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Background Evidence regarding the efficacy of adjunct statins to treat severe mental illness (SMI) is mixed. The varying pharmacokinetic properties of statins mean that specific statin-antipsychotic combinations might improve psychiatric symptoms. Objective To test whether some statin-antipsychotic/mood stabiliser combinations result in psychiatric symptom improvement in patients with SMI, while others do not, using target trial emulation in observational data. Methods We identified patients with SMI (schizophrenia, bipolar disorder, ‘other’ psychoses) prescribed antipsychotics/mood stabilisers and statins from 2000 to 2019 in English linked primary care records (Clinical Practice Research Datalink). We defined hypothetical randomised trials and observational emulations: (1) blood-brain barrier (BBB)-penetrant (simvastatin) versus non-penetrant (atorvastatin/pravastatin/rosuvastatin) statins; (2A) P-glycoprotein inhibitors (simvastatin/atorvastatin) versus non-inhibitors (pravastatin) in patients prescribed aripiprazole/risperidone/olanzapine (P-glycoprotein affinity); (2B) high (aripiprazole/risperidone/olanzapine) versus low (quetiapine) P-glycoprotein affinity antipsychotics in patients prescribed P-glycoprotein-inhibiting statins. Findings We found no reduction in our primary outcomes (12-month psychiatric admissions) in trial 1 (HR 1.07, 95% CI 0.88 to 1.31); trial 2A (HR 0.77, 95% CI 0.28 to 2.15); or trial 2B (HR 0.93, 95% CI 0.79 to 1.09). In trial 2B, we observed lower self-harm events (HR 0.60, 95% CI 0.38 to 0.97) in per-protocol analysis and lower psychiatric admissions in the ‘other’ psychoses subgroup (HR 0.53, 95% CI 0.34 to 0.85). Conclusions BBB penetrance appears unlikely to be the mechanism by which statins improve SMI symptoms. Interaction with P-glycoprotein may have some effect. Further mechanistic and clinical research is needed to understand statin-antipsychotic interactions and the role of interaction with P-glycoprotein. Clinical implications There is currently not enough evidence to guide the prescription of statins for psychiatric symptom improvement in patients with SMI. If there is an effect of statins, it may be through specific statin-antipsychotic combinations.

Background Stressful life events (SLEs) are associated with increased risk of depression or anxiety. Coping mechanisms may moderate this relationship but little is known on this topic in young people or in Latin America. Aim To investigate whether coping strategies predict odds of depression and/or anxiety and moderate the relationship between SLEs and depression and/or anxiety in young people in Peru, Lima and Bogotá. Method Using case–control data from people aged 15–24, we used logistic regression to examine associations between coping mechanism, SLEs and caseness for depression or anxiety, adjusting for sociodemographic and socioeconomic factors. We included interaction terms to model whether this association varied depending on coping mechanisms (positive cognitive restructuring, problem focused, support seeking, distraction, avoidant). Results We included 1437 cases and 965 controls. Cases reported less use of positive cognitive restructuring (OR 0.66; 95% CI 0.57 to 0.75) and problem-focused coping (OR 0.82; 95% CI 0.73 to 0.93), and more use of avoidance than controls (OR 1.33; 95% CI 1.19 to 1.50) in adjusted models. They had greater odds of reporting lifetime (OR 1.07; 95% CI 1.04 to 1.10) and past-year (OR 1.05; 95% CI 1.01 to 1.10) SLEs than controls. We found weak but consistent evidence of effect modification; the association between lifetime SLEs and case–control status was stronger in those who used less support seeking (p=0.09), problem-focused coping (p=0.08) or positive cognitive restructuring (p=0.09). Conclusions Relationships between SLEs, coping mechanisms and depression/anxiety appear similar in these Latin American cities to other contexts. Active coping strategies may ameliorate the impact of SLEs on mental health of young people.

Background Circadian disruption has been suggested to induce cognitive impairment and dementia. It remains unknown which brain structures are involved in the pathology. Objective To investigate which specific brain structure alterations are associated with dementia and cognitive impairment induced by circadian disruption. Methods Circadian disruption was represented by two accelerometer-derived circadian variables, composite phase deviations (CPD) and relative amplitude (RA), separately reflecting circadian disruption in timing and amplitude. The outcomes include brain structures (139 imaging-derived phenotypes), cognitive test performances (seven cognitive tests) and dementia (all-cause dementia, Alzheimer’s disease, vascular dementia (AD/VD) and non-AD/VD dementia). Association analysis was used to explore the relationships between circadian disruption and brain structure alterations, cognitive test performances and dementia. Mediation analysis was conducted to investigate which brain structure alterations mediated the cognitive impairment and dementia caused by circadian disruption. Findings A total of 88 461 participants (57% female, 62.0±7.8-year old) were included. CPD and RA correlated with substantially different brain structures. All CPD-related brain structures were located in the cerebrum, whereas most RA-related brain structures were located in the cerebellum. Furthermore, only the CPD-related brain structures, including the hippocampus and thalamus, exhibited significant mediation effects accounting for up to 8.6% of the risk for dementia and 13.5% of the risk for cognitive impairment. Conclusions Circadian disruption is associated with brain structural alterations involving dementia and cognitive impairments. Clinical implications These results provide a novel insight into the mechanism underlying circadian disruption-induced neurological disorder and may propose potential preventive strategy.

Objective To develop a clinician-guided, research-based guideline for adult outpatient psychotherapy for complex presentations of post-traumatic stress disorder (PTSD). Methods We used state-of-the-art methods to develop clinical guideline recommendations and conduct systematic reviews with meta-analyses for five research questions: (Q1) When treating adults with PTSD, should trauma-focused psychotherapy include exposure? Which psychotherapies are effective for PTSD with co-occurring: (Q2) personality disorder; (Q3) depression; and (Q4) dissociative disorder? (Q5) for complex PTSD (C-PTSD)? Results (Q1) We found no evidence of a difference between trauma-focused psychotherapies with or without exposure on PTSD symptoms (standardised mean difference (SMD) 0.02, 95% CI –0.11 to 0.15, p=0.75, I2=64%). (Q2) Dialectical behaviour therapy (DBT-for-PTSD) showed beneficial effects over cognitive processing therapy (CPT) on co-occurring borderline personality disorder (BPD) symptoms (mean difference (MD) –0.58, 95% CI –0.94 to –0.22, p=0.003). (Q3) Mindfulness and body-focused psychotherapies, prolonged exposure (PE), narrative exposure therapy (NET) and CPT showed beneficial effects on symptoms of PTSD and co-occurring depression. Results for present-centred therapy (PCT) were uncertain. (Q4) No statistically significant differences were found among psychotherapies for PTSD with co-occurring dissociation. (Q5) Skills training appeared promising for C-PTSD. Conclusion Weak clinical recommendations were reached for trauma-focused therapies with or without exposure for PTSD; DBT-for-PTSD for PTSD with co-occurring BPD; CPT, NET, PE and Mindfulness and body-focused psychotherapies for PTSD with co-occurring depression; and Skills training for C-PTSD. A weak recommendation was reached against PCT for PTSD with co-occurring depression. It is good practice to include interventions targeting dissociation for PTSD with co-occurring dissociation. Overall, the certainty of evidence was low; high-quality trials are needed to strengthen the recommendations. PROSPERO registration number CRD42022376117.

Background There is some evidence that perinatal anxiety (PNA) is associated with lower rates of infant vaccinations and decreased access to preventative infant healthcare, but results across studies have not been conclusive. Objective To investigate the relationship between maternal PNA and infant primary care use. Methods Cohort study of mother-infant pairs identified between 1998 and 2016 using IQVIA Medical Research Database (IMRD). PNA was identified through prescription, diagnosis and symptom records from start of pregnancy up to 1 year after birth. Outcomes include primary care consultation rate, attendance at the 6–8 week infant check and uptake of the infant 5-in-1 vaccination, comparing unadjusted rates of consultations and using logistic regression to analyse other outcomes. Findings Of the 248 618 women, 11 558 (4.7%) had a record of PNA. Infants of mothers with PNA had, on average, one more primary care consultation/person-year compared with those without (9.7 vs 8.7) in the year after birth. Mothers with PNA were more likely to have an infant who was vaccinated (adjusted OR (aOR) 1.33, 95% CI 1.20 to 1.48) but were less likely to have a record of attendance at the 6–8 week infant check (aOR 0.88, 95% CI 0.81 to 0.95). Conclusions Infants of mothers with PNA had, on average, a slightly higher rate of primary care consultations and were more likely to be vaccinated but less likely to have a record of an infant check. Clinical implications Midwives and General Practitioners (GPs) providing care should consider how PNA may impact on infant health and how infant health may impact on maternal anxiety.

Objectives Should a young person receive psychotherapy or medication for their depression and on what evidence do we base this decision? In this paper, we test the factors across modalities that may influence comparability between medication and psychotherapy trials. Methods We included 92 randomised controlled trials (RCTs) of psychotherapy and medication for child and adolescent depression (mean age 4–18 years). Using meta-analyses, we compared (a) participant characteristics and (b) trial characteristics in medication and psychotherapy trials. Lastly, we examined whether psychotherapy controls are well-matched to active conditions. Results Participants in medication RCTs had higher depression severity and were more frequently male compared with psychotherapy RCTs. There was a dramatic difference in the within-subject improvement due to placebo (SMD=–1.9 (95% CI: –2.1 to –1.7)) vs. psychotherapy controls (SMD=–0.6 (95% CI: –0.9 to –0.3)). Within psychotherapy RCTs, control conditions were less intensive on average than active conditions. Conclusions Medication and psychotherapy RCTs differ on fundamental participant and methodological characteristics, thereby raising questions about their comparability. Psychotherapy controls often involve little therapist contact and are easy-to-beat comparators. These findings cast doubt on the confidence with which psychotherapy is recommended for youth depression and highlight the pressing need to improve the evidence base.

Background Traumatic brain injury (TBI) is associated with an increased risk of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). We aimed to identify predictors and develop models for the prediction of depression and PTSD symptoms at 6 months post-TBI. Methods We analysed data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury study. We used linear regression to model the relationship between predictors and depression (Patient Health Questionnaire-9) and PTSD symptoms (PTSD Checklist for Diagnostic and Statistical Manual for Mental Health Disorders Fifth Edition). Predictors were selected based on Akaike’s Information Criterion. Additionally, we fitted logistic models for the endpoints ‘probable MDD’ and ‘probable PTSD’. We also examined the incremental prognostic value of 2–3 weeks of symptoms. Results We included 2163 adults (76% Glasgow Coma Scale=13–15). Depending on the scoring criteria, 7–18% screened positive for probable MDD and about 10% for probable PTSD. For both outcomes, the selected models included psychiatric history, employment status, sex, injury cause, alcohol intoxication and total injury severity; and for depression symptoms also preinjury health and education. The performance of the models was modest (proportion of explained variance=R2 8% and 7% for depression and PTSD, respectively). Symptoms assessed at 2–3 weeks had a large incremental prognostic value (delta R2=0.25, 95% CI 0.24 to 0.26 for depression symptoms; delta R2=0.30, 95% CI 0.29 to 0.31 for PTSD). Conclusion Preinjury characteristics, such as psychiatric history and unemployment, and injury characteristics, such as violent injury cause, can increase the risk of mental health problems after TBI. The identification of patients at risk should be guided by early screening of mental health.

Objective Agitation in the emergency department (ED) affects up to 2.6% of encounters, posing significant risks to patients and caregivers. This review investigates the impact of circadian rhythms on benzodiazepine (BZD) pharmacokinetics and pharmacodynamics, focusing on how dosing time influences outcomes in managing acute agitation. Methods A comprehensive literature search was performed using PubMed and Google Scholar (updated April 2024) to identify studies on BZD use in adult ED patients for acute agitation. Search terms included "antipsychotic agents," "lorazepam," "midazolam," "diazepam," and "emergency service." Studies focusing solely on substance intoxication were excluded. Priority was given to double-blind clinical trials, while open-label studies were included if no double-blind data were available. Referenced citations from identified publications were also reviewed. Results Twenty-nine studies met the inclusion criteria: 16 randomised, double-blinded placebo-controlled trials, 5 prospective open-label studies and 8 retrospective reviews. Of these, 22 studies either did not report the time of day of patient recruitment or recruited patients over a year-long time frame. Four studies that specified the time of day of patient recruitment suggested a possible circadian variation in BZD sedation efficacy. Additionally, three studies that reported recruitment months revealed potential seasonal patterns in sedation requirements and efficacy. Conclusions Circadian rhythms appear to influence BZD metabolism and therapeutic effects, which could have implications for optimising treatment strategies. Aligning BZD dosing schemes with biological timing may enhance treatment outcomes and minimise adverse effects. Further research is needed to validate these findings and develop personalised chronopharmacotherapy strategies for acute agitation in the ED.

Background Adolescence constitutes a critical window for preventing depression, but efforts have mostly targeted single risk factors. The Identifying Depression Early in Adolescence Risk Score (IDEA-RS) integrates easily obtainable sociodemographic variables and has been able to predict future depression across diverse populations. However, its performance within a prospective cohort remains untested. Objective To evaluate the performance of the IDEA-RS in a prospective sample of adolescents participating in the IDEA Risk Stratified Cohort. Methods Using the IDEA-RS, we screened 7720 adolescents aged 14–16 years in 101 public schools in Porto Alegre, Brazil, and recruited 50 low-risk (LR) and 50 high-risk (HR) participants without depression. The incidence of depressive disorders over 3 years was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Statistical analysis involved Poisson regression with robust variance to estimate incidence rate ratios (IRRs) for depression onset. Findings In the HR group, 14/45 developed depression, in comparison to 5/43 in the LR group. Poisson regression analysis confirmed a higher probability of developing depression in the HR group compared with the LR group (IRR of 2.68, 95% CI 1.05 to 6.79, p=0.04). Conclusion In a prospective cohort of Brazilian adolescents, the IDEA-RS effectively distinguished between those at HR and LR for developing depression. Clinical implications These results support the usefulness of an easy-to-administer sociodemographic composite risk score for stratifying the probability of developing depression among adolescents, a promising tool to be used in a variety of global contexts, including resource-limited settings.

Background Psychotic disorders are known to exhibit heterogeneity with regards to illness course and prognosis, yet few studies have examined long-term healthcare use. Objective To determine the prevalence and predictors of healthcare use for psychiatric disorders at 9 years after the first episode of psychosis (FEP). Methods National registers were used to identify all Swedish residents aged 18–35 years with FEP between 2006 and 2013. The 12-month period-prevalence of secondary healthcare use was determined at each year of the 9-year follow-up, categorised according to main diagnosis (psychotic disorder vs other psychiatric disorder vs none vs censored). Multinomial logistic regression models were used to examine associations between baseline characteristics and healthcare use at 9 years and derive predicted probabilities and 95% CIs for the four outcome groups, for each predictor variable. Findings Among 7733 individuals with FEP, 31.7% were treated in secondary healthcare for psychotic disorders at the 9-year follow-up, 24.1% were treated for other psychiatric disorders, 35.7% did not use healthcare services for psychiatric disorders and 8.5% were censored due to death/emigration. Having an initial diagnosis of schizophrenia was associated with the highest probability of secondary healthcare use for psychotic disorder at 9 years (0.50, 95% CI (0.46 to 0.54)] followed by inpatient treatment at first diagnosis (0.37, 95% CI (0.35 to 0.38)). Conclusion Although 56% of individuals with FEP were treated for psychiatric disorders in secondary healthcare 9 years later, a substantial proportion were treated for non-psychotic disorders. Clinical implications Individuals with an initial diagnosis of schizophrenia, who received their first diagnosis in inpatient settings, may need more intensive treatment to facilitate remission and recovery.

Background Depression alongside multiple long-term conditions (MLTCs) in older adults poses a critical public health challenge, worsening physical and mental health and increasing healthcare costs. COVID-19 restrictions further exacerbated these impacts. Behavioural activation (BA) shows promise as a remote intervention for depression during isolation, but its cost-effectiveness for depressed, socially isolated older adults remains uncertain. Objective This study aimed to assess the cost-utility of BA versus usual care for older adults with depression and MLTCs during COVID-19 restrictions. Methods A randomised controlled trial recruited and randomised individuals aged 65 and over with depressive symptoms and MLTC (n=435) to either the BA intervention or usual care. Costs were measured from the perspective of the National Health Service and personal social services. Quality-adjusted life years (QALYs) were measured using the EQ-5D-3L at baseline, and 1, 3 and 12 months postrandomisation. Incremental cost-effectiveness ratios were calculated, with uncertainty addressed through non-parametric bootstrapping. Sensitivity analyses were conducted to assess the robustness of the primary analysis. Findings Primary analysis indicated that BA generated a small cost-saving (£62.34 per older adult; 95% CI: –£120.44 to £239.70) while QALY improvements remained unchanged (0.007; 95% CI –0.036 to 0.022) compared with usual care. The probability of BA being the preferred option is 0.71. Sensitivity analyses supported the primary analysis findings, confirming their robustness. Conclusions and clinical implications Compared with usual care, BA demonstrated a slight cost reduction while maintaining QALY improvement. The findings provide promise for BA interventions for older people with depression and MLTCs facing isolation.

Background Trans, non-binary and gender-diverse (TGD) people experience poorer mental health relative to cisgender populations. However, we know little on how TGD mental health inequalities are changing over time. With newly available information on gender identity within Australia’s largest longitudinal household survey, we aimed to provide the first nationally representative estimates of temporal trends in TGD mental health inequalities. Methods We used the 2001–2022 Household, Income and Labour Dynamics in Australia Survey, a national probability sample of Australian adults. Using questions about sex at birth and gender identity, asked in the 2022 wave, we compared temporal trends in mental health among TGD and cisgender respondents. Mental health was measured using the five-item Mental Health Inventory (MHI). Adjusting for age, income and other observable characteristics, we calculated annual population-weighted estimates of mean MHI Scores for TGD and cisgender respondents and corresponding TGD mental health inequalities. Results Across the 22-year period, TGD respondents consistently reported poorer mental health than cisgender respondents. Prior to 2010, differences in MHI Scores were more variable, but TGD MHI Scores were generally lower than cisgender respondents. From 2010 onwards, there was a trend of widening inequalities, with TGD-cisgender MHI inequalities ranging from –5.1 (95% CI –10.6, 0.3) in 2010 to –7.6 (95% CI –10.8, –4.4) in 2022, indicating clinically relevant differences in mental health. Effects were driven by younger populations. Conclusion TGD-cisgender mental health inequalities are increasing in Australia, with inequalities more apparent between 2010 and 2022. Policy action and greater protections for gender-diverse Australians are urgently needed.

Background While patient and public involvement (PPI) in research is growing, PPI in the setting of research priorities at an early stage of the research process has been limited to date. Where research priorities have been assessed, this has been done by working with members of the general public. Research priorities are likely to vary between different groups, and families affected by depression have been recognised as an important group for research. Objective We aimed to explore the mental health research priorities of parents with a history of depression and their children. Methods Data came from the Early Prediction of Adolescent Depression (EPAD) study—a UK longitudinal cohort study of parents with a history of depression and their children. During interviews, parents (n=161) and their young adult children (n=131) were asked open-ended questions about their research priorities. Responses were analysed using qualitative content analysis. Findings Parents and their young adult children highlighted the following research priority categories: treatment and intervention, including prevention and early intervention, public understanding of mental health, environmental or social factors that might contribute to poor mental health, the role of genetics in intergenerational transmission, and a developmental and intergenerational approach to research. Conclusions While prior research has identified the importance of intervention and social factors, our study also identified public understanding of mental health and aetiological research, particularly on the contribution of genetics relative to environmental factors, as priorities for parents with depression and their children. Clinical implications Findings highlight the value of involving diverse groups in priority-setting exercises, including groups that are recognised as important for research, to allow their views to be incorporated into agenda-setting initiatives, including for research funding.

Background Suicidal thoughts and behaviours are common in people in prison and associated with poor health outcomes, including suicide, injury and repeat self-harm. Objective To develop and validate a model to stratify risk of repeat suicidality up to 3 months in people in prison. Methods In seven English prisons, we identified 754 people aged over 17 who had been placed on a suicide risk management plan after a self-harm episode or elevated risk. We developed a multivariable model to stratify risk of repeat suicidality at 3 months using routinely collected sociodemographic, clinical and prison-related factors, which were tested using Cox proportional HR models. In a prospective validation sample of 390 people from 13 prisons, we tested this model to assess risk of repeat suicidality at 3 months across a range of performance measures. Findings Of the overall sample of 1144 people in prison (n=966 men or 84%, mean age 33 years), 22% had the outcome of repeat suicidality over 3 months. The final risk model consisted of nine factors, including sex, calendar age and features of recent suicidal behaviour. Calibration and discrimination were similar in both development and validation samples, with O:E ratio=1.09 (95% CI 0.88 to 1.35) and c-statistic=0.66 (95% CI 0.60 to 0.72) in external validation. At a 25% cut-off, sensitivity was 58% (50 to 66) and specificity was 72% (68 to 75) in external validation. The tool (Risk Assessment for people in Prison at risk of Self-harm and Suicide, RAPSS) is available as an online risk calculator at https://oxrisk.com/rapsstrial/. Interpretation A novel assessment approach for repeat suicidality can provide an evidence-based approach to stratify risk and better allocate resources.

Background Antipsychotic treatments require physical health monitoring (PHM), especially among children and young people (CYP). Objective For CYP aged 5-17, to investigate recorded indications for antipsychotics prescribing and first-treatment durations, and, for psychosis, bipolar disorder, autism spectrum disorder (ASD) and Tourette’s syndrome, recorded levels of PHM for CYP with antipsychotics prescriptions and those without. Methods All CYP registered with QResearch English general practices between 2006 and 2021 were considered. To quantify PHM, 2158 CYP with antipsychotics prescriptions and 22 151 CYP with a condition but no prescriptions were followed for 2 years. Findings 47% (2363) of CYP with antipsychotics prescriptions had a recorded mental health condition of interest (of which 62% were ASD). 19% (921) had no relevant indication. For patients with ASD and Tourette syndrome, top quartiles for initial exposure to antipsychotics were >10 months. Recorded PHM was generally low, with over 50% of CYP showing no blood test during the 2-year follow-up. Conclusions Coverage of best practice is uneven across the condition-related national CYP guidelines, and this requires improvement. However, we suspect some apparently poor adherence to best practice also derives from treatment complexities and associated data flows leading to gaps in the encoded general practice data. To audit more exactly clinical practice against guidelines, we propose qualitative studies, targeted to cover the full range of local circumstances, nationally. Clinical implications General practices should be encouraged to prioritise encoding of all treatment data. Development of one central gold-standard set of recommendations for antipsychotics use could encourage better adherence levels across conditions.

Background Migraine is linked to increased suicidal behaviour, but its relationship with suicide mortality remains underexplored. In South Korea, suicide rates are among the highest in Organisation for Economic Co-operation and Development nations, particularly in young adults. Objective To investigate the effect of migraine on suicide mortality in young Korean adults. Methods Participants who underwent the Korean Health Examination from 2009 to 2012 were enrolled in this study and followed up until 2021. Participants aged 20–39 years (n=6 539 547) were categorised based on their migraine status. Cox proportional hazards regression models assessed the association between migraine and suicide mortality, adjusting for demographic factors, health behaviours and comorbidities. Findings Among 6 539 547 participants, 113 681 (1.74%) had migraine (6620 (0.10%) with aura, 107 061 (1.64%) without aura). Over 11 years, there were 21 suicides (0.32%) in migraine with aura, 219 (0.20%) in migraine without aura and 13 040 (0.20%) in no migraine. All migraine was not linked to increased suicide risk (HR 1.07, 95% CI 0.94 to 1.21), but migraine with aura showed a higher risk (HR 1.61, 95% CI 1.05 to 2.47). Migraine without aura had no increased risk (HR 1.03, 95% CI 0.90 to 1.18). Depression modified the association across migraine subtypes. Conclusion and implications Although all migraine and migraine without aura were not significantly associated with a higher suicide risk compared with that in the absence of migraine, migraine with aura was associated with a higher risk of suicide mortality. Depression significantly modified this relationship, showing different associations across migraine subtypes.

Background Electrodermal activity (EDA) is a measure of sympathetic arousal that has been linked to depression in laboratory experiments. However, the inability to measure EDA passively over time and in the real world has limited conclusions that can be drawn about EDA as an indicator of mental health status outside of controlled settings. Objective Recent smartwatches have begun to incorporate wrist-worn continuous EDA sensors that enable longitudinal measurement of sympathetic arousal in everyday life. This work (n=237, 4-week observation period) examines the association between passively collected, diurnal variations in EDA and symptoms of depression, anxiety and perceived stress in a large community sample. Methods We conducted a prospective, non-randomised study to investigate patterns and relationships between digital device use patterns, including sensor data from phones and wearables reflecting both behavioural and physiological processes, and self-reported measures of mental health and well-being. We recruited 395 participants who had a Fitbit Sense 2 device with the electrodermal sensor activated. We use a non-linear cosinor fitting method to estimate the difference in mesor, amplitude and phase, between the diurnal rhythms in heart rate (HR), heart rate variability (HRV) root mean square of successive differences, EDA, skin temperature and steps. Findings Subjects who exhibited elevated depressive and anxiety symptoms had higher tonic EDA, skin temperature and heart rate, despite not engaging in greater physical activity, compared with those that were not depressed or anxious. In contrast, subjects who exhibited elevated stress only exhibited higher skin temperature. Most strikingly, differences in EDA between those with high versus low symptoms were most prominent during the early morning. We did not observe amplitude or phase differences in the diurnal patterns. Conclusions Results indicate that participants with elevated depressive and anxiety symptoms have different diurnal physiological patterns. Specifically, EDA differences suggest elevated sympathetic activity throughout the day and in particular in the early morning. Clinical implications Our work suggests that electrodermal sensors may be practical and useful in measuring the physiological correlates of mental health symptoms in free-living contexts and that recent consumer smartwatches might be a tool for doing so.

Question The Green Brain Capital Model emphasises the bidirectional relationship between brain health and the environment, making it an environmentally focused type of brain capital. This work represents the initial stage of conceptualising the Green Brain Capital Model, which is essential to avoid ambiguity and misinterpretation while developing a quantitative model. Ecological intelligence (EI) is identified as a key component of the model in the literature. Therefore, the objective of this review was to systematically review the literature to define EI, its features and quantitative assessment tools, to develop comprehensive metrics for Green Brain Capital. Study selection and analysis We conducted a search in Scopus, ScienceDirect and Scopus secondary literature and identified 11 articles that provide definitions of EI and quantitative tools to assess it. Findings The study revealed that EI is a multifaceted concept with cognitive, affective and behavioural domains. Seven quantitative tools for measuring EI were identified, with the Ecological Intelligence Measurement Tool by Okur-Berberoglu and the Ecological Intelligence Scale by Akkuzu, demonstrating strong theoretical grounding, reliability and validity. Additionally, our review included searching open-access databases provided by reputable organisations, but no indicators for the assessment of EI were found in these databases. Conclusions All the available tools were designed to assess EI at the individual level and for research purposes within certain cultural contexts. There is a lack of global indicators reflecting countries’ EI development status and global positioning. Establishing country-level indicators across EI domains is essential for policymaking and public awareness.

