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We review the origins and history of community psychiatry and the challenges posed to it by advancing technology and the neoliberal political economy and society that have prevailed since the 1990s. We summarise both achievements and shortcomings and argue that the term ‘community’ fails to acknowledge the gap between its original ambition and the outcomes of its implementation. We argue that, because of the changes that have taken place, the implementation of community psychiatry's objectives as conceived originally is likely to continue to fail. To sharpen current awareness and thinking and optimise future policy discourse and service strategies we revisit the concept of ‘metacommunity’. This is a historical descriptive label that aims to encapsulate the fundamental transformations that have taken place. These in turn demand of psychiatrists and other mental health providers both more socially critical thinking and mental health activism in the public sphere. Ultimately, beyond both community and metacommunity psychiatry, what is required is a democratic psychiatry.

Indigenous people worldwide are at increased risk of mental health problems compared with non-Indigenous people. Longstanding impacts of colonisation, systematic exclusion from rights and subsequent discrimination, and lack of access to quality education and healthcare, including mental healthcare, have been identified as contributory factors to these disproportionate mental health problems. With limited access, Indigenous people are less likely to seek healthcare, owing to the insufficient number of healthcare professionals representing Indigenous communities. In the face of growing numbers of mental health problems in Indigenous people in Bangladesh, this paper sheds light on the inadequate number of mental health professionals, particularly from Indigenous communities, and the potential impacts of this on the well-being of Indigenous people, and considers ways to increase representation of Indigenous mental health professionals. The aim is to ensure that the mental health system in Bangladesh is inclusive and embraces the country's diversity.

Gypsy, Roma and Traveller (GRT) communities have considerably worse mental health outcomes than the general population and many other ethnic minority groups. We argue that there is a dynamic, interplaying ‘accessibility mismatch’, resulting in a failure of healthcare services to adequately understand and work with GRT communities in a meaningful way. The consequences are limited engagement and poor health outcomes. Contact with services is often at crisis points, such as in forensic services, which reinforces existing prejudice. Research is limited, and therefore so is the evidence base. It is critical that the UK's National Health Service takes a culturally informed approach to co-produce services that are accessible and responsive to GRT communities. Here we offer practical actions that healthcare organisations can undertake to help redress imbalances and increase equity of healthcare outcomes for these overlooked populations.

Previous research has revealed that stigma is not restricted to people with mental health problems but extends to the professionals involved in their care and treatment. Unlike other artistic manifestations, the study of the depictions of psychiatry in popular music is still a less-explored topic. This article addresses the subcultural portrayals of the psychiatrist and psychiatric treatments within Spanish popular music. The predominance of negative depictions of mental health professionals as social control agents was a striking finding, given the topicality that characterises punk music. It is suggested that the allegorical role assigned to the psychiatrist in such a specific narrative framework, marked by ideological factors, could potentially explain these findings. In contrast to other cultural manifestations that show a tendency towards more balanced views of psychiatric treatment and practice, the negative representations in Spanish punk songs seem to have evolved little over decades, reflecting outdated views of the psychiatric approach.

Historically, attention-deficit hyperactivity disorder (ADHD) was conceptualised as a disorder of childhood that gradually improved and diminished as individuals transitioned to adulthood. Over the past decade, several studies have been published describing a cohort of adolescents with a childhood diagnosis of ADHD experiencing a continuity of ADHD symptoms into adulthood. Untreated ADHD in adults is associated with personal relationship difficulties, educational and occupational underachievement, comorbid mental health problems, substance misuse, and increased rates of road traffic accidents and criminality. These result in an increased economic burden and broader public health challenges. This review outlines the current framework and stage of development of ADHD services for adults in the Republic of Ireland.

Aims and method There are numerous challenges in the recruitment and retention of the medical workforce in psychiatry. This mixed-methods study examined the role of psychiatry clinical attachments for international medical graduates (IMGs) to enhance recruitment and retention. An online survey was launched to capture views and perceptions of IMGs about clinical attachments. The quantitative and qualitative responses were analysed to elicit findings. Results In total, 92 responses were received, with respondents commonly from India, Pakistan and Egypt. Respondents were mostly aged 25–34, with ≥3 years of psychiatry experience. Over 80% expressed strong interest in completing a psychiatry clinical attachment and believed it would support career progression. Qualitative data indicated that IMGs hoped to gain clinical experience and understanding of the National Health Service (NHS). They wished for a clearer, simpler process for clinical attachments. Clinical implications Clinical attachment can be mutually beneficial, providing IMGs with opportunity to confidently start their psychiatry career in the UK and enhance medical recruitment in mental health services across the NHS.

