psychotic, non-psychotic and organic conditions in adults and older adults. Age, but not gender or ethnicity, influenced change in HoNOS scores. Patients entering secondary mental health services had increased initial HoNOS scores over time.

The UK repository of HoNOS scores provides a significant and relatively underutilised resource that can be exploited to gain insights into mental illness and treatment effectiveness. This is likely to have many applications, including influencing the commissioning of services.

Several studies have reported anxiety disorders in children with high intellectual potential (HIP). However, there are discrepant results possibly as a result of methodological biases (different/absent definitions of HIP, small sample sizes, non-validated/adapted/specific tools for assessing anxiety and a single observational source).

To examine more thoroughly the relationships between HIP and anxiety in large samples of children using clear definitions of HIP, different observational sources and specific assessments of anxiety.

Children with HIP (n = 211, total IQ ≥130) were compared with children without HIP (n = 397, total IQ <130) for anxiety using different observational sources (child psychiatric diagnosis, parental evaluation and child's self-evaluation). Intellectual functioning was assessed using the Wechsler Intelligence Scale.

There were significantly more children with HIP who had anxiety disorders than children without HIP based on the child psychiatric diagnosis. Moreover, based on the child's self-evaluation, children with a high Verbal Comprehension Index (VCI ≥130) were significantly more anxious than children with a VCI <130, whereas children with a high Perceptual Reasoning Index (PRI ≥130) were significantly less anxious than children with a PRI <130. Finally, there was no significant relationship between levels of intellectual functioning and anxiety according to parental observation.

The results highlight the importance of using multiple observational sources and conducting analyses on different dimensions of intellectual functioning (such as VCI and PRI), rather than only on the composite total IQ score. High verbal potential might be a factor of vulnerability for anxiety, whereas high perceptual reasoning might be a protective factor. Further studies are necessary to understand better the mechanisms underlying these results.

The only non-legal reference in Lord Cullen's Review of fatal accident inquiry (FAI) Legislation in Scotland (2009) was my audit of FAIs into 97 deaths in prison custody in Scotland, 1999–2003: recommending that waiting time from prisoner death to end of FAI should be less than 1 year for 90% of FAIs, and epidemiological rules for FAIs to have a written determination versus formal findings.

Audit of FAIs into 83 deaths in Scottish prison custody in the period 2010–2013.

Assessement of waiting times from prisoner death to end of FAI; dissemination of written determinations; self-inflicted death rate per 1000 prisoner-years; cause of natural deaths; and yellow card submissions. Detailed cross-checking was nec37essary between Scottish Prison Service and courts’ websites and the Scottish Fatalities Investigation Unit.

Of 83 FAIs into deaths in Scottish prison custody, 2010–2013, 37 (45%) were long-awaited (ongoing >2 years after the prisoner's death); 16 (19%, 95% CI 11–28%) beyond 3 years. Of 37 long-awaited FAIs, 27 made written determinations but only 12 of these (44%) were published. Self-inflicted deaths numbered 36: 1.1 per 1000 prisoner-years (95% CI 0.75–1.48). Of 47 deaths from natural causes, cardiovascular disease accounted for 23 (49%, 95% CI 34–63%); liver disease was implicated in 10 of 47. To support pharmacovigilance, submissions were made to Medicines and Healthcare Regulatory Agency for eight deaths (10%, 95% CI 4–19%).

FAIs into prisoner deaths in Scotland are too long-awaited given that four (5%) identified precautions that could have prevented death.