Background Climate change affects people’s mental health directly and indirectly. Climate anxiety, characterised by persistent worry and distress about environmental changes, is increasingly recognised as a factor affecting mental well-being. This study focused on potential implications of climate change worry for mental health. Objective To assess whether climate change worry is associated with an increased risk of depression, anxiety and sleep disturbance across European countries. Methods The study used longitudinal data from the European Social Survey-10 (2020–2022) and the follow-up CROss-National Online Survey 2 wave 4 (2022). A total of 5155 participants across 11 European countries were included in the analysis. Logistic regression models were used to examine the relationship between climate change worry and mental health outcomes (anxiety, depression and sleep), adjusting for potential confounding factors. Stratified analyses were conducted to assess variations between countries. Findings Climate change worry was associated with increased risk of anxiety (OR: 1.38, 95% CI: 1.13 to 1.68), but not depression (OR: 1.10, 95% CI: 0.94 to 1.29), or sleep disturbance (OR: 1.08, 95% CI: 0.92 to 1.27), in pooled analyses across countries. Country-specific analyses revealed notable differences, with the strongest associations between climate worry and anxiety observed in Slovenia and Italy. Conclusions These findings suggest that the psychological impact of climate change worry is not uniform across Europe and may be influenced by national policies, environmental risks and sociocultural factors. Given the varying effects across countries, policy-makers should consider contextual factors when designing strategies to address climate anxiety. Integrating mental health considerations into climate policies may enhance public engagement and resilience in the face of environmental challenges. Clinical implications Traditional therapeutic approaches may not fully capture the unique distress associated with environmental worries, necessitating the development of specialised interventions that validate individuals’ concerns while equipping them with coping mechanisms.

Background Depression is a major health issue in adolescence and young adulthood, emphasising the need for early risk identification. Patients with major depressive disorder (MDD) often show disturbed daily rest-activity patterns, but such changes are often confounded by medication intake, comorbidities and disease duration. Objective In this exploratory analysis, we tested whether there are specific changes in daily rest activity (from wrist-worn actigraphy) in women at the onset of MDD without medication, as compared with age-matched controls. Methods Participants from the MDD group (age 19–32, 24.73±5.13 (mean±SD), N=15) and control group (age 20–31, 24.89±3.82, N=9) completed ~7 day ambulatory actigraphy recordings, followed by a stringently controlled circadian laboratory protocol to assess endogenous circadian melatonin levels. We analysed the daily rhythm of mean activity levels and non-linear fractal dynamics in eight 3-hour time bin across the 24 hours, correlating these measures with depressive symptom severity and endogenous melatonin levels. Findings Using approaches from non-linear fractal dynamics, we showed that, compared with healthy controls, women at MDD onset had a higher fractal activity correlation (FAC) during the last hours of sleep, indicating more ‘wake-like’ patterns (FAC within 0–3 hour before wake: 0.92±0.64 (SD) in MDD vs 0.77±0.18 in controls, p=0.02). The alteration was independent of mean activity level and wake duration but appeared to be associated with depressive symptom severity (p=0.08). Moreover, there was a trend association for altered FAC with endogenous melatonin levels in the MDD group (for onefold increase in melatonin level in the last 3 hours before wake, the FAC increased by 0.33±0.17 (SE), p=0.08). Conclusions Pre-wake FAC is elevated in unmedicated women at MDD onset and may serve as a potential biomarker associated with symptom severity and circadian physiology. Clinical implications These findings provide proof-of-concept evidence that unique fractal motor activity patterns may support early detection of MDD.

Background Obsessive-compulsive disorder (OCD) is associated with an increased risk of morbidity and mortality due to cardiometabolic disorders. Whether this association is driven by familial factors is unknown. This population-based family study explored the familial co-aggregation of OCD and cardiometabolic disorders. Methods We identified 6 049 717 individuals born in Sweden between 1950 and 2008, including 50 212 individuals with OCD, and followed them up to 2020. These individuals were linked to their mothers, fathers, full siblings, maternal and paternal half siblings, aunts, uncles and cousins. We estimated the risk of cardiovascular diseases (CVD) and metabolic disorders (including obesity, type 2 diabetes and hyperlipidaemia), comparing the relatives of probands with and without OCD. Cox proportional hazards regression models, incorporating time-varying exposures, estimated HRs. Results OCD was associated with an increased risk of CVD (HR 1.47; 95% CI 1.43 to 1.51), obesity (HR 1.69; 95% CI 1.63 to 1.74), type 2 diabetes (HR 2.01; 95% CI 1.90 to 2.12) and hyperlipidaemia (HR 1.42; 95% CI 1.33 to 1.52). The relatives of probands with OCD exhibited small increased risks of CVD (HRs from 1.01 to 1.11) and obesity (HRs from 1.03 to 1.20). Slightly increased risks for type 2 diabetes were observed in mothers (HR 1.11; 95% CI 1.07 to 1.15) and full siblings (HR 1.12; 95% CI 1.05 to 1.20), while for hyperlipidaemia it was only observed in mothers (HR 1.06; 95% CI 1.02 to 1.10). Conclusions Our results do not support a major contribution of familial factors to the association between OCD and cardiometabolic disorders, suggesting a more prominent role of unique environmental factors.

Background Depression in older adults is often undertreated. A 2011 systematic review of treatments for treatment-resistant depression (TRD) in older adults identified one placebo-controlled randomised controlled trial (RCT). We aimed to update this review, synthesising evidence for the effectiveness of treatments for TRD in older people. Methods We systematically searched electronic databases (PubMed, Cochrane, Web of Science) from 9 January 2011 through 10 December 2023 (updating our search on 7 January 2024 for RCTs investigating TRD therapies in adults aged ≥55 years, defining treatment resistance as ≥1 unsuccessful treatment. We assessed bias with the Cochrane Risk of Bias (RoB) 2 tool, meta-analysed remission rates and evaluated evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. Results 14 studies (11 newly identified, 3 from previous review) involving 1196 participants (mean age 65.0, male/female 548/648) met the inclusion criteria; 10 were placebo controlled and 4 were rated as low RoB. The pooled proportion of participants in intervention arms remitting was 0.35 (17 arms; 95% CI=0.26; 0.45). Relative to placebo, intervention participants were more likely to remit (9 studies; OR 2.42 (95% CI=1.49; 3.92)). Relative to controls, remission rates favoured ketamine (n=3; OR 2.91 (1.11; 7.65)), with a trend towards transcranial magnetic stimulation (TMS) (n=3; 1.99 (0.71; 5.61)), and in single placebo-controlled studies, selegiline, aripiprazole augmentation, pharmacogenetic-guided prescribing (PGP) and cognitive remediation favoured interventions. Conclusions We identified weak evidence that ketamine therapy and aripiprazole augmentation, and very weak evidence that TMS, PGP and cognitive remediation increased remission. Lack of evidence regarding routinely prescribed antidepressants and psychosocial treatments is problematic, requiring clinicians to extend evidence from younger populations. PROSPERO registration number CRD42023494513.

Background Mental health conditions arising from work are a rapidly increasing burden for individuals, employers and society, and are challenging to diagnose and treat. Objective To assess the effectiveness of a multicomponent intervention on increasing general practitioners’ (GPs’) adherence to the ‘Clinical guideline for the diagnosis and management of work-related mental-health conditions in general practice’ (the Guideline) and improve patient work and health and work outcomes. Methods Pragmatic hybrid III parallel cluster randomised controlled trial involving Australian GPs and their patients. GP clinics were randomly assigned to receive the intervention (GP participation in an academic detailing session, enrolment into a virtual community of practice, and receipt of resources). Those assigned to the control group received no support related to the implementation of the Guideline. GP adherence to guideline recommendations was assessed at baseline and 9 months postbaseline, using virtual simulated patient scenarios (vignettes) describing a diverse range of patient circumstances. Patient work and health outcomes (using the 21-item Depression and Anxiety Stress Scale and 36-item short-form) were assessed using self-report surveys. Findings Thirty-eight intervention clusters (52 GPs) and 36 control clusters (46 GPs) contributed to the primary outcome data. Intervention clusters had significantly higher adherence scores than control clusters, by 0.98 points on a 0–9 scale (95% CI 0.38 to 1.58) with a Cohen’s d of 0.67. Patients recruited from 30 intervention (n=99) and 17 control (n=55) clusters contributed to the secondary outcome data. No differences were detected for patients’ work or health outcomes due to an underpowered sample. Conclusions GP adherence to the Guideline improved as a result of receiving the multicomponent intervention. Implications Purposively designed multicomponent implementation strategies to increase guideline-concordant care should be incorporated into guideline production activities and operationalised with guideline release to facilitate evidence-based care. Trial Registration number ACTRN12620001163998, November 2020

Background With the increasing prevalence of climate-related disasters, psychological responses, including climate change anxiety and anticipatory climate disaster stress, have received heightened attention. Objective We investigate the correlates of climate change anxiety and anticipatory climate disaster stress, as well as the nature of these psychological responses. Methods At the start of the annual fire season (June to August 2023), we recruited a county-representative sample of n=813 residents of Lake County, in Northern California, to complete an anonymous online survey. Multiple regression analyses identified correlates of climate change anxiety and anticipatory climate disaster stress and explored how anxiety and stress were associated with disaster preparedness. Findings Climate change anxiety, assessed via its cognitive-emotional impairment (odds ratio (OR)loss/injury=1.68; ORmedia=2.37) and functional impairment (ORloss/injury=1.68; ORmedia=2.63) subfactors, and anticipatory climate disaster stress (bloss/injury=0.15, bmedia=0.26) were associated with previous wildfire-induced loss/injury and media exposure to wildfire-related content. Anticipatory climate disaster stress was also associated with the frequency of being in an evacuation zone (b=0.05). Both the cognitive-emotional impairment subfactor of climate change anxiety (incidence rate ratio (IRR)=1.23) and anticipatory climate disaster stress (IRR=1.14) were associated with preparing an emergency kit and power outage supplies; anticipatory climate disaster stress was associated with evacuation intentions should an actual fire occur (b=0.12). Conclusions Prior experiences with climate disasters could explain people’s psychological responses to climate change. These responses could be temporally appropriate and functionally adaptive, given the immediacy of a potential fire. Clinical implications Climate change anxiety and anticipatory climate disaster stress should not be oversimplified as typical clinical symptoms because their presence might motivate adaptive self-protective behaviours in the face of an upcoming disaster.

Aim To identify sleep abnormalities in individuals at clinical high risk for psychosis (CHR-P) or with schizophrenia spectrum disorders (SSDs) compared with healthy controls (HCs) using wrist actigraphy, and to assess potential differences in the direction of effect with self-reported assessments of sleep. Methods We conducted a systematic review of observational studies, with the search last updated on 29 April 2024. Primary outcome was total sleep time (TST), with secondary outcomes including time in bed (TIB), sleep latency, sleep efficiency, wake after sleep onset, nighttime awakenings and self-reported sleep quality. Random-effects pairwise meta-analyses were used to summarise the effects of each outcome. Results Nineteen studies were included, with 18 contributing to the meta-analyses (202 CHR-P, 584 SSD, 582 HC). TST results were inconclusive for CHR-P (MD –4.88 min (95% CI –20.57 to 10.81)), while SSD participants showed an increase in TST compared with HC (MD 106.13 min (86.02 to 124.24)). Factors such as antipsychotic medications (pseudo-R²=88.14%), age (38.89%) and gender (26.29%) partially explained the heterogeneity between subgroups. Additionally, CHR-P individuals exhibited reduced sleep efficiency (MD –2.04% (–3.55 to 0.53)), whereas SSD participants had increased TIB (MD 121.58 min (88.16 to 155.00)) and sleep latency (MD 13.05 min (2.11 to 24.00)). The risk-of-bias assessment ranged from some concerns to high risk. Conclusions Our analyses identified sleep abnormalities in CHR-P and SSD compared with placebo. However, observed heterogeneity and potential biases across studies may limit the interpretability of findings. These limitations underscore the need for standardised guidelines and more precise participant stratification.

Background Mood episodes and high suicide risk of bipolar disorder (BD) are thought to derive from amygdala–ventral prefrontal cortex emotion regulation brain circuitry dysfunction and resulting emotion dysregulation, making these potential intervention targets. Objective To assess feasibility, acceptability, and preliminary efficacy in engaging the emotion regulation targets of two Brain Emotion Circuitry-targeted Self-Monitoring and Regulation Therapy (BE-SMART) variations in adolescents and young adults with BD (BDAYA): BE-SMART-ER, which directly targets emotion regulation, and BE-SMART-DR, a social rhythm therapy (SRT)-based chronotherapeutic intervention designed to reduce daily rhythm (DR) irregularities. Methods In a single-blind, parallel, pilot-randomised trial, 60 BDAYA (aged 16–29 years) were randomised to 12 weekly sessions (9 telehealth) of BE-SMART-DR or BE-SMART-ER. Nineteen BE-SMART-DR and 16 BE-SMART-ER participants completed the intervention, with 11 and 13, respectively, having pre-intervention and post-intervention functional MRI data. Findings In addition to demonstrating feasibility, only BE-SMART-DR showed pre-treatment to post-treatment improvements in DR regularity (Cohen’s d=0.55; 95% CI [0.06, 1.03]), associated with reductions in left amygdala responses to emotional face stimuli (pFWE (family-wise error)-SVC (small volume correction)<0.05), difficulties in emotion regulation (d=0.75; 95% CI [0.23, 1.25]) and suicide risk (d=0.65; 95% CI [0.15, 1.14]). Significant correlations were observed among these changes (p<0.05). Both interventions showed high acceptability and improvements in depression and mania symptoms. No intervention-related adverse events were observed. Conclusions Regularising DRs may enhance emotion regulation brain circuitry functioning, emotion regulation, and reduce suicide risk in BDAYA. Clinical implications Chronotherapeutic interventions regularising DRs, such as SRT, should be studied further as potential treatment strategies for BDAYA. Trial registration number NCT03183388.

Question Mental health complaints are increased in survivors of natural hazards and disaster responders. This meta-analysis assessed the efficacy of psychological and psychosocial interventions for the prevention of mental disorders after exposure to natural hazards. Study selection and analysis We searched Web of Science, PsycINFO and MEDLINE for peer-reviewed randomised controlled trials evaluating preventive interventions targeting symptoms of post-traumatic stress disorder, depression and anxiety. Trials conducted in both, civilians and disaster responders, were included. Random-effect meta-analyses were conducted to assess the efficacy of interventions relative to active and passive control conditions. Findings The results from 10 included studies (5068 participants) did not find preventive interventions to be superior compared with active or passive control conditions regarding symptoms of post-traumatic stress disorder (g=0.08 and g=0.05) and depression (g=0.13 and g=0.32, respectively). Effects on anxiety symptoms remain unclear. Aggregated effects for all outcomes were significant at follow-up compared with passive controls, but the interpretability is limited by the low number of studies. Intervention effects were not significantly associated with intervention type (psychotherapy vs psychosocial), age or delivery mode (online vs face-to-face). The risk of bias across studies was high. Conclusions The current evidence does not allow for any recommendations regarding prevention programmes in the aftermath of natural hazards. A larger body of high-quality research is needed to develop effective and evidence-based preventive interventions for disaster survivors and responders. Study registration https://osf.io/4es65

Background Social environment characteristics, including social relationships and cultural milieus, may influence the occurrence, course and management of depression. Effective questionnaires are needed to measure these factors and improve disease management. Objective We aimed to (1) evaluate the social environment, such as social isolation, social disability and social cohesion of depressed inpatients and outpatients, and (2) discuss the suitability of standardised questionnaires measuring it. Methods This cross-sectional study included adult patients with unipolar depression from a psychiatric hospital and general practitioner (GP) practices in Bavaria, Germany. Social isolation, disability and cohesion were measured using the Lubben Social Network Scale (LSNS), the WHO Disability Assessment Schedule (WHODAS) and the Social Cohesion and Trust Scale (SCTS), respectively. The suitability of these questionnaires was assessed with a context-specific quality appraisal. Findings Among 282 included patients (mean age 38.8 years, SD=13.3), 69.5% were inpatients and 30.5% were outpatients. Social isolation prevalence was 52.5%. Social disability was higher in our cohort than in the general population (p<0.001). LSNS and WHODAS showed no differences between inpatients and outpatients, and suggest good clinical suitability. The SCTS showed shortcomings in applicability and comparability. Conclusion People with depression, whether treated in psychiatric hospitals or in GP practices, reported more social isolation and social disability than the general population. Clinical implications Researchers and clinicians should monitor social aspects as potential intervention targets to support patient management. Social environment questionnaires should be selected carefully, ideally guided by guidelines or medical associations, to enhance the understanding, comparability and implementation.

Background COVID-19 restrictions led to increased reports of depressive symptoms in the general population and impacted health and social care services. We explored whether these changes affected antidepressant prescribing trends in the general population and those with learning disability or autism. Methods With the approval of NHS England, we used >24 million patients’ primary care data from the OpenSAFELY-TPP platform. We used interrupted time series analysis to quantify trends in those prescribed and newly prescribed an antidepressant across key demographic and clinical subgroups, comparing pre-COVID-19 (January 2018–February 2020), COVID-19 restrictions (March 2020–February 2021) and recovery (March 2021–December 2022) periods. Results Prior to COVID-19 restrictions, antidepressant prescribing was increasing in the general population and in those with learning disability or autism. We did not find evidence that the pandemic was associated with a change in antidepressant prescribing trend in the general population (relative risk (RR) 1.00 (95% CI 0.97 to 1.02)), in those with autism (RR 0.99 (95% CI 0.97 to 1.01)) or in those with learning disability (RR 0.98 (95% CI 0.96 to 1.00)). New prescribing post restrictions was 13% and 12% below expected had COVID-19 not happened in both the general population and those with autism (RR 0.87 (95% CI 0.83 to 0.93), RR 0.88 (95% CI 0.83 to 0.92)), but not learning disability (RR 0.96 (95% CI 0.87 to 1.05)). Conclusions and implications In this England study, we did not see an impact of COVID-19 on overall antidepressant prescribing, although unique trends were noted, such as trends in new antidepressant prescriptions which increased in care homes over the pandemic and decreased in the general population and those with autism since recovery.

Background Healthcare workers (HCWs) face substantial daily work-related pressures, leading to frequent reports of depression, anxiety and post-traumatic stress disorder (PTSD) symptoms. Objective To compare the effects of Self-Help Plus in its digital version Doing What Matters in Times of Stress (DWM) to an equally structured activity in reducing anxiety and/or PTSD symptoms among HCWs. Methods We compared the proportion of participants with moderate-to-severe anxiety (General Anxiety Disorder Scale; GAD-7 ≥10) and/or PTSD symptoms (Impact of Event Scale-Revised (IES-R)) ≥26) between DWM and the alternative activity. We used an intention to treat analysis and performed 2 tests at 1 and 14 weeks. We assessed compliance (≥five logins) and conducted per-protocol analyses. We also analysed GAD-7 and IES-R scores as continuous outcomes. Possible differential effectiveness was also assessed through login frequency. Findings At 14 weeks, 14.5% of DWM and 27.6% of control participants showed at least moderate anxiety and/or PTSD symptoms (2=3.712, p=0.054). Among those with ≥five logins, DWM participants had fewer moderate symptoms (10.6% vs 31.4%, p=0.012), with reductions in anxiety (6.3% vs 19.6%, p=0.049) and PTSD symptoms (6.4% vs 27.5%, p=0.006). At 1 week, 30.6% of DWM and 28.2% of control participants reported moderate symptoms (2=0.113, p=0.736). Interaction analysis suggested compliance influenced outcomes (OR 4.560, p=0.096 at 14 weeks; OR 0.266, p=0.067 at 1 week). Conclusions DWM is a promising strategy to reduce moderate-to-severe PTSD and/or anxiety symptoms in HCWs. Compliance is crucial to ensure efficacy. Clinical implications DWM is a scalable digital tool that could be considered as an intermediate or complementary intervention for distressed HCWs.

Climate change poses enormous, rapidly increasing risks to human well-being that remain poorly appreciated. The growing understanding of this threat has generated a phenomenon often called ‘eco-anxiety’. Eco-anxiety (and its synonyms) is best documented in the Global North, mostly among people who are better educated and whose reasons for concern are both altruistic and self-interested. However, the populations who are most vulnerable to climate change are disproportionately poor and live in the Global South, where evidence for eco-anxiety (or climate) anxiety is limited, especially among those who have been called the ‘bottom billion’, approximately the global population’s poorest decile. Here, I postulate reasons for this research gap as both ethical and practical. Additionally, the bottom billion experience many disadvantages, some of which plausibly lower their recognition of anthropogenic climate change. These disadvantages include nutritional and health factors that can reduce learning capacity, even if access to formal education exists. Many in this population have limited or no electronic access to information. Furthermore, the relationship between the stresses faced by such populations and climate change is often indirect, potentially also disguising recognition of the role of climate change. The world is characterised by many distressing forms of inequality, one of which is the effective ‘invisibilisation’ of the bottom billion. This group faces many challenges; some of these may exceed climate change as rational causes for anxiety. However, it is here argued that policy makers should act on their behalf, irrespective of evidence that they experience eco-anxiety.

Background The increasing prevalence of mental health disorders among adolescents highlights the importance of early identification and intervention. Artemis-A is a web-based application of computerised adaptive testing (CAT), originally developed for secondary schools, to quickly and efficiently assess students’ mental health. Due to its speed, reliability and accessibility, it may be a valuable tool for healthcare practitioners (HCPs) working with children and young people (CYP) in primary, community and potentially secondary care settings in the future. Objective To explore whether Artemis-A would be a useful, feasible and acceptable tool for HCPs working in primary and community care settings to identify CYP’s mental health difficulties. Methods Semistructured interviews were conducted with 20 HCPs: 5 general practitioners, 5 Child and Adolescent Mental Health Services (CAMHS) staff, 5 school nurses and 5 community paediatricians. Data were analysed using the Framework approach. Findings HCPs reported that Artemis-A has the potential to enhance mental health assessment and aid overburdened services by providing a quick, patient-centred assessment and monitoring mechanism. Benefits of the app include facilitating earlier intervention and appropriate referrals. However, some concerns emerged about safety netting and the way Artemis-A presents its information. Responsibilities for ensuring care continuity also require careful clarification. Conclusions With proper protocols and integration, Artemis-A could prove valuable in supporting HCPs to promptly detect mental health issues in CYP. Further research into optimal implementation is warranted. Clinical implications If paired with effective evidence-based interventions, the implementation of Artemis-A could help manage escalating demands in CAMHS.

Background Little is known about the impact of healthcare structural changes and socioeconomic indices, such as deprivation, mental health needs, and inequalities, on attention-deficit hyperactivity disorder (ADHD) medication prescribing across different regions in England. Objective The objective was to examine trends in ADHD medication prescribing and explore their association with socioeconomic factors. Methods A population-level observational study was conducted using the English Prescribing Dataset (from April 2019 to March 2024) published by the NHS Business Services Authority and the OpenPrescribing platform (Bennett Institute for Applied Data Science, University of Oxford). The study examined trends in five licensed ADHD medications at national, regional and integrated care board (ICB) levels, using linear regression and a generalised additive model to explore the association between socioeconomic factors and prescription rates. Findings The prescriptions increased significantly from 25.17 items per 1000 population in 2019/20 (pre-COVID-19) to 41.55 items in 2023/24 (post-COVID-19), with an average annual increase of 18% nationally. Methylphenidate remained the most prescribed medication, while lisdexamfetamine showed the highest growth rate (55% annually, 95% CI 40% to 71%, p<0.01). Significant regional variations were observed, with London experiencing the highest annual increase (28%), and the Northeast and Yorkshire the lowest (13%). Socioeconomic factors, including ethnicity and deprivation, were significantly associated with ADHD prescription rates (p<0.05). Conclusions Findings reveal a substantial increase in ADHD medication use in England following the COVID-19 pandemic, with significant variations at regional and ICB levels and complex socioeconomic influences. Clinical implications Findings highlight the need to understand and address drivers of disparities in ADHD care while optimising management strategies across diverse populations.

Most low- and middle-income countries (LMICs) have poor or non-existent mental healthcare. Many of LMIC countries allocate less than 1% of their health budgets to addressing mental illness, making large-scale public health interventions not a practical option, at least for the foreseeable future. Psychiatric services are limited to large urban centres, and mental health literacy is low. There is increasing international recognition of the need to build capacity to strengthen mental health systems in LMICs. The aim of this paper is to offer a reflective commentary on our research undertaken over 15 years in Pakistan psychiatric services to create a workforce and culturally adapted cognitive behaviour therapy (CBT) model for LMICs that works for diverse communities served. The exemplar of our work discussed in this article can be used as lessons for developing mental health therapies for LMICs and other countries with diverse communities globally. Our discussion is based largely, if not, on all aspects describing the key barriers and facilitators to implementation of a workable culturally adapted CBT model for use in Pakistan or any similar LMICs. We report on the implementation of culturally adapted CBT in Pakistan over the past 15 years to improve the identified gaps in evidence. We also highlight the successful dissemination strategies our group employed for successful adaption and implementation.

Question Evidence on the likelihood of receiving rapid tranquillisation (RT) across ethnic groups is mixed, with some studies suggesting that ethnic minorities are more likely to receive RT than others. We aimed to investigate the association between ethnicity and RT use in adult mental health inpatient settings and to explore explanations for RT use in relation to ethnicity. Study selection and analysis We searched six databases, grey sources, and references from their inception to 15 April 2024. We included studies reporting the association between RT and ethnic groups in adult mental health inpatient settings. A meta-analysis with a random-effects model was performed using odds ratio (OR) to estimate the association. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the overall certainty of the evidence. We reported narratively any explanations for RT use in relation to ethnicity. PROSPERO: CRD42024423831. Findings Fifteen studies with 38 622 individuals were included, mainly using white or native as the ethnic majority group compared with other ethnic groups. Individuals from ethnic minority backgrounds were significantly more likely to receive RT than those with ethnic majority backgrounds (OR=1.49; 95% confidence interval (CI): 1.25 to 1.78; moderate certainty), corresponding to a relative risk of 1.32 (95% CI: 1.17 to 1.48). Conclusion Disparities appear to exist in RT use across ethnic groups in adult mental health inpatient settings, disproportionately affecting ethnic minorities. Further research is required to gain a more comprehensive understanding of this issue.