Aims and method This study aimed to assess current levels of knowledge, opinions and attitudes regarding mental health among the local cohort of general practitioner trainees (n = 45) working in Malta. A questionnaire adapted from the Mental Health Literacy Scale was used. Data were analysed using one-way analysis of variance and Pearson correlation tests. Results All participants had scores equal to or more than the mean score in their knowledge and confidence assessments; 51% of the participants achieved the maximum score for a very positive attitude towards mental health, with such scores found particularly among female trainees. Increased levels of knowledge are associated with a more positive attitude, which can in turn lead to greater acceptance and reduce stigma. Clinical implications Knowledge is a powerful tool for reducing stigma and improving the doctor–patient relationship, indicating that regular training initiatives are necessary to equip budding general practitioner specialists with the necessary skills and confidence.

Background Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement. Aims To examine the impact of this intervention on people with lived experience, carers and staff. Method People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed. Results Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored. Conclusion This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

The recent Draft Mental Health Bill for England and Wales proposes changes to the Mental Health Act 1983 which will include, for the first time, a legal definition of autism. This article explores the specific potential issue that the definition, owing to its breadth, potentially encompasses a number of conditions other than autism, consequently leaving the definitionally dependent concept of ‘psychiatric disorder’ significantly narrowed in scope. The potential implications of this – primarily the concern that a range of other conditions and presentations could be unintentionally excluded from the scope of the civil powers in the Mental Health Act – are discussed.

Aims and method The prevalence of delaying psychiatric care until the patient has received ‘medical clearance’, and the definitions and understanding of ‘medical clearance’ terminology by relevant clinicians, are largely unknown. In a service evaluation of adult liaison psychiatry services across England, we explore the prevalence, definitions and understanding of ‘medical clearance’ terminology in three parallel studies: (a) an analysis of trust policies, (b) a survey of liaison psychiatry services and (c) a survey of referring junior doctors. Content and thematic analyses were performed. Results ‘Medical clearance’ terminology was used in the majority of trust policies, reported as a referral criterion by many liaison psychiatry services and had been encountered by most referring doctors. ‘Medical clearance’ was identified as a common barrier to liaison psychiatry referral. Terms were inconsistently used and poorly defined. Clinical implications Many liaison psychiatry services seem not to comply with guidance promoting parallel assessment. This may affect parity of physical and mental healthcare provision.

Aims and method Smoking and vaping are prohibited on Ireland's Health Service Executive (HSE) campuses. The HSE states that there is no evidence to suggest vaping is less damaging than cigarettes. Recent meta-analyses have shown that e-cigarettes are in fact less dangerous and can help smokers quit. Our study analyses the current smoking policies in place in mental health ‘approved centres’ in Ireland, what is being done to help smokers quit while in-patients and the level of support among staff for the introduction of e-cigarettes as a harm reduction tool. Clinical nurse managers from each mental health approved centre were surveyed to assess adherence to smoking policies. Results Only 5% of surveyed units enforce the HSE's Tobacco Free Campus Policy; 55% of units supported the idea of using e-cigarettes to help patients quit cigarettes. Clinical implications Ireland's hospital campuses are not tobacco free. Changes need to be made to our smoking policies and their enforcement.

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled ‘severe and enduring’ (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having ‘terminal’ illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word ‘enduring’ unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Domestic abuse often begins or escalates during the perinatal period, increasing the risk of adverse pregnancy outcomes and death of the woman and infant. The hidden nature of domestic abuse, compounded by barriers to disclosure, means many clinicians are likely to have unknowingly encountered a patient who is being abused and missed a vital opportunity for intervention. This educational article presents the experience of a woman who was abused during pregnancy. It describes how to facilitate a disclosure and conduct an assessment and illustrates safeguarding duties alongside interventions.