In the mental health research field, there is a need for effective and robust methodological approaches that are able to address complexity. In this article, we reassert the importance of mixed methods, an approach increasingly applied within mental health research, and examine the ongoing challenges in the field. We provide worked examples from our own research to demonstrate the diverse range of designs and benefits afforded by mixed methods approaches, along with personal reflections on barriers navigated. We outline pathways towards advancing mixed methods in mental health research, advocating for a shift from fragmentation to integration, improved publication routes for mixed methods studies and effective resourcing. To truly realise the potential of mixed methods, we call for a commitment from individual researchers, leaders, institutions, editors, funders and training providers to further these pathways.

Background There are long-standing ethnic and racial inequalities in experiences and outcomes of severe mental illness, including compulsory admission and treatment (CAT). Aims To gather professional experiences about (1) remedies for ethnic inequalities in the use of the Mental Health Act ((MHA) 1983 and 2007) and (2) recommendations for improving care experiences and for reducing ethnic inequalities. Method We undertook a participatory research process using photovoice to gather experience data. Photographs were assembled and narrated by 17 professionals from a variety of disciplines. We undertook a thematic analysis. Results Ineffective communications between inpatient and community services, insufficient staff capacity, a lack of continuity of care and language and cultural constraints meant MHA assessments were lacking information, leading to elevated perceptions of risk. Practitioners felt helpless at times of staff shortages and often felt CAT could have been prevented. They felt voiceless and powerless and unable to challenge stereotypes and poor practice, especially if they were from a similar demographic (ethnicity) as a patient. Interdisciplinary disagreements and mistrust led to more risk-aversive practices. The legislation created an inflexible, risk-averse and defensive process in care. Police involvement added to concerns about criminalisation and stigma. There were more risk-averse practices when team members and families disagreed on care plans. More rehabilitation and recovery-orientated care are needed. Legislative compliance in a crisis conflicted with supportive and recovery-orientated care. Conclusion Clear standards are needed, including specific protocols for MHA assessment, police interactions, alternatives to admission, early intervention and continuity of care.

Background The subcallosal cingulate gyrus (SCG) is integral to cognitive function and mood regulation. Open-label SCG deep brain stimulation (DBS) studies demonstrate improvement or stabilisation of cognitive function in treatment-resistant depression (TRD). Objective This randomised controlled study aims to evaluate the neuropsychological effects of SCG-DBS. Methods 35 participants with TRD received active or sham stimulation over two 3-month periods. A neuropsychological battery was administered to assess processing speed, learning and memory, and cognitive flexibility. Composite measures were derived for each domain after Period I. A mixed model for repeated measures analysis was performed for each test, with further analysis of significant measures to determine sustainability after Period II. Findings No significant differences in changes in depression scores were observed between groups. There were no significant deteriorations in cognitive performance following active SCG-DBS. Category Fluency Test performance improved after 3 months of active SCG-DBS (p=0.002); however, this was non-significant after correcting for multiple comparisons and was not observed after Period II (p=0.615). Conclusion and implications While no cognitive deterioration was observed following SCG-DBS, significant improvements in cognitive function were not evident. There may be a transient enhancement in processing speed; however, this effect is not fully understood. Future studies should include larger cohorts and extended stimulation periods to explore the long-term effects of SCG-DBS in TRD and the sustainability of improvements in cognitive domains.

Background People with severe mental illness (SMI) are at increased risk of cardiovascular disease (CVD), and initiatives for CVD risk factor screening in the UK have not reduced disparities. Objectives To describe the annual screening prevalence for CVD risk factors in people with SMI from April 2000 to March 2018, and to identify factors associated with receiving no screening and regular screening. Methods We identified adults with a diagnosis of SMI (schizophrenia, bipolar disorder or ‘other psychosis’) from UK primary care records in Clinical Practice Research Datalink. We calculated the annual prevalence of screening for blood pressure, cholesterol, glucose, body mass index, alcohol consumption and smoking status using multinomial logistic regression to identify factors associated with receiving no screening and complete screening. Results Of 216 136 patients with SMI, 55% received screening for all six CVD risk factors at least once during follow-up and 35% received all six within a 1-month period. Our findings suggest that patient characteristics and financial incentivisation influence screening prevalence of individual CVD risk factors, the likelihood of receiving screening for all six CVD risk factors annually and risk of receiving no screening. Conclusions The low proportion of people with SMI receiving regular comprehensive CVD risk factor screening is concerning. Screening needs to be embedded as part of broad physical health checks to ensure the health needs of people with SMI are being met. If we are to improve cardiovascular health, interventions are needed where risk of receiving no screening or not receiving regular screening is highest.

Background The SARS-CoV-2 pandemic was a major stressful event that significantly affected healthcare providers. Objective To evaluate the efficacy of a single-session intervention (SSI), with and without weekly personalised prerecorded videos, in preventing emotional distress worsening. Methods Nationwide randomised clinical trial conducted in Brazil from 19 May 2020 to 31 December 2021. We included healthcare professionals with anxiety, depression or irritability scores below a T-score of 70, measured by the Patient-Reported Outcomes Measurement Information System. Participants were randomised to SSI or SSI plus weekly personalised prerecorded videos for 4 weeks (SSI-ET). The primary outcome was the proportion of participants with a significant escalation of symptoms (ie, T-score above 70). Findings From 3328 assessed for eligibility, 1112 participants were randomised (SSI=549; SSI-ET=563). The cumulative proportion of incident cases at 6 months was 17.5% (95% CI: 13.1% to 21.6%) for SSI and 15% (95% CI: 10.9% to 18.8%) for SSI-ET, with no difference between groups (HR=0.81, 95% CI: 0.83 to 1.79). Both groups showed significant symptom reductions at 1 month follow-up, maintained at 3 and 6 months (Cohen’s d=0.68–1.08). Conclusions Adding asynchronous videos to SSI provided no additional benefit. While symptom improvements occurred over time, the lack of a control group limits conclusions about intervention efficacy. Clinical implications Given its simplicity and scalability, the synchronous component, which includes core mental health support elements, such as active listening, validation, and empathic care, may represent a feasible way to assist healthcare professionals in crisis settings, even though further research is needed to determine its specific impact. Trial registration number NCT04632082.

Background Mood is known to change over seasons of the year, days of the week, and even over the course of the day (diurnally). But although broader mental health and well-being also vary over months and weeks, it is unclear whether there are diurnal changes in how people experience and report their mental health. Objective To assess time-of-day association with depression, anxiety, well-being and loneliness. Methods The study analysed data from 49 218 adults drawn from the University College London COVID-19 Social Study, which gathered detailed repeated measurements from the same participants across time over a 2-year period (March 2020–March 2022, 18.5 observation per person). Data were analysed using linear mixed-effects models. Findings There is a clear time-of-day pattern in self-reported mental health and well-being, with people generally waking up feeling best and feeling worst around midnight. There is also an association with day of the week and season, with particularly strong evidence for better mental health and well-being in the summer. Time-of-day patterns are moderated by day, with more variation in mental health and individual well-being during weekends compared with weekdays. Loneliness is relatively more stable. Conclusions Generally, things do seem better in the morning. Hedonic and eudemonic well-being have the most variation, and social well-being is most stable. Clinical implications Our findings indicate the importance of considering time, day and season in research design, analyses, intervention delivery, and the planning and provision of public health services.

As the global impacts of climate change become more apparent, there is a corresponding increase in the psychological effects of the phenomenon, including climate change anxiety, stress and helplessness or hopelessness. Positive psychology provides a promising approach for tackling these mental health challenges by consolidating mental strength and building resilience. In this article, we consider how positive psychological coping mechanisms can lessen the negative impacts of climate change on mental health, especially in vulnerable populations. Based on evidence-based concepts such as psychological capital, positive psychology interventions seek to empower individuals, bolstering their capacity for optimism, self-efficacy and problem solving. By transforming anxiety into proactive behaviour, interventions such as mindfulness, cognitive reframing and encouraging environmental engagement could assist individuals in navigating the emotional toll of climate change. Although these strategies are not a solution to the climate crisis itself, they are adaptative strategies that equip individuals and communities with the means to cope with climate-related challenges more effectively and take positive actions. This perspective note also addresses the significance of incorporating these techniques into public health educational initiatives and policy-making, highlighting the necessity of accessible interventions that can be tailored to various cultural and socioeconomic contexts. Accordingly, we specifically discuss how positive psychology can be leveraged to foster resilience and hope, providing insight into how these concepts can support mental health and well-being in an era of climate change crisis.

Background Evidence regarding early interventions based on the Naturalistic Developmental Behavioral Interventions framework, such as the Early Start Denver Model (ESDM), suggests efficacy for autistic children. However, the effectiveness of ESDM across diverse cultural contexts remains under-researched. Objective To assess the effectiveness of ESDM compared with treatment as usual (TAU) on overall development in young children with autism spectrum disorder (ASD). Method This parallel, randomised controlled trial, using a modified Zelen design, was conducted in five Child and Adolescent Mental Health Services in France and Belgium. A total of 180 children aged 19–36 months, who met autism criteria and were referred by community professionals, were randomly assigned to either receive 12-hour weekly ESDM+TAU or TAU alone. The primary outcome was the change in developmental quotient (DQ) on the Mullen Scale of Early Learning, assessed blindly from baseline to 24 months post randomisation. Findings From September 2015 to March 2019, 180 children were randomly assigned to either ESDM+TAU (n=61, girls=21.7%) or TAU alone (n=119, girls=15.4%). Three children dropped out immediately after randomisation. Compared with TAU alone, children in the ESDM+TAU group did not significantly improve global DQ (endpoint mean difference 3.82 (95% CI –1.25 to 8.89), p=0.14). Conclusions and clinical implications Our findings suggest that ESDM+TAU cannot be universally recommended for young children with ASD. Further research is required to evaluate the long-term effectiveness of ESDM and identify subgroups that may benefit more, thereby guiding optimal implementation strategies. Trial registration number NCT02608333.

Background Evidence-based mental health requires patient-relevant outcome data, but many indicators lack clinical meaning and fail to consider youth perceptions. The minimally important change (MIC) indicator designates change as meaningful to patients, yet is rarely reported in youth mental health trials. Objective This study aimed to establish MIC thresholds for two patient-reported outcome measures (PROMs), the Columbia Impairment Scale (CIS) and the Strengths and Difficulties Questionnaire (SDQ), using different estimation methods. Methods A sample of 247 youths (14–17 years) completed the CIS and SDQ at baseline and at 6 months in a youth mental health and substance use trial. At 6 months, youths also reported perceived change. Three anchor-based (mean change, receiver operating characteristic analysis, predictive modelling) and three distribution-based methods (0.5 SD, measurement error, smallest detectable change) were compared. Findings Different methods yielded varying MIC thresholds. Predictive modelling provided the most precise anchor-based MIC: –2.6 points (95% CI –3.6, –1.6) for the CIS and –1.7 points (95% CI –2.2, –1.2) for the SDQ, indicating that score improvements of 12% for the CIS and 8% for the SDQ may be perceived as ‘important’ by youths. However, correlations between change score and anchor were below 0.5 for both measures, indicating suboptimal anchor credibility. Stronger correlations between the anchor and T2 PROM scores compared with T1 scores suggest the presence of recall bias. All MIC estimates were smaller than the smallest detectable change. Conclusions Predictive modelling offers the most precise MIC, but limited anchor credibility suggests careful anchor calibration is necessary. Clinical implications Clinicians may consider the MIC CI as indicative of meaningful change when discussing treatment impact with patients. Trial registration number NCT02836080.

Background Psychological prevention programmes delivered in schools may reduce symptoms of depression. However, high-quality, large-scale trials are lacking. Objective The aim was to examine whether a digital cognitive–behavioural programme (‘SPARX’), delivered at scale in schools, would reduce depressive symptoms 12 months later. Methods A cluster randomised controlled trial with parallel arms (intervention; control) was conducted in Australian schools, between August 2019 and December 2022. Cluster randomisation occurred at the school level (1:1 allocation). Investigators were blind to group allocation, and outcomes were assessed at baseline, 6 weeks, 6 months (primary outcome only) and 12 months post baseline. The intervention was delivered via smartphone app. Schools were instructed to provide in-class time for intervention completion. The primary outcome was the difference in depressive symptom change from baseline to 12 months between the intervention and control group. Secondary outcomes were change in anxiety, psychological distress and insomnia. Findings 134 schools participated in this study, and baseline data were collected from n=6388 students (n=3266 intervention; n=3122 control). Intent-to-treat analyses showed no difference in depression change between groups from baseline to 12 months, (mean change difference= –0.05, z= –0.32, 95% CI: –0.36 to 0.23, p=0.75). There were no differences on secondary outcomes. Many schools did not provide in-class time for intervention completion, and engagement was low (22% completion rate). Conclusions Scaled delivery of a digital cognitive–behavioural programme did not reduce symptoms of depression, relative to a control group. Clinical implications Given the variability in the engagement with and delivery of the digital universal cognitive–behavioural programme, caution is required prior to scaled delivery of SPARX in school contexts. Trial registration number ACTRN12619000855123.

Background There have been few rigorous evaluations of population, multi-strategy, suicide prevention programmes, despite increasing global recognition that such approaches are needed to reduce suicide. Objective To examine the effects of a multi-strategy suicide prevention model on age-standardised rates of hospital presenting self-harm and suicide after 24 months of implementation. Methods A stepped-wedge cluster randomised trial was conducted in four sites across New South Wales (NSW), Australia, from 2016 to 2020. Sites were randomised to a starting order and implemented the same set of interventions over a 24-month period. Changes in rates of hospital presenting self-harm and suicide deaths were measured using linked administrative health data sets of persons aged 10 or older. Results Negative binomial regression models adjusted for linear trends and seasonality showed that LifeSpan was associated with a 13•8% (incident response rate 0.86; 95% CI 0.79 to 0.94) reduction in hospital-presenting self-harm rates over the intervention period, compared with preintervention. These effects were not observed in the rest of NSW. There were statistically non-significant changes in suicide death rates during the intervention across all sites. Conclusions Locally implementing a multi-strategy suicide prevention model can reduce rates of hospital presentations for self-harm, but longer implementation and evaluation periods may be required to realise the full impacts of interventions for suicide, as a more intractable outcome. Clinical implications Our findings can inform policy at all levels of government to invest in actions that may build cross-sectoral capacity in local communities to detect and respond to suicide risk.

Background Cognitive deficits and reduced dopamine transporter (DAT) binding ratio have been reported in Parkinson’s disease psychosis (PDP). However, it remains unclear whether DAT striatal binding ratio (SBR) may contribute to worsening cognitive performance in PDP. Objectives We examined this using data from the Parkinson’s Progression Markers Initiative. Methods We analysed data from 392 PD patients, from baseline to year 4 follow-up, and classified patients into PD with psychosis (PDP) and without psychosis (PDnP). DAT SBR was available from 123I-FP-CIT-SPECT [(123) I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl) nortropane single photon emission computed tomography] imaging. We examined all cognitive measures assessed at each time point; sociodemographic characteristics, neuropsychiatric and PD-specific symptoms were entered as covariates of interest. Findings PDP patients had lower DAT SBR compared with PDnP patients (b=–0.092, p=0.035) over all time points, which remained significant after controlling for age, sex and ethnicity. PDP patients also reported worse trajectory of task performance on the Montreal Cognitive Assessment (MoCA) (b=–0.238, p=0.001) and symbol digit modality (b=–0.534, p=0.016) compared with PDnP patients. Declining performance in symbol digit modality (GroupxTimexDAT SBR interaction, b=0.683, p=0.028) but not MoCA was differentially associated with the decline in DAT SBR over time. MoCA scores declined more in PDP compared with PDnP patients over all timepoints (GroupxTime interaction, b=–0.284, p=0.016). Conclusions Decline in striatal presynaptic dopamine function may specifically underlie longitudinal decline in performance in the symbol digit modality task that engages processing speed, associative learning and working memory in PD psychosis. Whether striatal presynaptic dopamine changes explain accelerated longitudinal decline in other cognitive domains in people with PDP remains to be tested.

Background The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), a questionnaire designed for the assessment of mental well-being, is widely used in different countries and cultures worldwide. However, there is a lack of studies examining its metric performance and measurement invariance across countries. Objective This study aims to examine the internal structure, reliability and cross-country validity of the WEMWBS in three European populations. Methods WEMWBS data collected in 2016 from three representative population health surveys from an autonomous region in Spain (Catalonia) and two countries (Denmark and the UK) were used (n=13 940). The mean WEMWBS Scores were compared between populations. The internal consistency ( coefficients), internal structure (confirmatory factor analyses (CFA) and bifactor exploratory structural equation models), reliability (item response theory models, item and test information functions), and cross-cultural comparability (multigroup CFA) of the WEMWBS were assessed. Findings Differences in mean scores observed between regions merit further study. The WEMWBS showed high internal consistency across countries (=0.942). The unidimensionality of the scale was confirmed overall and for each population. Evidence of reliability and of measurement invariance at the configural, scalar and metric levels was found. Conclusions and implications The results support the use of the WEMWBS in different cultures to inform the understanding of population well-being in public health and its possible use as an outcome measure in clinical studies.

Background Approximately 30% of women experience intimate partner violence (IPV) in their lifetime, often with traumatic brain injury (TBI) exposure. Nevertheless, there has been limited research exploring lifelong brain health outcomes following IPV with TBI. To address this, we investigated the relationship between IPV, TBI and midlife mental health outcomes within an observational cohort study. Methods PREVENT Dementia is a cohort study with participants recruited aged 40–59 years for longitudinal measures of brain health. Participants reporting histories of IPV-related physical abuse (IPV-PA) at study recruitment were identified and compared with control participants with no IPV-PA exposure regarding histories of TBI and prevalence of lifetime and ongoing mental health outcomes using standardised assessments. Results Among 632 participants, 90 (14%) reported IPV-PA history. Compared with unexposed participants, history of IPV-PA was associated with higher TBI exposure, together with higher lifetime and ongoing diagnoses of depression, anxiety and sleep disorders, and post-traumatic stress disorder (PTSD) symptomology. Notably, the risk of ongoing and concurrent midlife mental health disorders remained despite IPV-PA exposure having ceased on average 27 years before assessment. History of TBI in individuals with IPV was associated with increased risk of ongoing PTSD symptomology and concurrent mental health outcomes. Conclusions Our data confirm high TBI exposure among individuals with a history of IPV-PA, while also demonstrating that this population shows higher rates of ongoing adverse mental health outcomes in midlife, often decades after abuse. This work underlines the prevalence of IPV-PA and the necessity to consider TBI exposure and long-term brain health outcomes among this population.

Aim The adoption of artificial intelligence (AI) tools is gaining traction in maternal mental health (MMH) research. Despite its growing usage, little is known about its prospects and challenges in low- and middle-income countries (LMICs). This study aims to systematically review articles on the role of AI in addressing MMH in LMICs. Methods This systematic review adopts a patient and public involvement approach to investigate the role of AI in predicting, diagnosing or treating perinatal depression and anxiety (PDA) among perinatal women in LMICs. Seven databases were searched for studies that reported on AI tools/methods for PDA published between January 2010 and July 2024. Eligible studies were identified and extracted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Covidence, and the data were synthesised using thematic analysis. Results Out of 2203 studies, 19 studies across eight countries were deemed eligible for extraction and synthesis. The review revealed that the supervised machine learning method was the most common AI approach and was used to improve the early detection of depression and anxiety among perinatal women. Additionally, postpartum depression was the most frequently investigated MMH condition in this study. Further, the review revealed only three conversational agents (CAs)/chatbots used to deliver psychological treatment. Conclusions The findings underscore the potential of AI-based methods in identifying risk factors and delivering psychological treatment for PDA. Future research should investigate the underlying mechanisms of the effectiveness of AI-based chatbots/CAs and assess the long-term effects for diagnosed mothers, to aid the improvement of MMH in LMICs. PROSPERO registration number CRD42024549455.

Background The Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Åsberg Depression Rating Scale (MADRS) are the two most common clinician-rated scales to quantify depression symptom change in repetitive transcranial magnetic stimulation (rTMS) trials. However, it is unclear how the values of one scale translate to the other. Being able to translate scores between these scales could allow for aggregating rTMS clinical trial data. Methods Clinical data from two randomised rTMS clinical trials (FOURD and CARTBIND, total N=380) were pooled. We used five crosswalk models: (1) a pharmacotherapy equipercentile model, (2) an rTMS equipercentile model, (3) a linear regression model, (4) a random forest (RF) regression model and (5) a support vector regression (SVR) model. Model performance was benchmarked using the root mean square error (RMSE). Results The linear regression model demonstrated the best performance (RMSE: 2.66–4.82), though the SVR model’s performance was slightly worse but comparable (RMSE: 2.69–5.32). The RF regression model generally performed worst (RMSE: 2.70–5.20). The rTMS equipercentile model’s performance was intermediate (RMSE: 2.69–5.32) in the primary analysis but achieved superior performance and demonstrated less bias in the additional analysis. Interpretation MADRS and HRSD scores from rTMS trials can be accurately converted between each other. The optimal model was the newly developed equipercentile model, though the results of the SVR model were promising. Nevertheless, independent external replication is required to demonstrate the external validity of these findings. Trial registration number FOURD: NCT02998580; CARTBIND: NCT02729792.

Background Rates of common mental disorders (CMDs) including anxiety, depression and stress, treated in primary care have increased among young adults, but it is unclear if this reflects more help-seeking and/or an increase in symptoms, and if there are differences across sociodemographic groups. Objective This study examined trends in primary care-recorded CMD and self-reported psychological distress symptoms in young adults over time. Methods We used data from participants born between 1980 and 2003 in two datasets: UK primary care records and longitudinal cohort data. Participants were followed from age 16 to age 39 (maximum) or the end of the follow-up (2019–2020). Annual incidence rates of recorded CMD overall and by sociodemographic group were calculated for 2009–2019, using incidence rate ratios to explore changes. We calculated annual self-reported psychological distress symptoms from cohort data, calculating ratios to explore changes over time. Findings Between 2009 and 2019, recorded CMD increased by 9.90%, while average psychological distress symptoms rose by 19.33%. The sharpest increases for both recorded CMD and average psychological distress symptoms were observed in older adolescents (ages 16–19) and those born after 1995. Recorded CMD increased more in males (20.61%) than in females (7.65%), despite similar symptom increases. Recorded CMD increased the most in the least deprived areas (16.34%) compared with the most deprived areas (3.55%), despite comparable rises in psychological distress symptoms. Conclusions Both recorded CMD and psychological distress symptoms in young adults increased between 2009 and 2019, which may indicate that the rising primary care-recorded CMD reflects increased symptom burden. Implications Differences between recorded CMD and psychological distress symptoms across sociodemographic groups highlight potential misalignment in mental healthcare with underlying population need, indicating that the most affected groups may not be those receiving the most care.

We argue that psychiatry has overlooked a significant modifiable risk factor for mental illness in female patients: cyclical symptoms associated with the menstrual cycle. Premenstrual dysphoric disorder has recently been included in the International Classification of Diseases-11, while there is growing evidence that menstrual cycle stage can impact mental health symptoms transdiagnostically and influence important outcomes such as suicide or admission to hospital. Intervention is possible using existing widely available hormonal treatments. Asking patients about the relationship between their menstrual cycle and mental health is an opportunity to improve diagnosis and treatment that should no longer be neglected.

Background Anaemia during pregnancy is associated with maternal depressive symptoms during pregnancy and the postpartum period. However, the effect of anaemia development during pregnancy on maternal psychological health in non-anaemic women remains unclear. Objective To investigate the effect of anaemia development during pregnancy on maternal psychological health during pregnancy and the postpartum period. Methods This study includes a secondary analysis of data collected prospectively from the Korean Pregnancy Outcome Study. Depression and anxiety were evaluated in each trimester and 4–6 weeks postpartum. The Hospital Anxiety and Depression Scale was used for anxiety and the Edinburgh Postnatal Depression Scale for depression. Findings Among 3310 women with normal haemoglobin concentrations in the first trimester, 270 (8.1%) developed anaemia in the third trimester. Depression during the first trimester and anxiety during the second trimester were significantly more frequent among patients who later developed anaemia in the third trimester than among those who did not. Even after adjusting for confounding factors, anaemia development during pregnancy was significantly associated with increased risks of depression during the first trimester (aOR, 1.45; 95% CI, 1.07 to 1.96; p=0.017) and anxiety during the second trimester (aOR, 1.57; 95% CI, 1.04 to 2.38; p=0.033), respectively. Conclusions and clinical implications Among women who were non-anaemic in the first trimester and developed anaemia by the third trimester, higher risks of maternal depression and anxiety were observed during the first and second trimester, respectively. It suggests that a decrease in haemoglobin concentrations during pregnancy negatively impacts on maternal psychological health.

Background Existing health inequalities and the lack of timely and appropriate support have long been a reality for many ethnic minority individuals living with mental health conditions, even before the pandemic. Limited access to services and the absence of culturally or religiously embedded care have led to increased severity of mental health problems. Objective To explore the complexity of interactions between ethnic minorities and mental health services and their experiences of seeking and receiving mental health support throughout the pandemic. Methods Semi-structured interviews with purposive and snowball sampling of ethnic minorities aged over 18 (n=32) across North East and North West in England were analysed using a framework approach. Findings Five themes were generated. Cultural stigma attached to mental health could lead to fear and reluctance to seek support. Individuals struggled to engage with non-culturally sensitive health services. Instead, they indicated a strong preference for wider community support, which continued through the pandemic despite interrupted health services. A collaboration between mental health services and ethnic minority communities was advocated to shape services to cultural contexts and improve patient-centred service delivery. Conclusions Ethnic minorities with mental health face significant challenges and disparities in seeking and engaging in mental health services. They often seek support from multicultural community settings even though the support is not specifically targeted at addressing mental health issues. Understanding cultural beliefs, religious influences and family and community structures are necessary components of culturally appropriate care. Clinical implications Culturally sensitive mental health services need to be integrated into existing systems through initiating collaborations with ethnic minority communities that tailor services to meet the needs of diverse populations, improving overall engagement and experiences.

Background Metformin is a pharmacological candidate to mitigate second-generation antipsychotic (SGA)-induced weight gain in patients diagnosed with severe mental illnesses (SMI). Objective To determine the incidence, prevalence and demographic patterns of metformin co-prescription among patients diagnosed with SMI initiating SGAs. To estimate the impact of metformin co-prescription on weight over 2 years post-SGA initiation. Methods A cohort study of patients diagnosed with SMI initiating aripiprazole, olanzapine, quetiapine or risperidone in 2005–2019 using primary care data from Clinical Practice Research Datalink. We estimated cumulative incidence and period prevalences of co-prescription and explored prescribing differences by demographic and clinical factors. We compared weight change among patients prescribed an SGA-only versus an SGA plus metformin, accounting for confounders using linear regression. Findings Among 26 537 patients initiating SGAs, 4652 were ever prescribed metformin and 21 885 were not. The two-year incidence of first metformin prescription was 3.3%. The SGA plus metformin group were more ethnically diverse, had greater social deprivation, more comorbidities and higher baseline weight (mean 90.4 vs 76.8 kg). By 2 years post-SGA initiation, mean weight in the SGA-only group had changed by +4.16% (95% CI –1.26 to +9.58) compared with –0.65% (95% CI –4.26 to +2.96) in the SGA plus metformin group. After confounder adjustment, the 2-year mean difference in weight with metformin co-prescription was –1.48 kg (95% CI –4.03 to 1.07) among females and –1.84 kg (95% CI –4.67 to 0.98) among males. Conclusion Metformin is infrequently co-prescribed, despite apparent efficacy and guidelines. Clinical implications Primary and secondary care collaboration should be strengthened and barriers to co-prescribing addressed.

Background Rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) are autoimmune illnesses characterised by chronic inflammation demonstrating differential associations with psychiatric conditions. Objective In this matched-cohort study, we aimed to investigate whether the associations between these inflammatory illnesses and mental disorders are predominantly the consequence of the burden of the former or whether common causes might underpin the susceptibility to both. Methods Using Czech national inpatient care data, we identified individuals with RA or axSpA during the years 1999–2012. We investigated the occurrence of psychiatric outcomes up to 2017 using stratified Cox proportional hazards models. In evidence triangulation, we assessed the potential moderation by age at inflammatory illness, the associations relative to counterparts with other similarly burdensome chronic illnesses and the temporal ordering of conditions. Findings Both RA and axSpA were associated with mood and anxiety disorders and behavioural syndromes. In evidence triangulation, the associations with depression showed a decreasing age-at-inflammatory-illness gradient in RA; the association between RA and depression was stronger than that between other chronic illnesses and depression; and excluding prevalent depression attenuated the RA–depression association. RA showed consistent inverse associations with schizophrenia and Alzheimer’s disease. Conclusions Common aetiologies might be involved in increasing the risk of developing both RA and depression. The consistent inverse associations between RA and schizophrenia and between RA and Alzheimer’s disease suggest that at least part of these associations might also be a consequence of shared aetiologies as well as potential medication effects. Clinical implications People with autoimmune arthritides are more likely to experience mood and anxiety disorders, even relative to counterparts with other similarly burdensome chronic illnesses.

Background Adolescent mental health problems and mental health help-seeking have increased in the later decades. We aimed to assess to which extent adolescents with high mental health symptom loads received help in general practice or specialist mental health services, and whether parental education influenced the association. Methods This cohort study included 7554 Norwegian adolescents who participated in the population-based Young-HUNT4 Survey (2017–2019). They reported their mental health by the Strengths and Difficulties Questionnaire (SDQ), measuring both internalising and externalising symptoms, summed up to a Total Difficulties score. During 1 year after participation, data on contacts with and diagnoses from general practice and specialist mental health services were collected from national registries. We used generalised linear models to analyse the probability of contact with general practice and specialist mental health services by low, moderate and high SDQ scores. We evaluated effect measure modification using interaction terms. Results Among adolescents with high total, internalising or externalising SDQ scores, 29–31% of females and 19–21% of males consulted a general practitioner for mental health problems, compared with 9–10% and 6–7% among those with low scores. Males and females with high internalising scores had a nine times increased risk of specialist mental health service contacts with internalising diagnoses, and similar associations were found for externalising scores and contacts/diagnoses. The associations were largely independent of parental education level. Conclusion Adolescents’ mental health symptom loads were positively associated with health service use in general practice and specialist mental health services and largely independent of parental education.

Background Differentiating major depressive disorder (MDD) from bipolar disorder (BD) remains a significant clinical challenge, as both disorders exhibit overlapping symptoms but require distinct treatment approaches. Advances in voxel-based morphometry and surface-based morphometry have facilitated the identification of structural brain abnormalities that may serve as diagnostic biomarkers. Objective This study aimed to explore the relationships between brain morphological features, such as grey matter volume (GMV) and cortical thickness (CT), and demographic and clinical variables in patients with MDD and BD and healthy controls (HC) using multivariate analysis methods. Methods A total of 263 participants, including 120 HC, 95 patients with MDD and 48 patients with BD, underwent T1-weighted MRI. GMV and CT were computed for standardised brain regions, followed by multivariate partial least squares (PLS) regression to assess associations with demographic and diagnostic variables. Findings Reductions in frontotemporal CT were observed in MDD and BD compared with HC, but distinct trends between BD and MDD were also detected for the CT of selective temporal, frontal and parietal regions. Differential patterns in cerebellar GMV were also identified, with lobule CI larger in MDD and lobule CII larger in BD. Additionally, BD showed the same trend as ageing concerning reductions in CT and posterior cerebellar and striatal GMV. Depression severity showed a transdiagnostic link with reduced frontotemporal CT. Conclusions This study highlights shared and distinct structural brain alterations in MDD and BD, emphasising the potential of neuroimaging biomarkers to enhance diagnostic accuracy. Accelerated cortical thinning and differential cerebellar changes in BD may serve as targets for future research and clinical interventions. Clinical implications Our findings underscore the value of objective neuroimaging markers in increasing the precision of mood disorder diagnoses, improving treatment outcomes.

Question What are the experiences and needs of parents of children and young people (CYP) aged 5–18 with diagnosed mental health difficulties, particularly in relation to the parents’ own well-being? Study selection and analysis A systematic review with thematic meta-synthesis was conducted, including qualitative studies published in English. Seven databases were searched (MEDLINE, PsycINFO, CINAHL Ultimate, AMED, EMBASE, Web of Science and Cochrane Library) from inception to September 2024. Studies focused on parents of CYP aged 5–18 years, where the CYP had a confirmed mental health diagnosis. Findings Of 75 862 screened studies, 46 met inclusion criteria. Six overarching themes were identified: support needs and gaps; impact on everyday life; altered family dynamics; parental worries and fears; emotional experience of caregivers and self-care paradox. Parents face significant challenges, including unmet support needs from healthcare and education systems, substantial impacts on daily life and altered family dynamics. Emotional experiences such as worry, guilt and stigma were pervasive, compounded by systemic gaps in information and resources. Parents often prioritise their child’s needs over their own, creating barriers to self-care. These challenges were consistent across diagnoses but heightened in cases of life-threatening conditions like eating disorders and depression. Conclusions The findings highlight support needs for parents of CYP with mental health difficulties. Tailored interventions, better professional training and family centred care are needed. Future research should focus on developing theoretical models of parental distress to guide interventions and inform support mechanisms that mitigate these broad impacts on parents’ well-being.

Background The prevalence of attention-deficit hyperactivity disorder (ADHD) drug treatment for youth and adults has been rising exponentially in Iceland over the past 15 years. The efficacy of ADHD drugs is not as strongly supported for adults as for children and adolescents, and adult use has been reported to increase the risk of psychosis or mania. Objective To assess the absolute risk of hospitalisation for first-onset psychosis or mania in adults diagnosed with ADHD within 1 year of being prescribed ADHD drugs and to examine the proportional attributable risk. Methods This study included all adults prescribed ADHD drugs in Iceland between 1 January 2010 and 31 December 2022. Records from the Icelandic Prescription Drug Register were linked to the Hospital Discharge Register to identify individuals who were admitted due to psychosis or mania. This risk was compared with the risk of all other first-onset hospitalisations for psychosis, mania or mixed episodes between 1 January 2018 and 31 December 2020. Findings 16 125 individuals aged 18 or older initiated ADHD drug therapy during the study period. Of those, 61 were hospitalised due to first-onset psychosis or mania within a year. This corresponds to an absolute risk of 0.38% for such an admission. The general population risk for all other first-onset hospitalisations for psychosis or mania from 2018 through 2020 for Icelanders aged 18–67 was 0.048%. The estimated relative risk was 7.99 (95% CI 6.06, 10.54), the proportional attributable risk 87.5% and the number needed to harm 302 (95% CI 271, 340). Within 1 year of hospital discharge, 69% (42/61) had been represcribed their ADHD medication, and 26.2% (11/42) of these had to be readmitted for psychosis or mania Conclusions The risk of hospitalisation for psychosis or mania with prescription ADHD drugs is small but real among adults, and represcription is strongly associated with readmission. Clinical implications Clinicians and adults diagnosed with ADHD should be aware of the association between ADHD drugs and the risk of developing psychosis or mania requiring hospitalisation in adults with ADHD.

Background Medical students experience disproportionately high rates of anxiety and depression, and treatment gaps may exist. To date, little is known about how these mental health outcomes have changed over time. Objective To examine recent trends in clinically significant anxiety, depression, suicidal ideation, and counselling service utilisation among US medical students. Methods We analysed five waves of the Healthy Minds Study throughout the academic years between 2018 and 2023. The analytic sample comprised 5313 students enrolled in MD programmes from diverse US universities. Study outcomes included clinically significant anxiety, depression, past-year suicidal ideation, and current counselling use. Weighted prevalences were calculated, and sample-weighted multivariable logistic regression, adjusted for age, sex, race/ethnicity, international status, and socioeconomic status, estimated temporal trends. Findings Between 2018 and 2023, the prevalence of anxiety increased by 12.3 percentage points from 21.6% to 33.9%, depression increased by 13.1 percentage points from 14.0% to 27.1%. and counselling service utilisation increased by 17.2 percentage points from 6.7% to 23.9%. These upward trends remained statistically significant even after adjustment for participants’ demographic differences. Suicidal ideation prevalence remained relatively stable over the same period. Conclusions The prevalence of anxiety and depression among US medical students have increased since 2018, paralleled by more but still insufficient counselling utilisation, suggesting a persistent treatment gap. Suicidal ideation remains concerning among this population with higher acquired capability for suicide over their lifespan. Clinical implications Medical schools should transform temporary support initiatives into enduring institutional strategies and foster school climates that enhance protective factors to promote medical students’ well-being.

Education plays a crucial role in equipping young people with the skills and knowledge necessary to navigate the challenges of adulthood. In the context of the escalating climate crisis, climate change education (CCE) has an essential role in this aim. Despite an increase of research in the area, where young people have been identified as being particularly concerned about climate change, CCE continues to be under-represented in the UK curriculum. This article explores critical considerations for developing an effective approach to CCE. It emphasises the importance of young people’s emotional responses to this aspect of their education that can shape their engagement with the topic. It addresses the need to consider how informal learning through social media and online platforms can have a significant impact on views of the crisis, as well as behaviour. Finally, the article proposes several evidence-based strategies to enhance the integration of CCE into formal education, fostering both critical engagement and actionable understanding among students.

Background and objective In recent years, growing scientific and public awareness has highlighted the negative impacts of climate change on mental health, particularly among young people, who are disproportionately affected. These findings underscore the need for effective and scalable interventions to support individuals experiencing climate change-related distress (CCD). At the initial stage, it is crucial to understand how this distress manifests and what the momentary risk and protective factors are that exacerbate and modulate its dynamic occurrence in everyday life. Methods In this context of need, nine qualitative, semistructured interviews with young individuals, aged between 14 and 25 and living in Germany, with CCD were conducted. Interviews centred on individuals’ burdens, putative triggers eliciting the experience, as well as putative protective factors. We analysed the data and developed themes via Braun and Clarke’s reflexive thematic analysis and electively structured the analysis according to the coding paradigm adopted from Strauss and Corbin. Results Participants reported experiencing a wide range of negative emotions as well as mental health difficulties associated with climate change, including sleep disturbances, reduced well-being and difficulties concentrating. The experience emerges from the understanding and awareness of the complexity of climate change and its associated consequences for the environment. Protective factors were reported, including positive emotions (eg, hope, finding meaning and purpose), self-efficacy, conceptual knowledge about climate change-related emotions and external factors (ie, social support). Participants employed various strategies to regulate their emotions, ranging from avoidance and distraction to strategies like acceptance, cognitive reappraisal and active engagement in pro-environmental behaviour or activism. Conclusion and clinical implications Overall, this study enhances our understanding of young individuals’ emergence and daily life experience of CCD. The findings suggest that a prolonged or overly extensive occurrence may result in mental health difficulties. Moreover, the results highlight the importance of strengthening factors associated with resilience at a young age, enabling individuals to cope with CCD. The findings have implications for the development of potential intervention components and suggest imparting conceptual knowledge and adaptive regulatory strategies, supporting habit formation and providing networking opportunities with others affected by CCD.

Background Premenstrual disorders (PMDs) are prevalent and impair women’s quality of life, but their long-term influence on work capacity is unclear. Understanding the association between PMDs and subsequent sick leave and unemployment could inform interventions and policies. Objective We hypothesised that women with PMDs have an increased risk of future sick leave and unemployment compared with those without PMDs. Methods We conducted a prospective cohort study involving 15 857 women aged 15–60 years who were employed at baseline in the LifeGene Study, with linkage to population and health registers in Sweden. PMDs were identified from clinical diagnoses and symptom questionnaires; sick leave and unemployment data were obtained from national registers. Poisson regression estimated incidence rate ratios (IRRs) for sick leave and unemployment in women with versus without PMDs. Findings A total of 2585 (16.3%) women (mean age 32.5 years) had probable PMDs. Over a median 9.17-year follow-up, 6741 (42.5%) and 1485 (9.4%) experienced at least one sick leave or unemployment, respectively. Compared with women without PMDs, those with PMDs had a 40% higher risk of sick leave (IRR 1.40, 95% CI 1.31 to 1.49) and a 27% higher risk of unemployment (IRR 1.27, 95% CI 1.10 to 1.46). Risk elevations were pronounced for sick leave≥90 days (IRR 1.69, 95% CI 1.50 to 1.91) and depression-related sick leave (IRR 1.41, 95% CI 1.27 to 1.56). Discussion Women with PMDs are at increased risk of sick leave and unemployment, suggesting significant long-term socioeconomic burden associated with PMDs. Clinical implications This study underscores the need for greater awareness of PMDs in clinical practice. Healthcare providers should recognise the potential impairment at work associated with PMDs, especially in women with recurrent symptoms or comorbidities like anxiety or depression.

Internationally, capacity building for mental health implementation and translation research has lagged. A review of literature found initiatives since 2008 indicating limited dedicated attention to growing capabilities of early-to-mid-career mental health researchers, and little reporting of tailored career pathways and skills growth. Significant gaps in capacity building thus exist. This perspective article describes a networked infrastructure for a capacity building strategy of the Australian-based ALIVE National Centre for Mental Health Research Translation. The Centre was funded as a special initiative in mental health with an initial five-year investment. In 2022, the Centre established the first national, cross-disciplinary mental health Next Generation Researcher Network, including a tailored Lived-Experience Research Collective with the aim to grow future research leaders and establish career pathways embedded within the research activities of the Centre. After three years of operation, membership is upward of 280 people in the Next Generation Researcher Network and more than 250 people for the Collective. Specific components implemented as part of the strategy include a central coordination hub, coleadership approaches, coresearch models, tailored traineeships, skills-building through short courses and learning events, cocreation of resources, an online peer discussion platform and annual seed funding schemes. A continuous capacity-building strategy is critical for advancing global research agendas to improve mental health implementation and translation outcomes. Success requires network infrastructure to ensure research methodologies advance, and research addresses the priorities of people most impacted, and early and mid-career researcher capabilities across all research settings connected with universities and service sectors grow.

Question Task-shared preventive psychological interventions combined with interventions addressing social determinants of mental health may prevent common mental health conditions (CMHCs), particularly in low- and middle-income countries (LMICs). However, an evidence synthesis of their combination has not yet been investigated. We aimed to systematically assess the effectiveness of these combined interventions in LMICs. Study selection and analysis We searched Epistemonikos, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, GIM, ClinicalTrials.gov and WHO ICTRP until 2 September 2024. Two reviewers independently abstracted the data and evaluated the risk of bias of included studies using the Cochrane Risk of Bias 2 tool. We performed random-effects meta-analyses to assess the primary outcome, which was the incidence of CMHCs, and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. The protocol was registered in PROSPERO (CRD42023451072). Findings Of the 21 780 records identified from electronic sources, we included 31 randomised controlled trials from 21 LMICs involving 35 885 participants. Combined interventions were effective in reducing the incidence of depression and post-traumatic stress disorders at postintervention compared with control conditions for adults (risk ratio (RR) 0.82, 95% CI 0.73 to 0.93) and children (RR 0.70, 95% CI 0.49 to 0.99). At 7–24 months, we only found beneficial effects of combined interventions for depressive symptoms in children (standardised mean difference –0.41, 95% CI –0.63 to –0.18). No data were available on the incidence of anxiety. Conclusions Combined task-shared interventions are effective in mostly short-term prevention of CMHCs in LMICs. Combining strategies targeting social determinants with psychological prevention approaches offers a potential opportunity to reduce the global mental health burden. Future research should focus on key intervention components and head-to-head comparisons between different interventions and between their components. PROSPERO registration number CRD42023451072.

Background Suicide attempts are common in youth and have potentially lethal outcomes. Effective treatments targeting suicide attempts are scarce. Objective To assess the feasibility and preliminary efficacy of a family-based cognitive behavioural treatment relative to an active control for youth with suicidal behaviour. Methods 30 youths (93% female; mean (SD) age=14.6 (1.5) years) residing in Sweden with recent suicidal behaviour (last 3 months) and at least one available parent were randomised to 12 weeks of the family-based cognitive behavioural treatment Safe Alternatives for Teens and Youths (SAFETY) or supportive therapy, an active control treatment. Primary endpoint was 3-month post-treatment. Feasibility outcomes included treatment and assessment compliance, adverse events, treatment credibility and treatment satisfaction. Secondary outcomes included suicide attempt, non-suicidal self-injury, anxiety, depression, quality of life and emotion dysregulation. Findings Both treatments showed high compliance, satisfaction, credibility and session completion, with few adverse events and dropouts as well as low attrition (7% at primary endpoint). At the primary endpoint, two (14%) participants in SAFETY and four (27%) in supportive therapy had attempted suicide. Non-suicidal self-injury was reduced by 95% (incidence rate ratio=0.05 (95% CI 0.01 to 0.20)) in SAFETY and 69% (incidence rate ratio=0.31 (0.11 to 0.83)) in supportive therapy. Participation in SAFETY, but not in supportive therapy, was associated with moderate-to-large within-group improvements in anxiety and depression (Cohen’s d=0.85 [0.33 to 1.40]), quality of life (d=1.01 [0.48 to 1.56]) and emotion dysregulation (d=1.22 [0.45 to 2.03]). Conclusions The results suggest that SAFETY is feasible and promising for youth with suicidal behaviour. Clinical implications A large randomised controlled trial is warranted to further examine the efficacy of SAFETY. Trial registration number NCT05537623.

Background Evidence-based psychological interventions for mental disorders are described in treatment protocols and manuals, which detail treatment components and conditions of application. Systematic evaluations of the accessibility of treatment protocols and manuals across multiple mental disorders are absent. Objective We assessed whether treatment protocols or manuals for psychological interventions for severe mental disorders are accessible and publicly available. Study selection and analysis We surveyed randomised controlled trials (RCTs) from six large network meta-analyses of psychological interventions for severe mental disorders (psychotic, borderline personality, substance use, bipolar, anorexia and bulimia nervosa). Between January 2024 and February 2025, we retrieved protocols and manuals of psychological intervention arms using a multipronged approach (published protocol, trial registries, author contact, commercial availability). We report the proportion of trials and intervention arms for which protocols or manuals were (1) Accessible, that is, retrievable by any method, and (2) Publicly versus commercially available. Findings We included 260 RCTs, with 422 active intervention arms. We retrieved published protocols for 20 RCTs (8%, 95% CI 5% to 12%) and contacted 450 authors for the remaining 240. Authors shared protocols for 43/240 trials (18%, 95% CI 13% to 23%), refused to share for 73 (30%, 95% CI 25% to 37%) and did not respond for 101 (42%, 95% CI 36% to 49%). Protocols or manuals were retrievable for 364 psychological intervention arms (86%, 95% CI 83% to 89%), with 191 available commercially (45%, 95% CI 40% to 50%) and 106 (25%, 95% CI 21% to 30%) publicly. Conclusions and clinical implications Retrieving detailed descriptions of psychological interventions used in trials, crucial for identifying treatment components, was challenging, resource-intensive and required multiple methods. Reliance on public availability and author sharing enabled access to about 40% of protocols or manuals.

Objectives This nationwide cohort study investigated the association between attention-deficit/hyperactivity disorder (ADHD) and various types of urticarial diseases. Methods We conducted a population-based cohort study using data from Leumit Health Services (LHS), a health maintenance organisation in Israel. The study population consisted of all members of LHS between 1 January 2002 and 30 November 2022 aged 5–18 years. Diagnoses of ADHD and urticarial diseases were based on International Classification of Diseases, 9th Edition codes. The study group consisted of subjects with ADHD, while matched controls were randomly selected non-ADHD subjects (2:1 ratio). Findings Demographic characteristics of ADHD (n=18 558) and control (n=37 116) groups were well-matched, with no significant socio-demographic differences. A significantly higher prevalence of various subtypes of urticarial diseases was found in the ADHD group compared with the control group. Specifically, urticaria (5.00% vs 4.22%, OR (95% CI) 1.19 (1.10 to 1.30), p<0.001), allergic urticaria (3.26% vs 2.73%, OR (95% CI) 1.20 (1.08 to 1.33), p<0.001). Inducible forms of urticaria did not show significant differences between the groups. The ADHD group had a higher use of systemic and topical antihistamines and systemic corticosteroids. Conclusions Various urticarial diseases are more prevalent in individuals with ADHD, possibly due to shared genetic factors, immune system dysfunction, or environmental triggers. Clinical implications This study suggests an association between ADHD and some urticaria subtypes. Physicians should be aware of this association and its public health implications.

Background Understanding the relationship between mental and physical health conditions is crucial for developing comprehensive healthcare strategies. The putative existence of a general disease factor (d-factor) that underlies the vulnerability to both physical and mental conditions could have important implications for our approach to health assessment and treatment. Objective To investigate the presence and characteristics of a general d-factor in children and adolescents. Methods This Swedish registry-based cross-sectional study included children and adolescents born between 1996 and 2003 with follow-up until 2013. We extracted data on 25 mental and physical health conditions according to the ICD-10 system. To determine the optimal dimensional structure of these conditions, several competing measurement models were tested, including correlated factors, one factor, various bifactor specifications and bifactor exploratory structural equation modelling (ESEM). Findings The study cohort included 776 667 individuals (mean age 13.96 years, IQR=11.96–16.04; 51% male). The bifactor ESEM model, including a general d-factor and specific mental and physical health factors, provided the best fit to the data compared to alternative models (Comparative Fit Index=0.971, Tucker-Lewis Index=0.962, root mean square error of approximation=0.007 (0.007–0.007)). The d-factor accounted for substantial variance (h=0.582, explained common variance (ECV)=0.498), while specific mental (hs=0.377, ECV=0.373) and physical (hs=0.423; ECV=0.130) factors also indicated additional significant unique contributions. Conclusions This study provided evidence for a multidimensional structure of health in children and adolescents, characterised by a general d-factor underlying both mental and physical conditions, alongside distinct domain-specific factors. These findings have important implications for clinical practice, providing evidence that suggests the need for more integrated approaches to health assessment and treatment that consider the interconnectedness of mental and physical health.

Background Predicting outcomes in schizophrenia spectrum disorders is challenging due to the variability of individual trajectories. While machine learning (ML) shows promise in outcome prediction, it has not yet been integrated into clinical practice. Understanding how ML models (MLMs) can complement psychiatrists’ predictions and bridge the gap between MLM capabilities and practical use is key. Objective This vignette study aims to compare the performance of psychiatrists and MLMs in predicting short-term symptomatic and functional remission in patients with first-episode psychosis and explore whether MLMs can improve psychiatrists’ prognostic accuracy. Method 24 psychiatrists predicted symptomatic and functional remission probabilities at 10 weeks based on written baseline information from 66 patients in the OPtimization of Treatment and Management of Schizophrenia in Europe (OPTiMiSE) trial. ML-generated predictions based on these vignettes were then shared with psychiatrists, allowing them to adjust their estimates. Findings The predictive accuracy of the MLM was low but comparable to that of psychiatrists for symptomatic remission (MLM: 0.50, psychiatrists: 0.52) and comparable to that of psychiatrists for functional remission (MLM: 0.72, psychiatrists: 0.79). Inter-rater agreement was low but comparable for psychiatrists and the MLM. Although the MLM did not improve overall predictive accuracy, it showed potential in aiding psychiatrists with difficult-to-predict cases. However, psychiatrists struggled to recognise when to rely on the model’s output, and we were unable to determine a clear pattern in these cases based on their characteristics. Conclusions MLMs may have the potential to support psychiatric decision-making, particularly in difficult-to-predict cases, but at present, their effectiveness remains limited due to constraints in predictive accuracy and the ability to identify when to rely on the model’s output. Addressing these issues is crucial to improve the utility of MLMs and foster their integration into clinical practice. Clinical implications MLMs are best suited as supplementary tools, providing a second opinion while psychiatrists retain decision-making autonomy. Integrating predictions from both sources may help reduce individual biases and improve accuracy. This approach leverages the strengths of MLMs without compromising clinical responsibility.

Question This study investigated the methodological rigour of randomised controlled trials (RCTs) of mental health apps for depression and anxiety, and whether quality has improved over time. Study selection and analysis RCTs were drawn from the most recent meta-analysis of mental health apps for depression and anxiety symptoms. 20 indicators of study quality were coded, encompassing risk of bias, participant diversity, study design features and app accessibility measures. Regression models tested associations between year of publication and each quality indicator. Findings 176 RCTs conducted between 2011 and 2023 were included. Methodological concerns were common for several quality indicators (eg, <20% were replication trials, <35% of trials reported adverse events). Regression models revealed only three significant changes over time: an increase in preregistration (OR=1.27; 95% CI 1.10, 1.46) and reporting of adverse events (OR=1.32; 95% CI 1.11, 1.56), and a decrease in apps reported to be compatible with iOS and/or Android (OR=0.78; 95% CI 0.64, 0.96). Results were unchanged when excluding outliers. Results were similar when excluding three high-quality studies published between 2011 and 2013, with additional evidence for an increase in modern missing data methods (OR=1.22; 95% CI 1.04, 1.42) and studies reporting intention-to-treat analysis (OR=1.20; 95% CI 1.03, 1.39). Conclusions Findings provide minimal evidence of improvements in the quality of clinical trials of mental health apps, highlighting the need for higher methodological standards in future research to ensure the reliability and generalisability of evidence for these digital tools.