Background Central nervous system (CNS)-active polypharmacy is frequent and potentially harmful in older patients. Data on its burden outside the USA and European countries remain limited. Aims To estimate the period prevalence of and factors associated with out-of-hospital CNS-active polypharmacy in older adults. Method We used data from a cohort of out-patients aged ≥60 years affiliated to the Hospital Italiano de Buenos Aires’ health maintenance organisation on 1 January 2021. A CNS-active polypharmacy event was defined as the concurrent exposure to ≥3 CNS-active medications (i.e. antidepressants, anti-epileptics, antipsychotics, benzodiazepines, Z-drugs and opioids) through filled out-of-hospital prescriptions. We calculated the period prevalence of CNS-active polypharmacy for 2021. We identified factors associated with CNS-active polypharmacy using a multivariable logistic regression model to estimate odds ratios and 95% confidence intervals (CI). Results We included 63 857 patients. Pre-existing mental health diagnoses included anxiety (21%), depressive (14%) and sleep (11%) disorders. CNS-active polypharmacy occurred in 4535 patients, for a period prevalence of 7.1% (95% CI: 6.9–7.3%). The combination of an antidepressant, an antipsychotic and a benzodiazepine accounted for 21% of the CNS-active polypharmacy events. Frontotemporal dementia (odds ratio: 14.67; 95% CI: 4.47–48.20), schizophrenia (odds ratio: 7.93; 95% CI: 4.64–13.56), bipolar disorder (odds ratio: 7.20; 95% CI: 5.45–9.50) and depressive disorder (odds ratio: 3.50; 95% CI: 3.26–3.75) were associated with CNS-active polypharmacy. Conclusions One in 14 adults aged 60 years and older presented out-of-hospital CNS-active polypharmacy. Future studies should evaluate measures to reduce CNS-active medication use in this population.

Background People with intellectual disability (PwID) and epilepsy have increased premature and potentially preventable mortality. This is related to a lack of equitable access to appropriate care. The Step Together guidance and toolkit, developed with patient, clinical, charity and commissioning stakeholders, allows evaluation and benchmarking of essential epilepsy service provision for PwID in eight key domains, at a care system level. Aims To evaluate care provisions for adult PwID and epilepsy at a system level in the 11 integrated care systems (ICSs) of the Midlands, the largest NHS England region (population: approximately 11 million), using the Step Together toolkit Method Post training, each ICS undertook its benchmarking with the toolkit and submitted their scores to Epilepsy Action, a national UK epilepsy charity, who oversaw the process. The outcomes were analysed descriptively to provide results, individual and cumulative, at care domain and system levels. Results The toolkit was completed fully by nine of the 11 ICSs. Across all eight domains, overall score was 44.2% (mean 44.2%, median 43.3%, range 52.4%, interquartile range 23.8–76.2%). The domains of local planning (mean 31.1%, median 27.5%) and care planning (mean 31.4%, median 35.4%) scored the lowest, and sharing information scored the highest (mean 55.2%, median 62.5%). There was significant variability across each domain between the nine ICS. The user/carer participation domain had the widest variation across ICSs (0–100%). Conclusions The results demonstrate a significant variance in service provision for PwID and epilepsy across the nine ICSs. The toolkit identifies specific areas for improvement within each ICS and region.

Background Childhood maltreatment and peer victimisation are common sources of early-life interpersonal stress. Childhood maltreatment is associated with atypical frontolimbic emotion processing and regulation, and increased vulnerability for self-harm/suicide. However, few studies have compared the neurofunctional correlates between caregiver- versus peer-inflicted mistreatment. Aims We compared the alterations of neurofunctional correlates of facial emotion processing in youths exposed to childhood maltreatment or peer victimisation, and explored their associations with self-harm. Method Functional magnetic resonance imaging data were collected from 114 age- and gender-matched youths (39 childhood maltreatment, 37 peer victimisation and 38 controls) during an emotion discrimination task. Region-of-interest (amygdala, insula) and whole-brain analyses were conducted. Results Groups differed significantly during disgust processing only. Both groups had lower activation in the right amygdala and bilateral posterior insula than controls; left insular underactivation was furthermore related to increased self-harm in maltreated youths. Compared with controls, at the whole-brain level, both groups also had underactivation in a cluster of bilateral limbic-thalamic-striatal, precuneus/posterior cingulate, temporal, fusiform/lingual and cerebellar regions, which was negatively associated with emotional problems in controls, as well as a cluster of somatosensory regions associated with increased self-harm in maltreated youths. Conclusions Early-life interpersonal stress from caregivers or peers is associated with common underactivation of limbic-thalamic-striatal, precuneus/posterior cingulate and somatosensory regions during disgust processing. The hypoactivation of key emotion and sensory processing and self-referential brain regions could be a potential suppressive mechanism to cope with the aversive emotion; however, it may also entail increased risk of affective psychopathology in seemingly healthy youths.