Background Repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) is an effective non-pharmacological, non-invasive intervention for depression. However, the optimal strategy for localising the DLPFC treatment site on the patient’s scalp is heavily disputed. Routine strategies were previously incrementally refined and compared in terms of anatomical accuracy, but little is known about their impact on clinical outcomes. Objective To assess the impact of three common scalp-based heuristics for magnetic coil positioning on the treatment outcome of rTMS. Methods This retrospective analysis of real-world clinical data involved patients suffering from a major depressive episode (n=94) who received a 4-week course of excitatory rTMS to the left DLPFC. The treatment target (ie, coil position) was either determined at an absolute distance anterior to the motor hotspot (‘6 cm rule’) or defined in reference to the EEG electrode position F3 using a traditional (‘Beam F3’) or optimised (‘Beam F3 Adjusted’) approach. Findings There was no statistically significant difference between the ‘6 cm rule’ and the ‘Beam F3’ method nor between the ‘Beam F3’ and the ‘Beam F3 Adjusted’ method in head-to-head comparisons of averaged per cent change of scores on depression rating scales (all p>0.605) and response rate (all p>0.475). Conclusions Enhancing targeting precision via scalp-based heuristics does not affect treatment outcomes. Clinical implications There is no need for clinicians to switch from their familiar to an ‘advanced’ approach among these common targeting heuristics.

Background Timely access to diagnostic assessment and treatment is essential to improve function and mitigate the risk of poor long-term outcomes in children and young people (CYP) with tics. Objective This study aimed to explore (i) how tic services for CYP in England are currently organised, including access to assessment and treatment and (ii) healthcare professionals’ (HCPs) experiences of assessing and treating tics. Methods Two methodologies were used to examine tic service provision. First, two freedom of information (FOI) requests were sent to Integrated Care Boards (FOI1) and service providers (FOI2) to gather data on referral and assessment processes, and treatments offered. Second, a national survey of HCPs explored their experiences and training needs when assessing and treating tics. Findings FOI responses indicated that 12 of 62 services (19.4%), primarily located in the London area, offered a full pathway for the referral, assessment and treatment of tics in CYP. The national survey sample (n=184) included psychologists, paediatricians, neurologists and mental health nurses. Most described services as poorly structured and reported a need for additional resources and training in the assessment and treatment of tics. Conclusions Inconsistent and underfunded tic service provision across England limits HCPs’ ability to support CYP with tics effectively. There is an urgent need to develop clear service pathways offering both assessment and treatment, and to equip HCPs with sufficient training and resources to provide appropriate care. Clinical implications Current tic service provision does not meet the healthcare needs of CYP in England. Without improvements, CYP are at increased risk of poorer long-term outcomes.

Background Acute mental health service use (AMHSU), that is, hospitalisations and emergency department (ED) visits for mental health, have been rising in the Canadian province of Ontario and globally; however, national-level estimates are not available. We examine trends and socioeconomic inequalities in AMHSU in the Canadian adult population between 2004 and 2019. Methods Using the Canadian Community Health Survey linked to tax and health administrative datasets, we reported prevalence rates of AMHSU using negative binomial regression models. Income-based absolute inequalities in AMHSU were reported using the Slope Index of Inequality. Results Over the study period, hospitalisations for mood disorders decreased from 144.8 (95% CI: 116.0–173.7) to 67.5 (95% CI: 54.5–80.4) per 100 000, while those for substance-related disorders (SRD) increased. Rates of ED visits increased for all conditions, with the largest increase for anxiety disorders, from 252.3 (95% CI: 210.9–293.6) to 434.1 (95% CI: 382.2–486.1) per 100 000. Females had higher rates of hospitalisations and ED visits for all conditions except SRD. We found pronounced income-based inequalities in both hospitalisations and ED visits for mental health, comparing those at the top versus bottom of the income distribution. Absolute inequalities for hospitalisations widened for SRD, from –93.6 (95% CI: –131.1 to –56.1) to –135.2 (95% CI: –203.4 to –67.1) per 100 000, and decreased for mood disorders, from –309.5 (95% CI: –443.8 to –175.3) to –126.0 (95% CI: –182.0 to –69.9) per 100 000. Additionally, absolute inequalities increased for ED visits across all mental health conditions. Conclusion Interventions aimed at improving access to preventive services could mitigate observed inequalities in AMHSU.

Background Improving preventative interventions for self-harm and suicide-related behaviour is a mental health policy priority. Existing evidence-based interventions can be lengthy, resource-heavy, difficult to access, and are not always acceptable or effective. Extending support through brief and remotely delivered interventions outside of traditional clinical services brings potential to expand access to timely and effective support. Objective The primary objective is to assess the effectiveness of two brief (6 week) interventions (Integrative Therapy and Stabilisation) in reducing self-harm frequency. Methods We evaluated data from a practice-based randomised controlled trial of hybrid Integrative Therapy and Stabilisation utilising a no-treatment control group to determine the effectiveness of each intervention targeting frequency of self-harm (primary outcome), suicidal ideation and depressive symptoms (secondary outcomes). Participants, 82 help-seeking adults with current self-harm behaviour aged 18–59 years (mean age=30.57, SD=12.5), received either Stabilisation (n=25) or Integrative Psychotherapy (n=25) or were assigned to a control waitlist (n=32). Six 1-hour sessions were delivered via video call in a 1:1 format. Outcome measures were completed at baseline and immediately postintervention. Findings In comparison to waitlist controls, those receiving Stabilisation had greater reductions preintervention to postintervention in self-harm frequency, suicidal ideation and depressive symptoms. Those receiving Integrative Psychotherapy had greater reductions in self-harm frequency and suicidal ideation, but not depression symptoms, compared with waitlist. Conclusions Interventions delivered in a service setting show promise in improving outcomes for self-harm and suicidal ideation, and to a lesser extent depression symptoms, over a 6-week period. Further evaluation and replication, including in longitudinal studies and fully randomised controlled trials, would be needed to build on these preliminary findings and extend beyond the current setting. Clinical implications Short, remotely delivered interventions outside of traditional clinical settings may offer an effective and timely treatment option.

Background Preventive interventions in the form of parenting support can reduce the risk of mental disorders in children. Summarising the effectiveness of parenting interventions across different levels of prevention can inform the prioritisation of the intervention. Objectives We conducted a meta-review of systematic reviews and meta-analyses on universal, selective and indicated parenting interventions to prevent adverse mental health outcomes in youth. Study selection and analysis PubMed, Ovid, Embase and PsycNet were searched. Systematic reviews consisting of randomised controlled trials of preventative parenting interventions were included. We provided a narrative synthesis of the results and assessed the quantity and quality of evidence for each level of prevention (ie, universal, selective, indicated) and mental health outcome. Findings We identified 32 systematic reviews and meta-analyses, which included 354 randomised controlled trials, consisting of over 74 558 children and adolescents. Universal parenting interventions were effective in delaying the initiation of alcohol and cannabis use, but did not have consistent findings in preventing disruptive behaviour and mood disorders. Selective interventions were predominantly beneficial for disruptive behavioural problems across a variety of risk factors. Indicated interventions found substantial and consistent evidence for reducing problems in children with behavioural problems. Caution is warranted when interpreting findings, as the overall confidence rating of most reviews was very low, especially in the reporting of study selection and justifying exclusions in the AMSTAR-2. Conclusions Our findings highlight the need for robust evidence synthesis. Despite the limitations of the current evidence base, parenting interventions hold promise for preventing mental health disorders.

Background The mental health of children and adolescents has declined in recent years. Self-harm is frequently an expression of this psychological distress. Objectives To examine trends in self-harm incidence among 10–24-year olds between January 2019–December 2023. Methods We conducted time-series analyses of all incident episodes of self-harm among 10–24-year olds using the Greater Manchester Care Record. The observation period was split into four phases: pre-pandemic (1/2019–2/2020); pandemic phase 1 (3/2020–6/2021); pandemic phase 2 (7/2021–12/2022) and post-pandemic (1/2023–12/2023). Rate ratios by sex, age, ethnicity and Indices of Multiple Deprivation were modelled using negative binomial regression. Findings Self-harm incidence rates decreased significantly in the post-pandemic phase, compared with the pre-pandemic period (male—incident rate ratios (IRR) 0.72; 95% CI 0.62 to 0.84, female IRR 0.85; 95% CI 0.74 to 0.99). In females, this followed increased rates, rising by 18% in pandemic phase 2 (IRR 1.18; 95% CI 1.04 to 1.34). In males, rates decreased throughout the study period. Incidence rates were lowest for 10–12 year olds. However, the greatest increase was observed in this age group, with rates in pandemic phase 2 being almost two times that seen pre-pandemic for females (IRR 1.91; 95% CI 1.47 to 2.48). The change in rates among females was also most marked in the least deprived neighbourhoods, rising by more than 50% (IRR 1.54; 95% CI 1.21 to 1.95) in pandemic phase 2. Conclusions Our results indicate a decrease in self-harm incidence during 2023. Analysis by age group showed the greatest increase in rates in 10–12-year olds. Further research is needed to confirm these findings and to identify the mechanisms driving these trends.

Background The lack of an early warning score for psychiatric hospitalisation means that the decision to initiate preventative interventions is based solely on clinical judgement, which is prone to bias. Objective The objective is to develop and externally validate a transdiagnostic score that predicts psychiatric hospitalisation. Methods In this retrospective cohort study using deidentified electronic health records from 20 healthcare organisations in the NeuroBlu Data, we identified all patients with any of seven major psychiatric disorders with at least five Clinical Global Impressions of Severity and five Global Assessment of Functioning measured over a period of 6 consecutive months before any hospitalisation. From these measurements, metrics of clinical severity and instability and functional severity and instability were derived and incorporated into a score predicting the 6-month risk of incident psychiatric hospitalisation. Discrimination and calibration of this score were validated in an external sample. The transdiagnostic validity of the score was evaluated and its performance was compared between white and non-white people. Findings Altogether, 37 049 individuals (531 incident hospitalisations) were included. The predictive model showed good discrimination in the training (optimism-adjusted c-index: 0.74, 95% CI 0.72 to 0.76) and external validation (c-index: 0.80, 95% CI 0.78 to 0.82) samples, with adequate calibration. Discrimination improved with adjustment for organisation-level hospitalisation rates (c-index: 0.80, 95% CI 0.78 to 0.82 and 0.84, 95% CI 0.82 to 0.86 in the derivation and validation samples). Good discrimination was also achieved for each diagnostic category (c-index: 0.71–0.82 and 0.64–0.75 with/without adjustment for organisation-level hospitalisation rates, respectively). There was no significant difference in model performance between white and non-white people. Discussion A transdiagnostic early warning system based on simple longitudinal measurements can reliably and robustly predict psychiatric hospitalisation. It will help target preventative interventions to individuals most at risk.

Background Individuals with attention deficit hyperactivity disorder (ADHD) are at a higher risk of depression and lower quality of life (QoL); however, it is unclear whether disrupted sleep and circadian rhythms mediate this increased risk. Objectives We investigated whether disruption of self-reported sleep and circadian factors mediate the associations of ADHD traits with depression symptom severity and QoL. Methods 1364 participants (mean: 51.86 (SD=0.37) years, 75% women) from a large-scale cross-sectional online survey (Netherlands Sleep Registry) completed a sociodemographic questionnaire, the Adult ADHD Rating Scale, Hospital Anxiety and Depression Scale, Satisfaction With Life Scale (SLS) and Cantril Ladder (CL) (QoL measures), Insomnia Severity Index, Pittsburgh Sleep Quality Index and Munich Chronotype Questionnaire. Findings Higher ADHD traits were significantly associated with depression symptom severity (p=0.03), lower QoL (p<0.001), insomnia severity (p<0.001), lower sleep quality (p<0.001) and later chronotype (p=0.01). No sleep or circadian factor significantly mediated the association of the severity of symptoms of ADHD and depression (all p>0.1). Conversely, only insomnia severity significantly mediated the association of ADHD traits and QoL (SLS: standardised β=–0.10, 95% CI (–0.12 to –0.04); CL: standardised β=0.103, 95% CI (0.04 to 0.16)). Conclusion ADHD traits were associated with lower QoL and it was partially mediated by insomnia severity. Future studies targeting insomnia complaints in this population may help mitigate their depression complaints and improve their QoL. Clinical implications Our results may help current clinical guidelines that do not typically link sleep/circadian complaints to QoL in ADHD assessment.

Question What are the values and preferences of safer opioid supply clients? Study selection and analysis We conducted a systematic review of qualitative studies on safer opioid supply client experiences published between January 2016 and August 2024. Searches were conducted across seven databases—MEDLINE, Embase, PsycINFO, CINAHL, EBM Reviews, Web of Science and Scopus—and supplemented with searches in Google Scholar and relevant repositories. Study quality was assessed using the Critical Appraisal Skills Programme. Data analysis was guided by Thomas and Harden’s thematic synthesis approach and confidence in review findings was evaluated using Grading of Recommendations Assessment, Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative research. The review was registered with PROSPERO (CRD42022384447). Findings Our thematic synthesis included 19 peer-reviewed original research articles involving 459 study participants from British Columbia and Ontario, of whom 60.1% were men and 36.1% were women. Our findings centred on four cross-cutting analytic themes: (1) client-relevant goals and outcomes (withdrawal management, pain management, socioeconomic improvements), (2) the right medications to optimise client-relevant outcomes (multiple medication and formulation options, flexible dosage), (3) supportive, client-centred care environment (safe, welcoming and non-judgmental spaces, coordinating access to health and social support services, shared decision-making) and (4) complex adaptive systems approach to clinical policies (understanding the complexity of clients’ living circumstances, flexible dose schedules, non-punitive policies). Confidence in findings ranged from moderate to high. Conclusions Safer opioid supply’s success depends on providing individualised opioid medications, fostering person-centred care and implementing adaptive clinical policies. A supportive and flexible model enhances client satisfaction, sustains programme participation and optimises client-relevant outcomes.

Objective To assess the effectiveness of NHS Talking Therapies (NHSTT) service for working-age adults with mild to moderate depression or anxiety and to evaluate the impact of multiple physical long-term conditions (LTCs) on treatment outcomes. Method We have linked routinely collected data from the NHSTT services in South London (UK) with primary care data for aged 18–64 years who had accessed the services between August 2008 and March 2021. The main outcome measures were NHSTT service key performance indicators of ‘recovery’ and ‘reliable improvement’. Multiple and specific physical LTCs represented the exposure of interest. Cox proportional hazard models were used to assess associations between physical LTC exposures and outcomes. Findings Among 35 814 adults (mean age=37, 67% women) attending the NHSTT, physical LTCs were associated with moderately lower ‘recovery’ rate (adjusted HR (aHR)=0.91, 95% CI 0.88 to 0.95) relative to no LTCs. A dose–response relationship was also observed: the likelihood of ‘recovery’ decreased with the number of physical LTCs (one condition: aHR=0.95, 95% CI 0.91 to 0.98; two conditions: aHR=0.88, 95% CI 0.83 to 0.93; three conditions: aHR=0.82, 95% CI 0.75 to 0.91; four or more conditions: aHR=0.72, 95% CI 0.61 to 0.85). Conclusion Among working-age adults, the effectiveness of NHSTT services varied with the number and type of physical LTCs. These findings highlight the need for tailored interventions for patients with multiple physical LTCs to improve treatment outcomes.

This editorial focuses on the seven studies published in the BMJ Mental Health topic collection Advances in Clinical Psychopharmacology in Children and Young People. Collectively, these articles provide evidence that informs key steps in the psychopharmacological management of children and adolescents with mental health or neurodevelopmental conditions. Papers in this collection contribute to strengthen evidence-based psychopharmacological practice. We look forward to further developments in the field, supported by adequate research funding.

Background Inconclusive findings regarding the association between suicidal ideation/suicide attempt and glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been recently revealed in a small number of studies. Methods This was a multinational self-controlled case series analysis using Hong Kong’s Clinical Data Analysis and Reporting System (2008–2023), Taiwan’s National Health Insurance Research Database (2012–2020) and the UK’s IQVIA Medical Research Database with The Health Improvement Network (2000–2021). A total of 642 suicide attempt or self-harm cases with GLP-1RA use were included to assess pooled incident rate ratios (IRRs) of suicide attempts or self-harm associated with GLP-1RA treatment versus non-treatment with their 95% CIs. Results The pooled IRR (95% CI) of suicide attempts or self-harm associated with GLP-1RA treatment versus non-treatment was 0.67 (0.51 to 0.88). The suicide attempt or self-harm risk varied with the time window of GLP-1RA use, with pooled IRRs (95% CIs) of 1.94 (0.86 to 4.37), 0.61 (0.23 to 1.63), 0.72 (0.37 to 1.41), 0.60 (0.32 to 1.09) and 0.63 (0.49 to 0.87) for the pretreatment period and Days 1–30, Days 31–90, Days 91–180 and Days>180 of GLP-1RA treatment, respectively. Subgroup analyses by age, sex and individual GLP-1RAs and sensitivity analyses showed no significant increase in the suicide attempt or self-harm risk associated with GLP-1RA use. The point estimate and CI of the E-value for suicide attempts or self-harm were 2.35 and 1.53, respectively. Conclusions We found no increase in the risks of suicide attempts or self-harm following GLP-1RA treatment, and even in the long-term use of GLP-1RAs. Close monitoring of potential suicide attempts or self-harm and ensuring treatment tolerability during treatment initiation are required, and well-controlled or pragmatic trials remain warranted to validate our findings.

Question As global ecological crises accelerate, it is becoming increasingly important to understand the impact of associated environmental changes on mental health. However, the psychological mechanisms underlying the link between environmental changes and mental health problems remain underexplored. This scoping review investigates whether solastalgia—a form of distress caused by environmental change—acts as a potential contributing factor to mental health problems. Study selection and analyses We conducted a systematic search of the databases PsycINFO and PubMed using the keyword ‘solastalgia’. Initially, only studies that quantitatively assessed solastalgia and used validated mental health measures were included. A second, non-preregistered search expanded the scope to include studies that mentioned solastalgia and mental health without requiring quantitative solastalgia measures. Findings The studies retrieved in the initial search showed that solastalgia was positively associated with depression, anxiety and post-traumatic stress disorder. The studies retrieved in the extended search supported these findings, with qualitative studies providing further evidence that solastalgia is a useful construct to understand the emotional responses of persons affected by environmental changes. Conclusions Solastalgia might be a factor contributing to the detrimental effects of climate change on mental health. Further quantitative research is warranted to inform the design of (preventive) interventions targeting solastalgia and thus mitigate climate change-induced mental health problems.

Question The rising prevalence of mental health conditions and a global treatment gap demand new solutions that address symptoms and foster psychological well-being. Just-in-time adaptive interventions (JITAIs) and ecological momentary interventions (EMIs) are emerging mobile health approaches, providing real-time, personalised support. However, the effectiveness of current JITAIs/EMIs and the longevity of effects remain uncertain. Study selection and analysis Studies investigating the effectiveness of JITAIs/EMIs for depression, anxiety and indicators of psychological well-being, published between 2018 and May 2025, were eligible. Following the standards for reporting (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) and quality assessment (Risk of Bias; RoB), a total of K=23 studies and N=2563 individuals (71.7% female) were included. Findings JITAIs/EMIs showed a small between-group effect (g=0.15, 95% CI 0.05 to 0.26, p=0.003). Nine studies reported follow-up effects (mean follow-up time M=3.06 months, SD=2.21) with significant results at 1 and 3–6 months. Interventions shorter than 6 weeks yielded greater longevity of effects (g=0.71, 95% CI 0.18 to 1.24, p=0.008). Funnel plots and sensitivity analyses confirmed robustness of findings. Risk of bias was moderate to high for intervention adherence and missing outcome data. Conclusions Currently existing JITAIs and EMIs slightly improve mental health, particularly mental illness, with long-term effects up to 6 months. A clear definition of JITAIs and decision rules, research on long-term effects and careful selection of control conditions are needed.

Background We previously demonstrated that a large language model could estimate suicide risk using hospital discharge notes. Objective With the emergence of reasoning models that can be run on consumer-grade hardware, we investigated whether these models can approximate the performance of much larger and costlier models. Methods From 458 053 adults hospitalised at one of two academic medical centres between 4 January 2005 and 2 January 2014, we identified 1995 who died by suicide or accident, and matched them with 5 control individuals. We used Llama-DeepSeek-R1 8B to generate predictions of risk. Beyond discrimination and calibration, we examined the aspects of model reasoning—that is, the topics in the chain of thought—associated with correct or incorrect predictions. Findings The cohort included 1995 individuals who died by suicide or accidental death and 9975 individuals matched 5:1, totalling 11 954 discharges and 58 933 person-years of follow-up. In Fine and Grey regression, hazard as estimated by the Llama3-distilled model was significantly associated with observed risk (unadjusted HR 4.65 (3.58–6.04)). The corresponding c-statistic was 0.64 (0.63–0.65), modestly poorer than the GPT4o model (0.67 (0.66–0.68)). In chain-of-thought reasoning, topics including Substance Abuse, Surgical Procedure, and Age-related Comorbidities were associated with correct predictions, while Fall-related Injury was associated with incorrect prediction. Conclusions Application of a reasoning model using local, consumer-grade hardware only modestly diminished performance in stratifying suicide risk. Clinical implications Smaller models can yield more secure, scalable and transparent risk prediction.

Background The rates of compulsory admission and treatment (CAT) are rising in mental health systems in the UK. Persistent disparities have been reported among migrants, and black and ethnic minorities in Europe and North America for decades. Lived experience data can provide novel insights to reduce coercive care. Methods We purposively sampled people within 2 years of receiving CAT, to maximise diversity by age, sex, ethnicity and different ‘sections’ of the Mental Health Act (England and Wales) from eight health systems in England. Using participatory photovoice workshops, we assembled images, captions and reflective narratives, which were transcribed and subjected to thematic and intersectional analyses. The interpretation privileged lived experiences of participants and peer researchers alongside the research team. Preventive insights informed a logic model to reduce CAT. Results Forty-eight ethnically diverse people contributed over 500 images and 30 hours of recorded narratives. A significant proportion of participants reported multimorbidity, adverse childhood experiences and carer roles. Their experiences indicated insufficient co-ordination to prevent CAT despite early help seeking; they were not taken seriously or believed when seeking help. Dismissive responses and even hostility from professionals and unnecessary police involvement were distressing, stigmatising and risked criminalisation. Participants wanted more (a) advocacy given in crisis, (b) trauma-informed therapeutic and creative support from inpatient into community settings, (c) family and carer involvement and (d) more information about how to negotiate care options, appeals, restriction and seclusion. Practitioners were felt to lack the essential skills to care for racialised and traumatised people subjected to CAT. Conclusions We propose a lived experience logic model for the practice, policy and legislative solutions to reduce epistemic injustice, CAT and criminalising care.

Background The association between the incidence of attention deficit hyperactivity disorder (ADHD) and the factors induced by the COVID-19 pandemic has not been fully investigated. Environmental stressors during or after the pandemic, including online classes and lifestyle disruptions, and postinfection neuroimmune changes likely contributed to the increase of ADHD. Methods The onset of ADHD was operationally defined as the diagnosis accompanied by a prescription history for ADHD medication. The incidence was observed among all Korean citizens (6–29 years). To evaluate the risk of ADHD, we established a retrospective and observational cohort, using data from the National Insurance Claims Database, the COVID-19 Vaccine Registry and the national surveillance system to find the patient. Our cohort (586 860 and 1 172 735 participants before and during the pandemic, respectively) comprised three age groups: school-aged children (6–12 years, n=227 276), adolescents (13–19 years, n=333 032) and young adults (20–29 years, n=1 199 287); sex ratio (male/female) was approximately 1.2. Results We analysed the incidence of ADHD in Korea (2012–2023), focusing on the COVID-19 pandemic’s impact on individuals. The incidence of ADHD increased during the pandemic, exceeding values predicted by negative binomial regression and autoregressive integrated moving average models. We also evaluated the risk of ADHD according to SARS-CoV-2 infection. As a result, these nationwide data revealed a significant rise in incidence (0.85 (before) vs 2.02 (during)), with SARS-CoV-2 infection identified as a critical risk factor. Conclusion These findings suggest the need for early intervention and neurological evaluations in ADHD risk groups, particularly among SARS-CoV-2-infected individuals.

Background Measurement based care (MBC) is a patient-centered approach that is gaining popularity in healthcare systems, particularly in mental health settings. However, attitudes towards MBC vary among mental health clinicians and patients, leading to variable implementation. Objective This systematic review synthesises clinician and patient perspectives on the benefits and drawbacks of measurement-based care (MBC) in psychiatry. Study selection and analysis We searched Ovid MEDLINE, EMBASE, EBM Reviews, APA PsychINFO and CINAHL databases from inception to January 2024. After screening 1644 titles and abstracts, 48 full papers were reviewed, and 24 studies were ultimately included. Quality assessment was conducted using the Mixed Methods Appraisal Tool, and key patterns were extracted using thematic analysis. Findings The review reflects opinions of 901 patients and 2831 clinicians across various settings. Patients valued MBC for enhancing communication, self-awareness and reducing stigma. However, they expressed concerns about the adequacy of measures in reflecting their clinical state and uncertainty about how responses influence treatment decisions. Clinicians appreciated MBC for improving patient involvement, tracking treatment response and enhancing communication efficiency. Concerns included inadequate capture of clinical complexity, potential reporting biases, time constraints, insufficient training and concerns with respect to data usage and privacy. Conclusions and clinical implications While patients and clinicians recognise significant benefits, including enhanced communication, improved insight and more structured clinical decision-making, they also identify important limitations. These include concerns about the adequacy of scales to capture complex clinical presentations, potential impacts on the therapeutic alliance and increased administrative burden. Moving forward, successful integration of MBC into routine care will require addressing these challenges through improved clinician training, clear guidelines for interpretation, greater transparency with respect to how data will be used and more seamless integration with existing clinical workflows. PROSPERO registration number PROSPERO CRD420250651562.

Background Only a minority of those with depressive disorder receive treatment. Besides system-level factors, individual factors could account for the gap between detection and treatment of depression in so far unreached but affected populations. Objective This study tests the predictive value of illness beliefs (IB) for the uptake of depression treatment 6 months after web-based depression screening. Methods This is a secondary analysis of the randomised controlled Germany-wide DISCOVER trial that investigated the effects of automated results feedback following web-based depression screening in untreated participants with at least moderate depression severity (Patient Health Questionnaire ≥10 points). IB were examined as predictors of depression treatment uptake. Eligible participants were at least 18 years old, reported proficiency in German language, and provided informed consent. IB were assessed at the time of screening (baseline) with an adapted version of the Brief Illness Perception Questionnaire. Uptake of depression treatment was operationalised as self-reported initialisation of psychotherapy and/or antidepressant medication 6 months after baseline. Analyses were adjusted for study arm. Findings Data from N=871 participants of the DISCOVER trial providing follow-up data were analysed. IB denoting more consequences (OR (95% CI) 1.12 (1.00 to 1.26)), higher treatment control (OR (95% CI) 1.19 (1.11 to 1.29)) and a depression-conforming illness identity (OR (95% CI) 1.65 (1.15 to 2.36)) were associated with up to 56.8% relative increase in predicted probability of depression treatment uptake 6 months after baseline. Conclusions Results suggest considerable effects of IB for depression treatment uptake in untreated populations. Clinical implications IB could reflect relevant barriers in access to depression care and, concurrently, intervention targets to foster health service utilisation in untreated populations.

Background Experience of racism is considered a predictor of ill health and poor well-being at all ages. Few studies examining the relationship between racism, mental health and self-harm are longitudinal. The aim of this study was to examine these associations longitudinally among youth in England. Methods The data were obtained from the Next Steps Longitudinal Study on participants born in 1989–1990 in England. Waves 4 (2007) and 8 (2015) were used to measure associations between experiencing racism at age 17 and mental health outcomes at age 25. Logistic regression analyses were conducted. Multiple imputation was used to address missing data. Findings Compared with those who did not experience racism, participants who experienced racism at 17 years scored 0.58 (95% CI 0.16 to 1.00) points higher in psychological distress (General Health Questionnaire-12) at age 25. No clear associations were found for overall life satisfaction (OR 1.06, 95% CI 0.85 to 1.34, p=0.597), self-harm (OR 0.79, 95% CI 0.40 to 1.56, p=0.494) or longstanding mental illness (OR 1.31, 95% CI 0.80 to 2.13, p=0.280). Conclusion Exposure to racism at youth increased the risk of psychological distress, but not life satisfaction, self-harm or longstanding mental illnesses for young adults in England. Ongoing and future longitudinal studies exploring racism and mental health should incorporate electronic health records and validated measures of racism to better understand its effects on mental health across the life course.

Background Routine outcome data in secondary mental health services have significant potential for service planning, evaluation and research. Expanding the collection and use of these data is an ongoing priority in the National Health Service (NHS), but inconsistent use threatens their validity and utility. If recording is more likely among certain patient groups or at specific stages of treatment, measured outcomes may be biased and unreliable. Objective The objective is to assess the scale, determinants and implications of incomplete routine outcome measurement in a secondary mental health provider, using the example of the widely collected Health of the Nation Outcome Scores (HoNOS). Methods A retrospective cohort study was conducted using routine HoNOS assessments and episodes of care for patients receiving secondary mental healthcare from an NHS Trust in Southeast England between 2016 and 2022 (n=30 341). Associations among demographic, clinical and service factors, and rates and timings of HoNOS assessments were explored with logistic regressions. Relationships between total HoNOS scores and related mental health outcomes (costs, relapse and improvement between assessments) were estimated after adjusting for the likelihood of assessment. Findings 66% of patients (n=22 288) had a recorded HoNOS assessment. Of the distinct episodes of care for these patients (n=65 439), 43% (n=28 170) were linked to any assessment, 25% (n=16 131) were linked to an initial baseline assessment, while 4.7% (n=3 094) were linked to multiple HoNOS assessments, allowing for evaluation of clinical progress. Likelihood and timing of assessment were significantly associated with a range of factors, including service type, diagnosis, ethnicity, age and gender. After adjusting for observed factors determining the likelihood of assessment, the strength of association between HoNOS scores and overall costs was significantly reduced. Conclusion Most of the activity observed in this study cannot be evaluated with HoNOS. HoNOS assessments are highly unlikely to be missing at random. Without approaches to correct for substantial gaps in routine outcome data, evaluations based on these may be systematically biased, limiting their usefulness for service-level decision-making. Clinical implications Routine outcome collection must increase significantly to successfully implement proposed strategies for outcome assessment in community mental healthcare without inconsistent records undermining the use of resulting data.

Background There is limited research on premenstrual exacerbation (PME) of depression. It is unclear how mood and fatigue fluctuate across the menstrual cycle, and whether heart rate variability (HRV) tracks these fluctuations. Objective To determine if there is PME of mood, energy and HRV in depressed women. Methods Cohort study in women with depression, using the mobile health platform, Juli, to track their menstrual cycle, HRV, mood and energy using ecological momentary assessment (EMA). We modelled the relationship between mood, energy, HRV and menstrual cycle with different lag times (0–3 days) using simple polynomial regression. Results are reported as the SD change from the average rating for an individual for each day across the menstrual cycle. Findings Women diagnosed with depression (N=352) tracked their menstrual cycle (≥2 periods), HRV and recorded ≥5 daily mood and energy levels (N=9393 entries). We found a gradual decline in mood beginning at 14 days before menstruation and continuing until 3 days before the next menstruation (β=0.0004, 95% CI 0.0001 to 0.0008, p<0.001). Mood ratings were lowest from 3 days before until 2 days after menstruation; 54.3% (95% CI 48.9% to 59.6%) had a lower mean score during this period than the rest of the cycle. Through the rest of the cycle, participants experienced improvement in mood. Mood rating was associated with HRV on the same day (β=–0.0022, 95% CI –0.0020 to –0.0026, p=0.005) and 1–3 days prior. Energy was not associated with the day of the menstrual cycle. Conclusions There is variation in mood across the menstrual cycle in women with depression, consistent with PME. Clinical implications EMA over two consecutive cycles could be useful for understanding menstrual cycle-related mood changes and diagnostic clarity may lead to alternative treatment and management options.

Question This scoping review aimed to examine the state of research on patient engagement in forensic mental health (FMH) care to inform future research, practice and policy development. Study selection and analysis A systematic literature search was conducted in Medline, Embase, CINHAL, PsycINFO and EBSCO from database inception to June 2024, supplemented by grey literature and reviews. We analysed the included studies descriptively and narratively. Findings Of the 7010 records retrieved, 73 studies were included. Research on patient engagement in FMH has increased since 1999, with all studies conducted in high-income countries and the majority (64%) employing qualitative designs. The focus was primarily on risk assessment and management, recovery and therapeutic or medication interventions. Most patient participants were male, white and diagnosed with schizophrenia, personality disorders or substance use disorders. Nurses were the major staff participants. The levels of engagement were typically involvement and collaboration. Commonly reported outcomes were a sense of engagement and risks of violence and aggression. We identified barriers and potential strategies for patient engagement across five levels: patient, staff, process, organisational and sociopolitical. Barriers to patient engagement included, but were not limited to, patients’ mental health conditions, paternalistic staff attitudes and power imbalances. Potential strategies to enhance patient engagement were identified, such as the adoption of recovery-oriented care models. Conclusions Patient engagement in FMH is hindered by multilevel barriers, requiring coordinated efforts from policymakers, organisational leaders, professionals and patients to facilitate its integration into routine practice. Greater attention is needed to ensure the meaningful engagement of marginalised populations and patients from low and middle-income countries.

Background Individuals with mental health conditions can experience lower life expectancy, partly due to risk factors, such as smoking and alcohol use. Objective To assess potential differences in receiving support for smoking cessation or alcohol reduction in British general practice based on history of a mental health condition. Methods Self-reported data were collected between October 2020 and June 2023 from the monthly cross-sectional Smoking and Alcohol Toolkit Study. The sample included 23 790 adults who smoked in the past year and/or drank at risky levels (ie, Alcohol Use Disorders Identification Test—Consumption≥5). Outcomes included the receipt of brief interventions, the recommendations provided during brief interventions and quit or cut-down attempts triggered by healthcare professionals. Logistic regression models measured associations between outcomes and lifetime mental health history, without and with adjustment for demographic and behavioural factors. Findings Overall, 36.6% had a history of a mental health condition. About two-thirds of people with a history of a mental health condition and half of those without saw their general practitioner (GP) in the past year. Among those with a history of a mental health condition who saw their GP, 41.2% who smoked in the past year received smoking brief interventions and 7.0% who drank at risky levels received alcohol brief interventions. Receipt of smoking brief interventions was similar by history of mental health condition (with 41.2% vs without 41.1%). Individuals with a history of a mental health condition compared with those without had higher odds of receiving alcohol brief interventions (7.0% vs 2.8%, adjusted OR=2.69, 95% CI: 2.17 to 3.34) and receiving more comprehensive support as part of the intervention. Discussion Among respondents with a history of a mental health condition, only around 4 in 10 smokers who visited their GP received brief interventions from their GP and 1 in 20 for alcohol. Clinical implications Considering the links between smoking or risky drinking and mental health conditions, healthcare professionals should increase screening and brief advice to reduce health disparities.

Objective Telomere length (TL) is an indicator of cellular ageing, with patients with severe mental disorders tending to have shorter telomeres than the general population. Coffee consumption may reduce oxidative stress, helping prevent biological ageing processes like telomeric shortening. The UK National Health Service advises limiting caffeine intake to 400 mg/day (4 cups of coffee). However, the role of coffee consumption and TL in psychiatric populations remains unclear. Methods This cross-sectional study included 436 participants (schizophrenia spectrum (n=259) and affective disorders (n=177)) from the Norwegian TOP study. Leucocyte TL was measured via blood using quantitative real-time polymerase chain reaction (qPCR). Patients self-reported coffee consumption, quantified as cups per day (no coffee, 1–2, 3–4, 5+). Results An inverted J-shape was found between TL and coffee intake, peaking at 3–4 cups/day before declining after 4 cups (F=3.29, p=0.02). The largest TL difference was between those drinking the highest recommended dose and non-drinkers (F=6.13, p=0.01). Coffee drinkers within the recommended dose had longer TL, comparable to 5 years younger biological age, adjusted for confounders. Conclusion Coffee intake within the recommended dose is linked to longer telomeres in severe mental disorders, comparable to 5 years younger biological age.

Background The onset of a severe physical illness of a child has been associated with earnings and employment losses among parents, but less is known in the context of children’s mental disorders. Objectives We estimated parental income and employment trajectories associated with a child’s mental disorder diagnosis in nationwide register-based cohorts from Finland and Denmark. Methods All parents whose child was diagnosed with a mental disorder (F00–F99 in ICD-10) at ages 1–25 in Finland and in Denmark during 1994–2019 were matched 1:1 to parents with a child without a mental disorder on psychiatric and sociodemographic characteristics. Generalised estimating equations were used to estimate the associations of a child’s mental disorder with parental annual income and employment outcomes from 5 years before to 5 years after the child’s diagnosis. Findings In 1994–2019, over one million parents in Finland and Denmark had at least one child diagnosed with a mental disorder at age 1–25. Parents exposed to a child’s mental disorder had consistently lower income and were more often unemployed compared with the matched unexposed parents, already 5 years before the child’s diagnosis. These differences became slightly larger over time, especially in analyses on strata involving parents whose child was diagnosed at a younger age. However, there was no consistent evidence of a change in parental annual income or employment around the time of their child’s diagnosis. Conclusions Our analysis shows that even in countries with strong welfare systems, a younger child’s mental disorder may contribute to widening socioeconomic inequity among families. However, the inequity in children’s mental health appears to primarily exist prior to, rather than in response to, a child’s mental disorder. Clinical implications Clinical and policy efforts should prioritise addressing pre-existing socioeconomic vulnerabilities for effective primary prevention of children’s mental disorders.

Background Chronic inflammation is associated with psychiatric disorders. If inflammation is linked mechanistically to mental health, people living with chronic inflammatory conditions may experience mental health issues at higher rates than others. Objective To test this hypothesis, we analysed data from 1 563 155 adults living in the UK within the newly launched UK-wide Our Future Health research cohort. Methods Participants were split between two groups: people with self-reported lifetime diagnoses of six autoimmune conditions (n=37 808) and those without these diagnoses (n=1 525 347). Findings Lifetime prevalence (95% CI) of self-reported lifetime diagnoses of any affective disorder (depression, bipolar disorder, anxiety) was significantly higher (p<0.001) among people with autoimmune conditions (28.8% (28.4% to 29.3%)) than in the general population (17.9% (17.8% to 18.0%)), with similar trends observed for individual affective disorders. Prevalence of current depressive symptoms (9-item Patient Health Questionnaire (PHQ-9) ≥10, 18.6% vs 10.5%) and current anxiety symptoms (7-item Generalised Anxiety Disorder Scale (GAD-7) ≥8, 19.9% vs 12.9%) was also higher among people with autoimmune conditions. Odds of experiencing affective disorders, calculated using logistic regression models, were significantly higher in this group compared with the general population (OR (95% CI) = 1.86 (1.82 to 1.90), p<0.001), and these odds remained elevated when adjusting for the effects of age, sex, ethnicity (OR=1.75 (1.71 to 1.79), p<0.001) and additionally, for household income, parental history of affective disorders, chronic pain status and frequency of social interactions (OR=1.48 (1.44 to 1.52), p<0.001). Conclusions Overall, the risk of affective disorders among people living with autoimmune conditions was nearly twice that of the general population. Clinical implications Although the observational design of this study does not allow for direct inference of causal mechanisms, this analysis of a large national dataset suggests that chronic exposure to systemic inflammation may be linked to a greater risk for affective disorders. Future work should seek to investigate potential causal mechanisms for these associations.

Background Attention-deficit/hyperactivity disorder (ADHD) symptomatology in childhood is associated with a high risk of suicide attempt later in life. However, symptom presentation in ADHD is heterogeneous, and little is known about how suicide risk varies according to different profiles of ADHD symptoms and sex. Objective The aim was to investigate the longitudinal associations between childhood profiles of ADHD symptoms (ie, hyperactivity–impulsivity and inattention) and youth suicide attempt in males and females, separately. Methods This population-based cohort study used data from three longitudinal cohorts: the Quebec Longitudinal Study of Child Development (QLSCD), the Quebec Longitudinal Study of Kindergarten Children (QLSKC) and the Quebec Newborn Twin Study (QNTS) for a total of 4399 participants (1490 from the QLSCD, 2134 from the QLSKC and 775 from the QNTS; 50% females) followed up from ages 6–23 years. Symptoms of hyperactivity–impulsivity and inattention were assessed by teachers five times from ages 6–12 years. Suicide attempt in adolescence and young adulthood (by age 23) was self-reported. Multitrajectory modelling was used to identify profiles of ADHD symptoms, and regression analysis was used to test their association with suicide attempt, adjusting for childhood socioeconomic and clinical characteristics. Findings We identified four ADHD symptom profiles with distinct associations with suicide attempt for males and females. Compared with those with persistently low symptoms, females with persistently high inattention and hyperactivity–impulsivity (OR: 2.54, CI 1.39 to 4.63) or high inattention and low hyperactivity–impulsivity (OR: 1.81, CI 1.21 to 2.70) were at higher risk of suicide attempt, while, among males, only those with decreasing hyperactivity–impulsivity and inattention over time (OR: 2.23, CI 1.20 to 4.13) were at higher risk of suicide attempt. Conclusions Risk of suicide attempt in children with ADHD symptoms varies according to both symptom profile and sex, the highest risk being for females with high inattention symptoms (with or without hyperactivity), and males with decreasing symptoms. Clinical implications Taking into account differences in both sex and ADHD symptoms profile may be relevant to more accurately identify and manage suicide risk in individuals with high ADHD symptoms, though caution is needed when generalising our population-based findings to clinical populations.

Question How effective is pharmacogenomic (PGx)-guided antidepressant treatment compared with treatment-as-usual (TAU) in major depressive disorder (MDD), and how do ethnicity, disease severity and genetic panel scope influence outcomes? Study selection and analysis This systematic review and meta-analysis comprised 13 randomised controlled trials (2013–2024) comparing PGx-guided therapy with TAU in MDD. PubMed, Ovid Embase, Ovid Medline, Ovid PsycINFO and the Cochrane Library were searched up to December 2024. Outcomes included response and remission rates at 8 and 12 weeks. Subgroup analyses examined ethnicity and MDD severity. Cumulative meta-analyses assessed gene panel size. The pooled risk ratios (RRs) with 95% CIs were calculated to estimate the overall effect. Findings PGx-guided treatment significantly improved response rates at 8 weeks (RR 1.23, 95% CI 1.05 to 1.43) and 12 weeks (RR 1.29, 95% CI 1.17 to 1.43). Remission was significant at 8 weeks (RR 1.37, 95% CI 1.19 to 1.57) but not at 12 weeks (RR 1.56, 95% CI 0.93 to 2.61). Benefits appeared stronger in the Asian country subgroup compared with non-Asian country subgroup (interaction p=0.02), but this requires validation due to the smaller Asian country sample size. No significant subgroup differences were observed between the MDD not-specified and MDD difficult-to-treat subgroups, despite the latter demonstrating significant improvements in both response and remission rates with PGx-guided treatment compared with TAU at 8 weeks. Cumulative analyses showed effect sizes plateaued, with broader panels offering minimal incremental gains. Conclusions PGx-guided treatment seems to offer moderate benefits for antidepressant efficacy, with potential advantages in Asian and difficult-to-treat subgroups. Genetic and ethnic variability in drug metabolism underscores the need for population-specific approaches. While multigene panels show clinical benefits plateau, suggesting cost-benefit optimisation is critical. Future research should address adverse events, the cost-effectiveness of expanded panels, long-term remission outcomes and treatment efficacy across more precisely stratified disease severity levels to maximise clinical relevance. PROSPERO registration number CRD42024570014.

Background Individuals with mental health conditions may experience disparity in cancer diagnosis and health outcomes. This study aims to examine diagnostic pathways and mortality in patients with colon cancer with pre-existing mental health conditions. Methods A population-based cohort study on colon cancer cases diagnosed in 2014–2020 in the provinces of Milan and Lodi, using linked cancer registration and health data. We examined cancer diagnostic pathways (screening, emergency presentation (EP), inpatient/outpatient visits) and short-term mortality in patients with and without pre-existing mental health conditions, accounting for physical comorbidities and sociodemographic factors. Mental health conditions were systematically categorised into distinct groups according to the International Classification of Diseases, 10th Revision. Results Out of 11 429 patients with colon cancer, 16.2% had a pre-existing mental health condition. Individuals with mental health conditions versus those without had a higher risk of cancer diagnosis following EP: 43.8% versus 33.8%, adjusted OR (aOR) 1.32, 95% CI 1.19 to 1.47. EP risk was higher for patients with diagnoses of dementia and related cognitive conditions (aOR 1.69, 95% CI 1.41 to 2.03), substance use/behavioural syndromes/personality-related conditions (aOR 1.92, 95% CI 1.34 to 2.75) and anxiety (aOR 1.44, 95% CI 1.16 to 1.79). The likelihood of screening-detected cancer was lower (4.6% vs 9.1%; aOR 0.78, 95% CI 0.60 to 0.99), especially for dementia and related cognitive conditions (aOR 0.27, 95% CI 0.08 to 0.86). Short-term mortality was higher in patients with cancer with mental health conditions than in those without. Conclusion Mental health conditions were associated with a lower likelihood of screening and a higher risk of emergency cancer diagnosis. Tailored strategies are warranted to enhance cancer diagnosis for the non-negligible group of individuals with mental health conditions.

Background With rapid population ageing, depressive symptoms in older adults have become a pressing public health concern. While functional dependency is a known risk factor, the impact of changes in dependency over time remains unclear. Objective To examine the association between changes in daily living dependency and incident depressive symptoms in older adults across international cohorts. Methods We used data from 46 327 adults aged ≥50 years across four longitudinal ageing studies: China Health and Retirement Longitudinal Study (China), Health and Retirement Study (USA), English Longitudinal Study of Ageing (England) and Survey of Health, Ageing and Retirement in Europe (Europe). Daily living dependency was classified into three levels based on difficulties in activities of daily living (ADLs) and instrumental ADLs (IADLs). Change in dependency was assessed using baseline and 2-year follow-up data. Depressive symptoms were measured using the Center for Epidemiologic Studies depressive symptoms Scale or the European Depression Scales (EURO-D). Cox proportional hazard models estimated HRs and 95% CIs for incident depressive symptoms over a median follow-up of 4.2–5.1 years. Findings A total of 12 902 new depressive symptom cases occurred during follow-up. Compared with participants whose dependency status remained unchanged, those who recovered to independency had a significantly reduced risk of depressive symptoms. Functional deterioration, including transitions from independency to ADL or IADL dependency, was associated with increased risk of depressive symptoms (both pooled HRs 1.55), while functional improvement, from ADL or IADL dependency to independency, was linked to reduced risk (HRs 0.83 and 0.80, respectively). Conclusions Improvement in ADL dependency is linked to a lower risk of depressive symptoms, while worsening dependency significantly increases depressive symptoms risk. Clinical implications Routine assessment of functional status and early interventions to maintain or restore daily living independency may help prevent depressive symptoms in older adults. Targeted rehabilitation and support services could play a key role in reducing the mental health burden of ageing populations.

Background Decreased cerebrospinal fluid (CSF) levels of synaptic proteins, possibly reflecting impaired synaptic function, have been observed in major depressive disorder (MDD). Objective To investigate the diagnostic utility of the soluble N-ethylmaleimide-sensitive-factor attachment receptor (SNARE) complex protein, synaptosomal-associated protein of 25 kDa (SNAP-25), for MDD. Methods Overall, 208 participants with one of MDD, schizophrenia (SCZ) or bipolar disorder (BD), and healthy controls (HCs) were retrospectively enrolled. CSF levels of SNAP-25 were assessed relative to MDD characteristics and the diagnostic potential was analysed. In subgroups of patients, CSF levels of presynaptic neurexin 3 (NRXN3), postsynaptic neurogranin (NRGN) and Alzheimer’s disease biomarkers were measured for comparison. Findings SNAP-25 levels, but not the levels of the other synaptic markers, were significantly decreased in MDD compared with HCs, allowing for discrimination with 68% sensitivity and 67% specificity. SNAP-25 was not associated with MDD severity or antidepressant medication. Compared with HCs, SCZ also displayed decreased SNAP-25 enabling discrimination with 64% sensitivity and 77% specificity. There were strong correlations between levels of synaptic proteins and established Alzheimer pathology markers, with subtle differences in the association pattern between disorders. Discussion Our data suggest that SNAP-25, NRXN3 and NRGN versus beta-amyloid and phosphorylated tau protein 181 (ptau) are regulated differentially across psychiatric disorders and that SNAP-25 has a moderate diagnostic potential for MDD and SCZ. We propose that CSF SNAP-25 level might represent an integrated readout of reduced synaptic function, rather than of synaptic degeneration, in MDD. Further studies are needed to analyse whether this potential can be increased by using multimarker measurements and whether it will be possible to subtype psychiatric disorders according to synaptic involvement in pathophysiology. Clinical implications SNAP-25 and other synaptic proteins in CSF might aid diagnosis and subtyping of MDD and SCZ. The current development of sensitive methods to also determine synaptic proteins in blood samples from patients will advance the validation of the biomarker potential and contribute to understanding of synaptic involvement in the pathophysiology of MDD and SCZ.

Background Individuals with serious mental illness (SMI) living in supported accommodation often lead lonely and sedentary lives. Everyday Life Rehabilitation (ELR) is a collaborative, person-centred, activity-oriented and recovery-oriented intervention that integrates outreach rehabilitation efforts into routine practices. This intervention aims to enhance personal recovery and quality of life by promoting engagement in meaningful everyday activities within real-life contexts. Objective To evaluate the effectiveness of ELR on personal recovery and quality of life among residents with SMI in supported accommodation, compared with treatment-as-usual (TAU). Methods This was a pragmatic, parallel-group, cluster-randomised controlled trial (RCT) (NCT05056415) conducted in Sweden between August 2021 and June 2024. The RCT included 60 housing units (clusters) randomly assigned (1:1) to receive either ELR or TAU. Data were collected by independent, blinded assessors, with partial blinding of residents. The primary outcome, Recovering Quality of Life (ReQoL-20), was assessed at the individual level and analysed using a mixed-effects model and an intention-to-treat (ITT) approach by a statistician blinded to the allocation. Findings Participants in the intervention group showed significantly greater improvements in ReQoL scores at 6 months compared with the control group (20.1, 95% CI: 15.8 to 24.4), with a statistically significant between-group difference (p<0.001). The ITT analysis included 60 housing units with 161 participants (86 men and 72 women), of whom 90 were allocated to ELR (33 units) and 71 to TAU (27 units). The overall attrition rate was 24% in both groups, and no major adverse events were reported. Conclusions These findings indicate that ELR is an effective intervention with a clinically relevant impact on recovering quality of life for individuals with SMI living in supported accommodation. While these results should be interpreted within the context of the Swedish system, they contribute to the growing body of evidence supporting recovery-oriented and activity-oriented interventions in supported accommodation. Clinical implications Responsive, person-centred, goal-oriented activity training, grounded in collaborative alliance, represents a valid strategy for recovery-oriented interventions. While multilevel approaches must be tailored to specific contexts, the integration of occupational therapists may provide clinical benefits in supported accommodation. Trial registration number NCT05056415.

Background Eating disorders are serious psychiatric disorders associated with high levels of co-occurring physical and mental health conditions and poor treatment outcomes. The collection of standardised, routinely collected data within clinical services holds promise to improve patient care. Objective To agree on a set of biopsychosocial variables for routine data collection within eating disorder services in the UK. Methods Two online workshops were conducted using an adapted nominal group technique to agree on priorities for data collection in adult and child/adolescent eating disorder services. Workshop participants (n=43) consisted of people with lived experience, carers, clinicians and researchers. Two researchers independently conducted a reflexive thematic analysis of the workshop transcripts to identify qualitative priorities for data collection. Descriptive statistics were used to analyse the results of online voting. Findings Thematic analysis identified four superordinate themes for data collection in eating disorder services: (1) a mutually valued and beneficial collaboration; (2) a holistic approach; (3) a balance between standardisation and individualisation; (4) doing no harm. Quantitative analysis of voting identified priorities across a range of domains, leading to a proposed biopsychosocial dataset. Conclusions This project agreed on a set of biopsychosocial variables for routine data collection in the UK Eating Disorders Clinical Research Network. Further research should evaluate the implementation success of these variables. Clinical implications Patients, caregivers and clinicians support routine data collection in eating disorder services so long as the measures used are considered meaningful, not overly burdensome, non-stigmatising and collected in collaboration between patients and treatment providers.

Background Subclinical psychotic symptoms (SPS) are common among college students and can lead to future mental health issues. However, it is still not clear which specific childhood trauma, stressors and health factors lead to SPSs, partly due to confounding factors and multicollinearity. Objective To use machine learning to find the main predictors of SPS among university students, with special attention to gender differences. Methods A total of 21 208 university students were surveyed regarding SPS and a wide range of stress-related factors, including academic pressure, interpersonal difficulties and abuse. Nine machine learning models were used to predict SPS. We examined the relationship between SPS and individual stressors using 2 tests, multicollinearity analysis and Pearson heatmaps. Feature engineering, t-distributed stochastic neighborhood embedding (t-SNE) and Shapley Additive Explanation values helped identify the most important predictors. We also assessed calibration with calibration curves and Brier scores, and evaluated clinical usefulness with decision curve analysis (DCA) to provide a thorough assessment of the models. In addition, we validated this model using independent external data. Findings The Extreme Gradient Boosting (XGBoost) model had the best prediction results, with an Area Under the Curve (AUC) of 0.89, and validated with external data. It also showed good calibration, and DCA indicated clear clinical benefit. Interpersonal difficulties, academic pressure and emotional abuse emerged as the strongest predictors of SPS. Gender-stratified analyses revealed that academic pressure and emotional abuse affected males more, while health issues like chest pain and menstrual pain were stronger predictors for females. Conclusions Machine learning models effectively identified key stressors associated with SPS in university students. These findings highlight the importance of gender-sensitive approaches for the early detection and prevention of psychotic symptoms. Clinical implications SPSs in college students can be predicted by interpersonal difficulties, academic stress and childhood emotional abuse. This information can help mental health professionals develop better ways to prevent and address SPSs.

Background Living systematic reviews (LSRs) maintain an updated summary of evidence by incorporating newly published research. While they improve review currency, repeated screening and selection of new references make them labourious and difficult to maintain. Large language models (LLMs) show promise in assisting with screening and data extraction, but more work is needed to achieve the high accuracy required for evidence that informs clinical and policy decisions. Objective The study evaluated the effectiveness of an LLM (GPT-4o) in title and abstract screening compared with human reviewers. Methods Human decisions from an LSR on prodopaminergic interventions for anhedonia served as the reference standard. The baseline search results were divided into a development and a test set. Prompts guiding the LLM’s eligibility assessments were refined using the development set and evaluated on the test set and two subsequent LSR updates. Consistency of the LLM outputs was also assessed. Results Prompt development required 1045 records. When applied to the remaining baseline 11 939 records and two updates, the refined prompts achieved 100% sensitivity for studies ultimately included in the review after full-text screening, though sensitivity for records included by humans at the title and abstract stage varied (58–100%) across updates. Simulated workload reductions of 65–85% were observed. Prompt decisions showed high consistency, with minimal false exclusions, satisfying established screening performance benchmarks for systematic reviews. Conclusions Refined GPT-4o prompts demonstrated high sensitivity and moderate specificity while reducing human workload. This approach shows potential for integrating LLMs into systematic review workflows to enhance efficiency.

This May, the World Health Assembly (WHA) will vote on re-establishing a mandate for the WHO to address the health consequences of nuclear weapons and war.1 Health professionals and their associations should urge their governments to support such a mandate and support the new United Nations (UN) comprehensive study on the effects of nuclear war. The first atomic bomb exploded in the New Mexico desert 80 years ago, in July 1945. Three weeks later, two relatively small (by today’s standards), tactical-size nuclear weapons unleashed a cataclysm of radioactive incineration on Hiroshima and Nagasaki. By the end of 1945, about 213 000 people were dead.2 Tens of thousands more have died from late effects of the bombings. Last December, Nihon Hidankyo, a movement that brings together atomic bomb survivors, was awarded the Nobel Peace Prize for its ‘efforts to achieve a world free of nuclear weapons...

This editorial discusses the importance of maintaining diversity within science, noting especially its significance to research in psychiatry. It follows a recent directive that was issued by the US administration that places unreasonable constraints on US government-funded scientific inquiry. The article draws attention to the harmful intended consequences of the directive. It also discusses its unintended consequences, which are likely to be damaging because heterogeneity is inherent in nature, and recognition of diversity in medical science helps achieve specificity. This is essential for the detection and diagnosis of disease and for tailoring therapies and developing targeted treatments.

Background Large language models (LLMs) offer significant potential to streamline research workflows and enhance productivity. However, limited data exist on the extent of their adoption within the mental health research community. Objective We examined how LLMs are being used in mental health research, the types of tasks they support, barriers to their adoption and broader attitudes towards their integration. Methods 714 mental health researchers from 42 countries and various career stages (from PhD student, to early career researcher, to Professor) completed a survey assessing LLM-related practices and perspectives. Findings 496 (69.5%) reported using LLMs to assist with research, with 94% indicating use of ChatGPT. The most common applications were for proofreading written work (69%) and refining or generating code (49%). LLM use was more prevalent among early career researchers. Common challenges reported by users included inaccurate responses (78%), ethical concerns (48%) and biased outputs (27%). However, many users indicated that LLMs improved efficiency (73%) and output quality (44%). Reasons for non-use were concerns with ethical issues (53%) and accuracy of outputs (50%). Most agreed that they wanted more training on responsible use (77%), that researchers should be required to disclose use of LLMs in manuscripts (79%) and that they were concerned about LLMs affecting how their work is evaluated (60%). Conclusion While LLM use is widespread in mental health research, key barriers and implementation challenges remain. Clinical implications LLMs may streamline mental health research processes, but clear guidelines are needed to support their ethical and transparent use across the research lifecycle.

Background Little is known about the health and healthcare needs of the behavioural health peer specialist workforce in the USA. This study explored the physical and mental health-related quality of life (QOL) of a US multistate cohort of certified peer specialists, and factors associated with health-related work absences among those employed in peer specialist positions. Methods Data come from 419 participants surveyed 18 months after state certification as part of a 2-year longitudinal cohort study of peer specialists in four US states. Measures included the Veterans RAND 12 Item Health Survey, the Epidemic-Pandemic Impacts Inventory and items from the National Health & Nutrition Examination Survey and Medical Expenditure Panel Survey. Multivariable hierarchical regression models predicted physical and mental health-related QOL and occurrence of work absences due to health. Results High rates (60%) of multiple physical health conditions characterise both those working in peer support positions and those not employed. Better physical health-related QOL was associated with younger age, not having multiple physical health conditions, not experiencing cost as a barrier to healthcare and not being enrolled in Medicaid or Medicare. Better mental health-related QOL was associated with older age, being Black/African-American, employment in peer support positions, moderate exercise, having a usual source of medical care and cost not being a barrier to care. Among those employed as peer specialists, health-related work absences were associated with physical and mental health QOL and other factors. Conclusions Certified peer specialists have high rates of physical comorbidities, and this affects their mental and physical health-related QOL and likelihood of working in peer support positions. Factors such as cost, having a regular source of healthcare, insurance coverage and demographic features are also associated with their QOL. These findings can inform efforts to attract and retain certified peer specialists in the behavioural health workforce.

Background Mental health research has long been structured around qualitative and quantitative methodologies, often marginalising experiential knowledge and reinforcing hierarchies of expertise. Although coproduction has gained traction as a participatory approach, its methodological status remains contested, leading to inconsistent practices and risks of tokenism. Objective This paper explores whether coproduction should be recognised not merely as a participatory ideal but as a third methodological pillar in mental health research, with distinct philosophical, ethical and practical foundations. Methods This paper critically integrates interdisciplinary sources from empirical research and theoretical literature to examine coproduction as a distinct methodological paradigm in mental health research. The analysis is informed by the author’s reflexive engagement as a lived experience researcher. Findings Five inter-related challenges to meaningful coproduction are identified: persistent tokenism; the emotional labour required of lived experience contributors; power imbalances in decision-making and recognition; structural exclusions in participation and systemic barriers within academic governance and norms. In response, the paper proposes five strategies for integrating coproduction as a distinct methodological paradigm: creating sustainable fora for dialogue across difference; establishing coproduction as a core research competency; embedding a relational culture of care; fostering methodological innovation and evaluation; and challenging narrow definitions of academic value, authorship and output. Conclusions Reframing coproduction as a third methodological pillar offers a way to address the exclusion of knowledge derived from lived experience and can enhance the rigour, relevance and inclusivity of mental health science. This shift requires systemic changes in how research is conceptualised, taught, funded and evaluated. Clinical implications Embedding coproduction as a core methodology can improve the relevance and responsiveness of research to clinical realities. Grounding research in lived experience offers insights that enhance service design, build trust and support more equitable, person-centred care, ultimately contributing to better clinical outcomes and more inclusive mental health systems.

Background Reasons for first using cannabis (RFUC) may influence later use patterns and mental health outcomes. However, limited research has explored self-medication versus social RFUCs in depth, and their associations with cannabis use patterns and psychopathology in the general population. Objectives We examined RFUCs and their associations with (1) reasons for continuing cannabis use, (2) weekly THC (delta-9-tetrahydrocannabinol) unit consumption and (3) symptoms of paranoia, anxiety and depressive symptoms. Methods We analysed data from the Cannabis&Me (CAMe) population survey (March 2022–July 2024), including 2573 (75.9%) current and 816 (24.1%) past cannabis users aged 18 years or older. Findings Participants reported a mean weekly consumption of 206 THC units (SD=268). Initiating cannabis use for anxiety (β=36.22, p=3.3e–03), depression (β=40.37, p=1.74e–03) or because ‘family members were using it’ (β=87.43, p=1.22e–09) was associated with higher weekly THC units. RFUC to relieve physical discomfort (β=8.89, p=4.12e–07), pain (β=7.24, p=5.56e–06), anxiety (β=9.67, p=1.63e–16), depression (β=9.12, p=1.21e–13) and minor psychotic symptoms (β=16.46, p=1.2e–04) were linked to higher paranoia scores. Similar associations were observed for anxiety and depression. Conversely, starting for fun (β=–3.71, p=3.49e–05) or curiosity (β=–2.61, p=5e–03) was associated with lower paranoia and anxiety. RFUC for ‘boredom’ was linked to increased depression (β=1.09, p=3.8e–03). Conclusions Initiating cannabis use for self-medication is associated with higher average THC consumption, and increased anxiety, depression and paranoia. Clinical implications Asking individuals why they first used cannabis may serve as a cost-effective screening tool to identify those who could benefit from monitoring, support, or referral to intervention services.

Background Digital phenotyping provides passive monitoring of behavioural health but faces implementation challenges in translating complex multimodal data into actionable clinical insights. Digital navigators, healthcare staff who interpret patient data and relay findings to clinicians, provide a solution, but workforce limitations restrict scalability. Objective This study provides one of the first systematic evaluation of large language model performance in interpreting simulated psychiatric digital phenotyping data, establishing baseline accuracy metrics for this emerging application. Methods We evaluated GPT-4o and GPT-3.5-turbo across over 153 test cases covering various clinical scenarios, timeframes and data quality levels using simulated test datasets currently employed in training human digital navigators. Performance was assessed on the model’s capacity to identify clinical patterns relative to human digital navigation experts. Findings GPT-4o demonstrated 52% accuracy (95% CI 46.5% to 57.6%) in identifying clinical patterns based on standard test cases, significantly outperforming GPT-3.5-turbo (12%, 95% CI 8.4% to 15.6%). When analysing GPT-4o’s performance across different scenarios, strongest results were observed for worsening depression (100%) and worsening anxiety (83%) patterns while weakest performance was seen for increased home time with improving symptoms (6%). Accuracy declined with decreasing data quality (69% for high-quality data vs 39% for low-quality data) and shorter timeframes (60% for 3-month data vs 43% for 3-week data). Conclusions GPT-4o’s 52% accuracy in zero-shot interpretation of psychiatric digital phenotyping data establishes a meaningful baseline, though performance gaps and occasional hallucinations confirm human oversight in digital navigation tasks remains essential. The significant performance variations across models, data quality levels and clinical scenarios highlight the need for careful implementation. Clinical implications Large language models could serve as assistive tools that augment human digital navigators, potentially addressing workforce limitations while maintaining necessary clinical oversight in psychiatric digital phenotyping applications.

Well-synchronised circadian rhythms are fundamental for human health and particularly mental health, but patterns of modern living—including, for example, shift work and excess light at night—can cause desynchronisation of rhythms and result in a wide range of adverse mental health outcomes. In recent years, there has been a renaissance of interest in the overlap between sleep/circadian science and mental health, from basic discovery science through to novel chronotherapies and public health policy.1 This topic collection brings together five original research papers, two systematic reviews and a perspectives piece, representing an up-to-date overview of current research and innovation in the emerging field of chronopsychiatry. In a study of almost half a million participants in the UK Biobank cohort, Daudali and colleagues investigated the effects of common genetic variation in the circadian regulator gene BMAL1.2 Their hypothesis was that circadian disruption (indexed by BMAL1 polymorphisms) may represent...

Background While 17% of new mothers experience symptoms of postpartum depression (PPD), emotional distress is more widespread in the postpartum period. This descriptive study described item-level responses on the Edinburgh Postnatal Depression Scale (EPDS) to better understand common postpartum experiences. Methods We analysed EPDS data from 170 218 childbirths (2015–2021) in the Danish HOPE cohort collected during routine postpartum visits. We described the distribution of responses to each item and total scores. Results Most mothers reported mild or no symptoms. Items on self-blame, anxiety and feeling overwhelmed showed large variation. Self-harm thoughts were rare (1.7%). The median total score was 4 (IQR 2–7); 7.8% scored ≥11, indicating possible PPD. Discussion Diverse emotional responses are common postpartum and often reflect normal adjustment. Item-level insights may help reduce stigma and support open dialogue around maternal mental health.

Background Suicide mortality among Vietnam War-era veterans has been examined for nearly five decades. Research on sex-based differences in postwar suicide risk among this veteran cohort, however, remains scant. Objective To examine the association of theatre deployment or deployment to Vietnam or the surrounding theatres of war operations between 1961 and 1975, and sex differences in risk of postwar (1979–2019) suicide mortality among Vietnam War-era veterans. Methods This was an observational study using a retrospective cohort design to examine the impact of sex and theatre deployment or deployment to Vietnam or the surrounding theatres of war operations between 1961 and 1975 on risk of postwar suicide mortality among 9 494 656 US Vietnam War-era veterans. Suicide mortality data were drawn from the Veterans Affairs Mortality Data Repository, 1979–2019. Findings A total of 94 497 suicide deaths were observed. Theatre deployment was not associated with increased risk of suicide among male, HR 0.94 (95% CI 0.93 to 0.96), or female, HR 1.22 (95% CI 0.94 to 1.59), veterans. Relative to the general population, female veterans had heightened risk of suicide, standardised mortality ratios (SMR) 1.75 (95% CI 1.66 to 1.86); male veterans did not, SMR 0.97 (95% CI 0.97 to 0.98). Firearms were used in 45% of all observed suicides. Conclusions Theatre deployment was not associated with increased risk of suicide. Female veterans’ elevated risk of suicide relative to the general population, however, warrants attention. Clinical implications Vigilant attention to the heightened risk of suicide among female Vietnam War-era veterans relative to the general population is needed.

Background Self-harm is a prevalent health concern among youths, with significant psychosocial impacts on both youths and their parents. The aim of this study is to describe the impact of offspring self-harm on parental work absence. Methods This cohort study included 176 472 mothers and 161 833 fathers of 17 726 youths with a first self-harm diagnosis between the years of 2006 and 2016 and 177 260 matched youths without self-harm. It examined work absence due to family leave to care for a sick child and sick leave, before and after the child’s self-harm. Data were sourced from Swedish population-based registers. Conditional Poisson regression, adjusting for potential confounders, was used to analyse associations between self-harm and work absence in parents of youth with and without self-harm after the self-harm event, as well as in parents of self-harming youth before and after the self-harm event. Results Parents of both sexes experienced work absence. Nevertheless, mothers were particularly affected. Youth self-harm was linked to increased family leave (rate ratios: mothers 3.47 (95% CI 3.25 to 3.72), fathers 2.71 (2.47 to 2.98)) and sick leave (mothers 1.25 (1.20 to 1.31), fathers 1.25 (1.17 to 1.33)). Parents of affected youth took more family leave during the self-harm year compared with the previous year (mothers 1.65 (1.55 to 1.75), fathers 1.41 (1.29 to 1.54)), with no corresponding rise in sick leave. Conclusions Parents of self-harming youths experience increased work absence, especially family leave, peaking around self-harm events. These results highlight the broader impact of youth self-harm on families and the need for support systems addressing both youth and caregiver well-being and work–life balance.

Climate change creates unique forms of psychological distress for Indigenous Peoples whose identities and cultural practices are often intrinsically connected to ancestral lands, yet research on culturally appropriate methodologies for studying Indigenous mental health in the context of climate change remains limited. This perspective paper presents methodological reflections from Land Body Ecologies research collective, which collaborates with Ogiek (Kenya), Batwa (Uganda), Iruliga (India), Pgak’yau (Thailand) and Sámi (Sápmi) Indigenous Peoples to explore climate change-related mental health impacts through the lens of solastalgia. Through participatory dialogues conducted during in-person gatherings, team members reflected on three years of community-based participatory research and identified two critical methodological challenges underexplored in the existing literature: (1) language and concept translation difficulties, where terms such as ‘mental health’ and ‘climate change’ lack direct cultural equivalents and may carry stigmatising connotations and (2) barriers to cultural practices, where climate change and conservation-related legislation restricts Indigenous Peoples’ access to ancestral lands and traditional practices essential for well-being. These challenges reflect deeper epistemological tensions between conventional research approaches and Indigenous holistic worldviews that understand land, body and ecosystems as interconnected. It concludes that meaningful mental health research with Indigenous Peoples demands active recognition of Indigenous cultural rights and self-determination, collaborative approaches that honour Indigenous knowledge systems and systemic changes that normalise Indigenous timelines, relationality and knowledge sovereignty within research institutions.

Background Major depressive disorder (MDD) remains underdiagnosed worldwide, partly due to reliance on self-reported symptoms and clinician-administered interviews. Objective This study examined whether a speech-based classification model using emotionally and thematically varied image-description tasks could effectively distinguish individuals with MDD from healthy controls. Methods A total of 120 participants (59 with MDD, 61 healthy controls) completed four speech tasks: three emotionally valenced images (positive, neutral, negative) and one Thematic Apperception Test (TAT) stimulus. Speech responses were segmented, and 23 acoustic features were extracted per sample. Classification was performed using a long short-term memory (LSTM) neural network, with SHapley Additive exPlanations (SHAP) applied for feature interpretation. Four traditional machine learning models (support vector machine, decision tree, k-nearest neighbour, random forest) served as comparators. Within-subject variation in speech duration was assessed with repeated-measures Analysis of Variance. Findings The LSTM model outperformed traditional classifiers, capturing temporal and dynamic speech patterns. The positive-valence image task achieved the highest accuracy (87.5%), followed by the negative-valence (85.0%), TAT (84.2%) and neutral-valence (81.7%) tasks. SHAP analysis highlighted task-specific contributions of pitch-related and spectral features. Significant differences in speech duration across tasks (p<0.01) indicated that affective valence influenced speech production. Conclusions Emotionally enriched and thematically ambiguous tasks enhanced automated MDD detection, with positive-valence stimuli providing the greatest discriminative power. SHAP interpretation underscored the importance of tailoring models to different speech inputs. Clinical implications Speech-based models incorporating emotionally evocative and projective stimuli offer a scalable, non-invasive approach for early depression screening. Their reliance on natural speech supports cross-cultural application and reduces stigma and literacy barriers. Broader validation is needed to facilitate integration into routine screening and monitoring.

Background Little is known about the mechanisms underlying associations between air pollution exposure in childhood and mental health disorders in adulthood. Objective To examine the prospective associations between age-10 air pollution exposure and age-18 mental health disorders and to test potential mediation by impaired cognition at age 12. Methods We used longitudinal observations of 1969 members of the Environmental Risk Study who were born across England and Wales in 1994–1995. Exposure to nitrogen dioxide, nitrogen oxides (NOx) and particulate matter (PM2.5 and PM10) was modelled for residential addresses at age 10. Past-year prevalence of anxiety, depression, conduct disorder and attention-deficit/hyperactivity disorder was assessed by interview at age 18. Overall cognition (full-scale IQ) and specific domains (fluid ability, crystallised ability and working memory) were assessed at age 12. We employed binary logistic regression to examine pollution–disorder associations and generalised structural equation modelling to examine mediation via impaired cognition. Findings Higher exposure to NOx was associated with greater odds of depression after covariate adjustment (OR=1.25, 95% CI 1.01 to 1.55). No robust associations were evident for the other pollutants or outcomes. Overall cognition (indirect effect (IE): OR=1.00, 95% CI 0.99 to 1.01) and crystallised ability (IE: OR=1.00, 95% CI 0.99 to 1.01) did not mediate the association between NOx and depression. Conclusions We found no evidence that impaired cognition mediated associations between childhood residential exposure to NOx and depression in early adulthood. Clinical implications Policies to reduce childhood exposure to NOx may help reduce depression in early adulthood. Future research should examine alternative mechanisms.

Background Prenatal exposure to per- and polyfluoroalkyl substances (PFAS) may adversely affect neurodevelopment, but comparative risks and metabolic disruptions remain unclear. Objective To integrate various levels of evidence and illustrate the relationship between prenatal PFAS exposure and neurodevelopmental trajectories in children. Methods In the Shanghai-Minhang birth cohort, maternal PFAS were measured from plasma collected at 12–16 weeks’ gestation. Neurodevelopment was assessed at 6, 12 and 48 months using the Ages and Stages Questionnaire-3 and group-based trajectory modelling was performed. Associations between PFAS (co-)exposure and neurodevelopment were evaluated using logistic regression and mixture model effects. Metabolomic perturbations of PFAS with potential neurodevelopmental effects were analysed in PC12 neuronal cells. Findings Among 412 mother-child pairs, higher PFAS exposure was linked to suboptimal development in communication (highest vs lowest tertile: ORPFHxS=2.96, 95% CI 1.05 to 8.35, ptrend=0.064; ORPFOS=3.45, 95% CI 1.27 to 9.43, ptrend=0.012), personal-social (highest vs lowest tertile: ORPFNA=2.41, 95% CI 1.05 to 5.56, ptrend=0.036), and total score (highest vs lowest tertile: ORPFOS=2.32, 95% CI 1.09 to 4.91, ptrend=0.028) across early childhood. Metabolomic analysis revealed disrupted excitatory/inhibitory (E/I) neurotransmission. Integrated toxicological assessment, including exposure risk information, toxicogenomic signatures, bioassay-inferred toxicity and in vitro neurotoxicity profiles, ranked PFOS as the most neurotoxic, followed by perfluorooctanoic acid, perfluorohexanoic acid, perfluorohexanesulfonic acid and 6:2 chlorinated polyfluorinated ether sulfonate. An E/I imbalance-based screening identified 8.3% of children as high-risk for PFAS-related neurodevelopmental deficits. Conclusions Prenatal PFAS exposure is associated with suboptimal neurodevelopment, particularly in communication and social interaction. Clinical implications Maternal exposure profiles during early gestation that are associated with disrupted E/I neurotransmission may serve as early indicators of increased risk for suboptimal neurodevelopment, thereby informing timely preventive interventions.

Objective To evaluate gender and geographic representation (within the USA) and assess financial conflicts of interest and industry payments among task force, panel and cross-cutting review group members of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). Design Cross-sectional analysis. Setting Open Payments database, USA; National Provider Identifier (NPI) registry, USA. Participants The 116 physicians who served on a task force (n=5), panel (n=83) and cross-cutting review group (n=28) for the DSM-5-TR with information recorded in the Open Payments database and NPI registry. Main outcome measures Demographic patterns among contributors to the DSM-5-TR, including gender and geographic location (USA) and type and extent of industry payments received by contributors to the DSM-5-TR during 2016–2019. Results Women represented 30.2% (n=35) of all DSM-5-TR contributors. Men accounted for 70.8% (n=46) of the contributors receiving industry funding and received 91.8% of all compensation, totalling US$13.4 million. Three states were represented by 43.9% (n=51) of contributors. Of the 116 contributors, 65 (56%) received financial compensation from industry, totalling US$14.6 million. Conclusion Female contributors accounted for less than one-third of all DSM-5-TR contributors and had fewer financial ties to industry compared to their male counterparts. There was a disproportionate representation of contributors in three states, while 23 states were not represented. To promote gender parity and equitable geographic representation in the DSM, sixth edition, the adequate inclusion of male and female contributors, as well as those from various regions of the USA, should be prioritised to increase diversity. Finally, financial conflicts of interest should be minimised and more thoroughly managed in future DSM editions.

Background A higher prevalence of neurological conditions has been found in schizophrenia, bipolar disorder and other psychotic illnesses compared to the general population. We aimed to understand the cumulative prevalence of 15 neurological conditions in people with severe mental illness (SMI) from 5 years before to 5 years after their SMI diagnosis. Methods We identified patients with SMI, aged 18–100 years from 1 Jan 2000 to 31 Dec 2018, from the UK Clinical Practice Research Datalink. Each SMI patient was matched 1:4 to individuals without SMI. The cumulative prevalence of 15 neurological conditions was recorded at 5, 3 and 1 years prior to SMI diagnosis; at SMI diagnosis; and 1, 3 and 5 years after SMI diagnosis. Prevalences were compared with logistic regression. Results We identified 68 789 patients with SMI and 274 827 comparators. Of 15 neurological conditions, 13 (multiple sclerosis, cerebrovascular disease, dementia, ataxic disorders, epilepsy, Parkinson’s disease, other parkinsonism, paralysis, other movement disorders, cerebrospinal fluid disorders, cerebral palsy, disorders of nerve root, plexus or peripheral nerves and autonomic disorders) were more prevalent in SMI compared with comparators at the time of SMI diagnosis. Dementia (OR: 4.22; 95% CI 3.88 to 4.58), epilepsy (OR: 3.01; 95% CI 2.83 to 3.19) and Parkinson’s disease (OR: 3.97; 95% CI 3.45 to 4.57) were particularly elevated at 5 years post-SMI diagnosis. Conclusions Many neurological conditions have higher prevalence in the SMI cohort compared with those without SMI. The different prevalence patterns observed in our study highlight the need to establish the causal pathways between specific SMI and neurological disease diagnoses.

Background Major depressive disorder (MDD) with comorbid anxiety presents a greater treatment challenge and higher relapse risk. Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have shown efficacy individually, but their combined effect remains unclear. Objective To assess the efficacy and acceptability of rTMS, tDCS and their combined therapy in alleviating depressive and anxiety symptoms in patients with MDD. Methods In this double-blind, randomised, sham-controlled trial, 240 patients with MDD with anxiety symptoms were assigned to four groups: active rTMS+active tDCS, active rTMS+sham tDCS, sham rTMS+active tDCS and sham rTMS+sham tDCS. Participants received 10 sessions over 2 weeks and were followed for an additional 2 weeks. Primary outcomes were changes in Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Scale (HAMA) scores from baseline to post-treatment. ² tests and mixed-design analysis of variance were used for group comparisons. Findings After 2 weeks of treatment, the combined rTMS+tDCS group showed significantly greater reductions in HDRS scores than the other three groups. Reductions in HAMA scores were also larger compared with the sham–sham group and remained superior to that of the other groups at the 4-week follow-up. The combined group had the highest anxiety response rate (82.83%, p=0.014) and remission rate (26.17%, p=0.020) at post-treatment. No serious adverse events were reported across groups. Conclusions Combined rTMS and tDCS were more effective than monotherapy or sham in alleviating depression and anxiety in MDD, with good tolerability and no significant side effects. Clinical implications This combined neuromodulation approach may serve as a promising and well-tolerated non-pharmacological option for patients with MDD with comorbid anxiety. It offers a clinically scalable intervention that could complement current first-line therapies. Trial registration number ChiCTR2100052122.

Background One in four cases of schizophrenia begins in late life, resulting in high unemployment and reduced life expectancy. However, knowledge of the modifiable risk factors for late-onset schizophrenia and their combined effects is limited. Aims To identify modifiable risk factors for late-onset schizophrenia and estimate their joint disease risk effects. Methods This prospective cohort study using UK Biobank data included 482 708 participants without late-onset schizophrenia at baseline, followed up for a mean of 14.36 years. We conducted an exposure-wide association study of 232 potentially modifiable factors linked to late-onset schizophrenia risk. Late-onset schizophrenia is diagnosed using ICD-10 (International Classification of Diseases, 10th Revision) criteria. Cox proportional hazard models identified significant factors across six domains: lifestyle, environment, medical history, physical measures, mental health and socioeconomic status (SES). Domain-specific weighted scores were calculated from Cox model coefficients and stratified into tertiles (favourable, intermediate, unfavourable) for risk assessment. Population attributable fractions (PAFs) quantified prevention potential. Results During follow-up, 1276 participants developed late-onset schizophrenia. We identified 109 significant potentially modifiable factors, with intellectual disability (HR 35.15, 95% CI 11.23 to 110.09), manic episode (HR 33.14, 95% CI 21.16 to 51.90) and bipolar affective disorder (HR 32.91, 95% CI 27.07 to 40.01) showing the strongest risks, while higher household income (>£100 000: HR 0.14, 95% CI 0.09 to 0.22), regular friends/family visits (HR 0.23, 95% CI 0.18 to 0.28) and higher hand grip strength (HR 0.35, 95% CI 0.29 to 0.44) showed the strongest protection. PAF estimations indicated that shifting individuals from unfavourable to intermediate/favourable risk profiles could prevent 71.3% (95% CI 71.2% to 71.4%) of late-onset schizophrenia cases, mainly from mental health (25.1%, 95% CI 25.0% to 25.2%), medical history (13.6%, 95% CI 13.5% to 13.7%) and SES domain (11.2%, 95% CI 11.1% to 11.3%); shifting individuals from intermediate/unfavourable risk profiles to favourable could prevent 89.2% of cases. Conclusions A substantial proportion of late-onset schizophrenia risk appears modifiable, with mental health and medical history as key contributors. Physical health and natural environment exposure provided protective benefits. Findings supported integrating clinical interventions and structural changes addressing socioeconomic and environmental factors to reduce late-onset schizophrenia burden.

Background Suicide is more common among males and in older age, but the understanding of sex-specific and age-specific risk indicators is limited. Objective To describe the sex-specific and age-specific prevalence of 25 suicide risk indicators in the year preceding suicide and estimate their associations with suicide. Methods Register-based population-nested case-control study in Sweden, 2009–2021, comprising 19 741 suicide cases and 197 296 general population controls matched by sex, age and county of residence. Death by suicide was collected from the cause of death register. 25 suicide risk indicators covering psychiatric history, somatic disorders, bereavement and sociodemographic factors in the previous year were collected from nationwide registers. Sex-specific and age-specific ORs of suicide for the presence/absence of each risk indicator in the prior year were estimated and complemented by risk differences. Findings Suicide cases were 70% male, 9% were aged 15–24 years, 29% 25–44 years, 36% 45–64 years and 26% 65+ years. In the year preceding suicide, the prevalence of most risk indicators was the lowest among males and people aged 65+ years. Most risk indicators also showed weaker 1-year associations with suicide in these groups. The median OR (IQR) of suicide across the 25 risk indicators was 14.6 (5.2, 29.1) in females versus 10.3 (4.3, 21.3) in males, and 17.4 (6.5, 28.9) in 24–44 year-olds versus 8.0 (3.6, 23.7) in people aged 65+years. Risk differences of suicide were larger in males across nearly all risk indicators. Conclusions There was considerable heterogeneity across sex and age groups, both in the prevalence of risk indicators preceding suicide and in their associations with suicide. Risk indicators were generally less common and displayed weaker associations with suicide on the relative risk scale among males and older people. Clinical implications Suicides in males and older people may be harder to predict, as indicators are rarer. When males present with risk indicators, they generally have a higher absolute risk of suicide, making them important targets for prevention even when risk indicators do not cause suicide. Our findings underscore the importance of considering sex-specific and age-specific risk indicators for individualised suicide prediction and prevention.

Background Poorer psychological and social well-being has been linked to increased mortality. Objective To delineate the trajectories of psychological and social well-being during the last two decades of life. Methods Within the Rush Memory and Aging Project, 1971 older adults were followed up for up to 22 years. Aspects of psychological well-being (ie, depression symptoms, loneliness and purpose in life) and social well-being (ie, cognitive activity, social activity and social network) were annually measured through structured interviews. Survival status was tracked during the follow-up period. Data were analysed using Cox regression and mixed-effect models with a backward timescale. Findings During the follow-up, 1119 (56.77%) participants died. In multiadjusted Cox regression models, higher depression symptoms and poor social activity were associated with increased mortality. Compared with survivors, decedents showed steeper declines in psychological and social well-being, leading to significant differences up to 13 years before death for purpose in life (mean difference: –0.14 (–0.26, –0.01)), 9 years for depression symptoms (0.35 (0.10, 0.60)) and social activity (–0.16 (–0.26, –0.06)), 6 years for loneliness (0.13 (0.05, 0.21)), 4 years for social network (–1.06 (–1.77, –0.36)), and 3 years for cognitive activity (–0.12 (–0.21, –0.04)). Among decedents, the terminal phase began 11 years before death for purpose in life, 10 years for cognitive activity, 9 years for social activity and depression symptoms and 6 years for loneliness. Conclusions and implications Psychological and social well-being may begin to exhibit terminal decline approximately 6–11 years prior to death. Longitudinal surveillance of well-being should be incorporated into the context of geriatric medical care.

Question What are the cognitive, functional and affective characteristics of brain fog in individuals with long covid and following chemotherapy, and how are these features assessed across studies? Study selection and analysis In March 2024, we conducted a systematic review and meta-analysis of peer-reviewed studies assessing cognition, function or mood in adults (≥18 years) with brain fog after COVID-19 or chemotherapy. PubMed, Embase and Web of Science were searched systematically according to eligibility criteria to March 2024, with an update in May 2025. Random-effects meta-analyses using the ‘dmetar’ package (V.0.0.9000) in R V.4.3.1 were performed for studies comparing individuals with and without brain fog. Bias was assessed using the National Institutes of Health Study Quality Assessment Tools. Findings Of 3077 records screened, 65 studies met inclusion criteria: 40 investigated brain fog in long covid and 25 in chemotherapy populations. Considerable variation in assessment tools was observed. Montreal Cognitive Assessment was the most common cognitive test in long covid studies; Functional Assessment of Cancer Therapy—Cognitive Function was most used in chemotherapy studies. Nine long covid studies were eligible for meta-analysis. Compared with controls, individuals with brain fog had significantly lower cognitive performance (Hedge’s g=–0.63, 95% CI –1.15 to –0.12), higher fatigue (Hedge’s g=2.64, 95% CI 0.41 to 4.86) and more depressive symptoms (Hedge’s g=1.48, 95% CI 0.40 to 2.55). Heterogeneity was high (I2>70%). No chemotherapy studies were appropriate for meta-analysis, preventing direct comparison of brain fog features between long covid and chemotherapy groups. Conclusions Brain fog in long covid and chemotherapy populations is associated with cognitive complaints, fatigue and mood disturbance, though assessment methods differ widely. To improve comparability and clinical understanding, we propose adoption of consistent tools and definitions in future studies. This will be a crucial step in generating findings that can be meaningfully compared across populations. PROSPERO registration number CRD42024520549.

Lifestyle-related behaviours—such as sedentary behaviour, physical inactivity, poor nutrition, disrupted sleep and substance use—are increasingly recognised as important factors in the onset and persistence of mental illness. Evidence for the efficacy and cost-efficiency of lifestyle interventions in mental health is growing, and such approaches are now embedded in international guidelines and endorsed by major health organisations and associations as ‘lifestyle psychiatry’. Nevertheless, despite this progress, these interventions remain underused in mental healthcare and support. One contributing factor is the lack of a shared conceptual understanding of ‘lifestyle psychiatry’, which risks fragmented practice, inconsistency in research and uncertainty around its role in policy, care and support. This paper presents a conceptual framework for lifestyle psychiatry, developed through an iterative, collaborative process involving 43 contributors across 15 countries, representing clinical, academic, policy and lived experience expertise. The framework defines core domains, outlines key challenges to behaviour change specific to mental health populations and emphasises multilevel and equity-oriented approaches. It aligns with person-centred and recovery-oriented care and serves as a shared reference point for practical application and future development. With this, we aim to support the structured, context-sensitive integration of lifestyle psychiatry into mental healthcare and support.

Background Major depressive disorder (MDD) poses a significant global public health challenge. Although the Patient Health Questionnaire-9 (PHQ-9) is widely used for MDD screening, its validation in psychiatric samples is limited. Additionally, variability in cut-off values across populations may lead to diagnostic inaccuracies. This study aims to develop a highly accurate nomogram tailored to improve MDD screening precision in psychiatric samples. Methods From March 2024 to February 2025, participants were consecutively recruited from psychiatric outpatient clinics at Xijing Hospital and the 904 Hospital, assigned to training and validation cohorts. Using Least Absolute Shrinkage and Selection Operator regression for dimensionality reduction and predictor identification, we then weighted key factors via multivariable logistic regression to construct a clinically interpretable nomogram. The model’s discriminative ability, calibration, clinical utility and improvement metrics underwent rigorous evaluation. Findings In the training cohort (n=519) and validation cohort (n=225), 53.95% and 53.33% of participants were diagnosed with MDD. We constructed a nomogram using 11 predictors selected from 20 variables. In internal validation, the nomogram’s area under the curve (AUC) (95% CI) surpassed the PHQ-9’s (0.932 (0.910–0.954) vs 0.874 (0.844–0.905), p<0.001). Similarly, in external validation, the nomogram’s AUC (95% CI) was higher than the PHQ-9’s (0.935 (0.902–0.968) vs 0.888 (0.844–0.932), p<0.001). Moreover, the nomogram demonstrated better performance than the PHQ-9 in calibration and clinical utility during both internal and external validation. These improvements suggest that the nomogram has the potential to reduce false-positive and false-negative rates in MDD screening. Conclusion This study developed a novel tool for MDD screening in psychiatric samples by integrating weighted relevant factors, which demonstrates significantly improved accuracy in identifying MDD.

Background Risky sexual behaviours (RSB) and attention deficit hyperactivity disorder (ADHD) are both major concerns among university students. However, their association remains insufficiently understood. This study aimed to evaluate the relationship between ADHD symptoms and a broad range of RSB in university students. Methods A total of 13 085 French students enrolled in the i-Share (Internet-based Students’ Health Research Enterprise study (mean age: 20.6 years, SD=2.4) completed self-reported questionnaires assessing ADHD symptoms (Adult Self-Report Scale V.1.1), RSB, sociodemographic characteristics and alcohol and cannabis use. Logistic and Poisson regression models were used to examine the cross-sectional associations between ADHD symptoms and RSB, adjusting for relevant confounders. Results A high level of ADHD symptoms was observed in 5.3% of students. In multivariable models, ADHD symptoms were associated with a wide range of RSB, including early first sexual intercourse (adjusted odds ratio (aOR) 1.26; 95% CI 1.06 to 1.51), inconsistent condom use in the last 12 months (aOR 1.26; 95% CI 1.05 to 1.51), diagnosis of a sexually transmitted infection in the last 12 months (aOR 1.49; 95% CI 1.08 to 2.07) and having had a higher number of sexual partners in the last 12 months (adjusted incidence rate ratio 1.20; 95% CI 1.14 to 1.27). Among female students, ADHD symptoms were associated with lower current use of any form of contraception (aOR 0.59; 95% CI 0.48 to 0.71), and higher odds of having ever used emergency contraception (aOR 1.22; 95% CI 1.02 to 1.47), and having ever had an abortion (aOR 1.77; 95% CI 1.21 to 2.58). Conclusions University students with a high level of ADHD symptoms are at increased risk of engaging in a wide range of RSB. Targeted preventive strategies may be particularly beneficial for this population.

Question Means restriction for suicide prevention at a population level typically involves policy or environmental changes to limit access to suicide methods. Several systematic reviews of suicide means restriction exist. This umbrella review aimed to synthesise their findings, assess evidence quality, quantify primary study overlap and identify evidence gaps. Study selection and analysis Searches were conducted across Web of Science, Ovid (PsycINFO, EMBASE), Cochrane and PubMed, supplemented by reference list screening. Study quality was assessed using A MeaSurement Tool to Assess systematic Reviews-2. Study overlap was calculated using the corrected covered area. Findings We included 20 systematic reviews, synthesising evidence from 179 unique primary studies. Physical barriers to prevent jumping showed strong effect sizes, although primary study overlap was high. Train platform screen doors were associated with reduced site-specific suicide mortality, with no evidence of displacement to other sites, although the number of studies was small. Paracetamol pack size limitation reduced self-poisoning admissions, with mixed impacts on mortality. Bans on highly hazardous pesticides reduced suicide rates. More recent reviews suggest firearms restrictions may reduce suicides, but with small effect sizes and methodological limitations. Evidence quality ranged from high to critically low (12/20 rated as critically low). With the exception of pesticide restrictions, lower and middle-income settings were not represented. Conclusions Several means restriction approaches demonstrate effectiveness, although high study overlap and variable study quality were evident. A focus on differential impacts across sociodemographic groups, more evidence from lower and middle-income countries and evidence for suicide prevention on roads and from residential buildings is needed. PROSPERO registration number CRD42024620103.

As Editor in Chief of BMJ Mental Health, I’m delighted to announce the launch of BMJ Connections Mental Health, a new open access journal from BMJ Group which is part of the BMJ Connections series focusing on rapidly growing areas of biomedical research. BMJ Connections Mental Health aims to be an international journal for peer-reviewed mental health research, bridging clinical practice, scientific research and translational applications. We are interested in publishing the full spectrum of robust, methodologically sound and reproducible research in mental health that can move discoveries from the lab to clinical settings and connect the research community to improve real-world outcomes for patients. As an author publishing in BMJ Connections Mental Health or as a reader of our journal, you can expect the same rigorous approach to content integrity and publication ethics that you would receive from every BMJ journal. We welcome submissions in all areas of...

Background The impact of comorbid post-traumatic stress disorder (PTSD) and depression on cognitive outcomes after traumatic brain injury (TBI) is not well understood. Objective To investigate associations of PTSD and depression with cognitive performance over the first year post-injury. Methods 1550 participants with Glasgow Coma Scale 13–15 TBI from the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) Study were included. Participants underwent in-person assessments at 2 weeks, 6 months and 1 year post-injury. Meeting screening criteria for PTSD was determined using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders. Meeting screening criteria for depression was determined using the Patient Health Questionnaire–9. Cognition was assessed using a five-test battery. Linear mixed effects models were used to examine associations of PTSD and depression with cognition after TBI. Findings Participants had a mean age of 41 years, 34% were female, 65% did not meet screening criteria for PTSD or depression, 3% met screening criteria for depression only, 16% met screening criteria for PTSD only and 16% met screening criteria for both depression and PTSD in the first year post-TBI. Mean performance on all cognitive tests improved at a similar rate over the first year post-injury in all PTSD/depression groups, but cognitive test performance was consistently worse among individuals with concurrent PTSD and/or depression compared with individuals with neither. Conclusions Individuals with TBI meeting screening criteria for PTSD and/or depression have consistently worse cognitive performance over the first year post-injury compared with individuals without psychiatric comorbidities, but the average rate of cognitive improvement over the first year was similar regardless of PTSD/depression status. Clinical implications Further work is warranted to determine if cognitive and psychiatric-focused interventions may improve rates of cognitive improvement post-injury among individuals with comorbid PTSD and/or depression so that these individuals may ultimately achieve levels of cognition comparable to individuals without psychiatric comorbidities.

Background Electroconvulsive therapy (ECT) is among the most effective treatments for treatment-resistant mood disorders. Objective This study aims to meta-analyse the effects of ECT on all-cause mortality and suicide deaths in severe unipolar or bipolar depression using longitudinal studies. Study selection and analysis PubMed/MEDLINE, PsycINFO, Cochrane Library, Embase and Google Scholar were searched from inception through 21 January 2025. Inclusion criteria were: (1) patients with diagnoses of mental disorders; (2) intervention consisted of ECT compared with placebo, usual care or another intervention; (3) all-cause mortality and suicide deaths as outcomes measures; and (4) clinical trial or longitudinal cohort study designs where the aforementioned interventions preceded the observations of outcome measures. Adjusted HR with their corresponding 95% CIs were estimated using random-effects models. Moderator analyses were also performed. Findings Overall, 17 studies consisting of 1 182 501 individuals (n=40 867 for patients with ECT, n=1 141 634 for patients with non-ECT) were included. 94.1% of the studies focused on patients with unipolar or bipolar depression and one study was focused on schizoaffective disorder. ECT was associated with a reduction in risk of all-cause mortality (HR 0.70 (95% CI 0.61 to 0.81); p<0.001), a finding that was consistent at 3 months, 6 months and 12 months of follow-up. Regions had a moderating effect; Japan had the largest effect size (HR 0.17 (95% CI 0.04 to 0.72)) and Denmark had the smallest (HR 0.87 (95% CI 0.83 to 0.92)). ECT was associated with a reduction in suicide risk at 3 months of follow-up (HR 0.53 (95% CI 0.39 to 0.72); p<0.001) but not at 1, 6 or 12 months of follow-up. Conclusions ECT is associated with a reduced risk of all-cause mortality. However, ECT use for suicide protection appears transient and inconsistent. Clinical implications ECT may be safely used among patients with severe unipolar or bipolar depression. PROSPERO registration number CRD42025641749.

Background To drive improvement in clinical services, an important innovation will be to regularly assess patients’ psychotic experiences in order to guide, monitor and, when needed, alter treatment provision. The great heterogeneity in presentations of psychosis means that a comprehensive assessment battery is impractical. A plausible solution is computerised adaptive testing (CAT), which uses real-time computation to present the most informative questions to an individual. Fewer questions are needed to reach similar precision as a full questionnaire. Objective We tested the potential of a CAT for paranoia to halve the number of items that need to be presented. Methods We used the established item response theory psychometric properties of the 10-item Revised Green et al Paranoid Thoughts Scale (Persecution) to run CAT simulations in four datasets in which participants had completed the full scale: a representative survey of 10 382 UK adults; a clinical trial with 319 patients with psychosis; a cohort study of 836 National Health Service (NHS) male patients with psychosis; and a clinical trial with 89 patients with persecutory delusions. The CAT algorithm used the graded response model and the test was concluded when the SE of estimation dropped below 0.3 or five items had been answered. Findings On average, the CAT administered 4.2, 4.0, 4.2 and 4.0 items to each person in the four datasets. The correlations between the CAT score and the full-scale paranoia score were 0.95, 0.94, 0.94 and 0.87. Minimal systematic error in paranoia estimation occurred (mean bias scores=–0.01, –0.06, –0.07 to –0.10). Estimation was the least precise for people at the boundary of normal and elevated levels of paranoia. Conclusions In datasets with people across the whole paranoia continuum, accurate estimates of paranoia can be provided by a CAT with fewer than half the items of the full scale. Tailored testing may work well with people with psychosis. Clinical implications CAT may be a way to implement informative measurement-based care in psychosis services.

Background Suicide was the cause of 86 000 deaths in Europe in 2021. Accordingly, suicide prevention has been designated as a serious public health concern by the World Health Organization (WHO). Alcohol use is a causal risk factor for suicide and may be a cost-effective target for prevention efforts. Globally, the United Nations’ Sustainable Development Goals have set a target of a 20% reduction in alcohol consumption per capita (APC). However, evidence on the utility of APC as a metric in relation to the prevention of alcohol-attributable suicides is currently limited. Objective To evaluate the association between APC and suicide mortality rate across 30 European countries. Methods Suicide mortality rates were obtained for 27 European Union countries as well as the UK, Switzerland and Norway for 1991–2021 from the Institute of Health Metrics and Evaluation. APC data was obtained from the WHO Global Information System on Alcohol and Health. Linear mixed effects models with random intercepts for country and first-order autoregressive errors were used to test the association between APC and suicide mortality rate. Tests of interaction were conducted to examine the impact of sex, country-level drinking patterns and the 2008 global economic recession. All models were adjusted for relevant population-level confounders. Findings On average, a 1 L increase in total APC was associated with a 0.39% increase in the suicide mortality rate (95% CI 0.03% to 0.76%; p value=0.03) among males, and a 0.59% increase in the suicide mortality rate (95% CI 0.12% to 1.06%; p value=0.01) among females. There was no evidence of a significant sex difference, nor was there evidence of a modifying effect of country-level drinking patterns or 2008 global economic recession on the respective association. Conclusions National suicide prevention strategies should consider incorporating APC as an indicator for monitoring and assessing the impact of interventions targeting alcohol use on suicide.

Psychological Science, Volume 36, Issue 12, Page 887-898, December 2025. Childhood language interventions appear promising for improving children’s lives and yielding economic returns. However, few studies have evaluated long-term effects of these interventions. Our study did this using a large, cluster-randomized trial of a ...

Psychological Science, Volume 36, Issue 12, Page 930-940, December 2025. To navigate the world, our minds must represent not only how things are now (perception) but also how they are about to be (prediction). However, perception and prediction blur together for objects in motion, a classic finding known as “representational ...

Psychological Science, Volume 36, Issue 12, Page 913-929, December 2025. Across five studies and one supplementary study (five preregistered;N= 3,215 adults), we found that men, more than women, avoided shared experiences (e.g., going to the movies, sharing food) with individuals of the same gender. Furthermore, persistent ...

Psychological Science, Volume 36, Issue 12, Page 899-912, December 2025. Can nonnative English accents become barriers to garnering attention in public discourse? The current study examined this question. Analyzing 5,367 TED Talks through computational methodologies such as voice recognition, natural language processing, and ...

Psychological Science, Volume 36, Issue 12, Page 941-951, December 2025. A fundamental underlying question about the nature of overconfidence has continued to be subject to scholarly dispute: Is overconfidence a genuine psychological trait? To advance this contested research topic, we engaged in an adversarial collaboration in ...

Psychological Science, Ahead of Print. Context drives our interpretations of music as surprising, frightening, or awe-inspiring. However, it remains unclear how formal musical training affects our ability to hierarchically integrate complex tonal information to efficiently predict, remember, ...

Psychological Science, Ahead of Print. Americans readily identify with class labels, such asworking classandmiddle class. In turn, these identities affect their social affiliations, cultural values, and physical health. Despite theoretical predictions that class identity can change, little ...

By Mohammad Nahid (Human Rights Activist)* The death penalty in the Islamic Republic of Iran has consistently been one of the most critical areas of human rights violations. In 2025, this issue has taken on new dimensions. Reports by human rights organizations indicate that from the beginning of 2025 until mid-November, more than 1,400 executions […]

This report documents structural human rights violations at Arak Central Prison in Iran, based on corroborated field information and testimonies from released prisoners. It examines chronic overcrowding, inadequate health and hygiene conditions, systematic forced labor inside and outside the prison, and abusive practices surrounding the implementation of death sentences. The report highlights how these conditions reflect institutional and managerial failures rather than isolated misconduct, and how they undermine human dignity and basic safeguards for detainees. Written in a UN-compatible, non-official analytical framework, the report aims to provide reliable documentation for international human rights audiences, researchers, and accountability mechanisms.

An Iranian political prisoner, Bijan Kazemi, remains arbitrarily detained in Evin Prison after nearly eleven months without formal charges, legal representation, or family visits. His mother reports that prison authorities have blocked all in-person visits without explanation, allowing only a brief and irregular phone call after weeks of silence. Lawyers have been denied access to his case file, and even the alleged charges have not been disclosed to the family. Despite the issuance of an exceptionally high bail order, authorities have refused his release, underscoring the security-driven nature of the case. Kazemi’s prolonged solitary confinement, pressure for forced confessions, and denial of basic legal rights exemplify a broader pattern of systematic human rights violations against political prisoners in Iran. His case has been conveyed to international human rights mechanisms, including Amnesty International and United Nations special procedures, for follow-up and monitoring.

On Tuesday, December 23, 2025, the “No to Execution Tuesdays” campaign marks its 100th week, and with the women’s ward of Yazd Prison joining, this protest movement now continues in 55 prisons across the country. The prisoners participating in this campaign, continuing their 100 weeks of relentless struggle against the regime’s “killing machine” and in […]

Iran has carried out an unprecedented surge in executions in 2025, including a sharp rise in the execution of women. By mid-December 2025, at least 60 women had been executed, marking a nearly 70 percent increase compared to the previous year. Overall, 1,791 executions were recorded nationwide by the end of November. This report documents recent cases, patterns of executions involving qisas, drug-related charges, child marriage, and security cases, and provides a legal analysis demonstrating systematic violations of the right to life, fair trial guarantees, and protections against gender-based violence under international law.

This report documents the execution of Aqil Keshavarz, a 27-year-old architecture student, in Iran’s Urmia Central Prison following conviction on a security-related charge. It details his arrest amid a highly securitized environment, allegations of coercive interrogations, denial of fair trial guarantees, and restricted access to legal counsel. The report provides a legal analysis outlining violations of the right to life, prohibition of torture, protection against arbitrary detention, and the right to a fair trial under international human rights law. It concludes with a call on UN bodies and the international community to condemn the use of the death penalty in security cases and demand accountability

This report documents the systematic violation of the right to health in Iran, based on official admissions, regime-affiliated media, resistance data, and international reactions. It examines lethal COVID-19 policies, concealment of real death tolls, Ali Khamenei’s vaccine ban, profiteering from ineffective vaccines, the rise of the Naser Khosrow pharmaceutical black market, and soaring drug prices that have pushed treatment beyond the reach of ordinary citizens. The report also highlights the deliberate denial of medical care to sick prisoners, turning Iranian prisons into waiting rooms of death, and reviews international condemnations of these practices.

In the ninety-ninth week of the “No to Execution Tuesdays” campaign, prisoners in 55 of the country’s prisons are continuing this protest movement. This week’s statement, released concurrently with the International Day of “Reconciliation,” points to the escalation of executions by the government, which have claimed the lives of at least 67 individuals in the […]

This report examines the systemic corruption embedded in Iran’s prison system, where the judiciary, the Islamic Revolutionary Guard Corps (IRGC), and the Prisoners’ Cooperative Foundation jointly operate a hidden economic network based on forced labor, illicit trade, and structural exploitation. Drawing on documented cases from state-controlled media and verified independent sources, the report reveals how prisons have become economic engines for the ruling regime. Published on the occasion of International Anti-Corruption Day, it highlights the broader system of institutionalized corruption in Iran and calls for urgent international scrutiny and accountability to address this entrenched and destructive governance model

Zeynab Hezbapour, the wife of Masoud Jamei, a political prisoner sentenced to two death penalties, has been transferred to the women’s ward of Sepidar Prison in Ahvaz to serve a 15-year prison sentence. Her transfer comes at a time when her daughter, Nahid Jamei, is also facing a 12-year prison sentence; verdicts that, according to […]