Background Internationally, stresses related to the COVID-19 pandemic negatively affected the mental health of family caregivers of adults with intellectual and developmental disabilities (IDDs). Aims This cross-sectional study investigated demographic, situational and psychological variables associated with mental wellbeing among family caregivers of adults with IDDs during the COVID-19 pandemic. Method Baseline data from 202 family caregivers participating in virtual courses to support caregiver mental well-being were collected from October 2020 to June 2022 via online survey. Mental well-being was assessed using total scores from the Warwick-Edinburgh Mental Wellbeing Scale. Demographic, situational and psychological contributors to mental well-being were identified using hierarchical regression analysis. Results Variables associated with lower levels of mental well-being were gender (women); age (

Background The COVID-19 pandemic initiated a mass switch to psychological therapy being delivered remotely, including at Anxiety UK, a national mental health charity. Understanding the impact of this forced switch could raise implications for the provision of psychological therapies going forwards. Aims To understand whether the forced switch to remote therapy had any impact on outcomes, and if certain groups should continue to be routinely offered certain delivery modalities in future. Method Data were available for 2323 individuals who accessed Anxiety UK services between January 2019 and October 2021. Demographic data, baseline and discharge anxiety and depression symptoms, and mode of therapy delivery were available. Regression models were built to model (a) the mode of therapy delivery received pre-pandemic using logistic regression, and (b) outcomes pre- and post-pandemic onset within demographic groups. Results No statistically significant changes in baseline anxiety symptoms, demographics or outcomes were observed before and after the onset of the COVID-19 pandemic. Pre-pandemic, males were more likely to receive online video therapy than telephone therapy (Relative Risk Ratio (RRR) 1.42, [1.01, 1.99]), while older clients were less likely to receive online video therapy (RRR 0.98, [0.97, 0.99]). However, no differences in outcomes were observed post-pandemic onset within these groups, with only the number of sessions of therapy being a significant predictor of outcomes. Conclusions Anxiety UK services remained effective throughout the pandemic. We observed no evidence that any demographic group had worse outcomes following the forced switch to remote therapy.

Background Although immigrants are considered to be vulnerable to mental illness, there is limited knowledge regarding their suicide mortality. Aims To investigate standardised mortality ratios (SMR) for suicide among the largest immigrant populations in Germany before and after the refugee movement of 2015. Method Data on immigrants and the general population in Germany between 2000 and 2020 were provided by the scientific section of the Federal Statistical Office. SMR with 95% confidence intervals were calculated by indirect standardisation for gender, age and calendar year for the pre-2015 and post-2015 time interval, first for all the immigrant populations studied and second for the Syrian, Afghan and Iraqi populations separately. Results Immigrants from the countries studied showed a lower suicide risk compared with the German reference population (SMR = 0.38, 95% CI = 0.35–0.41). No differences in SMR were found between pre- and post-2015 time intervals, in either the aggregate data for all populations or the data for Syrian, Afghan and Iraqi populations. Post-2015, Afghan immigrants (SMR = 0.68, 95% CI = 0.54–0.83) showed a higher SMR than Syrians (SMR = 0.30, 95% CI = 0.25–0.36) or Iraqis (SMR = 0.37, 95% CI = 0.26–0.48). Conclusions Despite the many and varied stresses associated with flight, comparison of the pre- and post-2015 time intervals showed that the suicide risk of the populations studied did not change and was considerably lower than that of the German reference population. We attribute this to lower suicide rates in the countries of origin but also to flight-related selection processes that favour more resilient individuals.

Background COVID-19 was a collective traumatic event; however, different individuals may have perceived it differently. Aims This study investigated what older people in a collective culture perceived as stressful during COVID-19 and examined how different stressors related to COVID-19 infection and mental health risks. Method Thirty-six participants from diverse backgrounds engaged in a three-round Delphi study to generate items for a COVID-19-related stress scale for older adults (CSS-OA). Subsequently, 4674 people (aged ≥60 years) participated in a cross-sectional telephone survey; interviewers collected their responses to CSS-OA and information about COVID-19 infection, depressive symptoms, anxiety, loneliness and demographics. Exploratory factor analysis and confirmatory factor analysis were conducted on CSS-OA. A multiple indicator multiple cause (MIMIC) model was used to examine associations between CSS-OA and other measures. Results The Delphi process generated eight items, all secondary or tertiary stressors related to infection. Exploratory factor analysis revealed a three-factor model, and confirmatory factor analysis confirmed an excellent fit (comparative fit index = 0.99, root mean square error of approximation = 0.06). Pre-existing mental health conditions, having family members/friends infected with COVID-19, loneliness, anxiety and depressive symptoms were associated with higher stress. Conversely, self-infection with COVID-19, older age, being female and living alone were negatively associated with some domains of CSS-OA (all P < 0.05). Conclusions The Delphi process enhanced our understanding of what older people perceived as stressful, much of which resulted from certain healthcare strategies and reflected cultural influences. These and the MIMIC results highlight the need to balance public health policies with respect to infectious diseases and older people's mental health and quality of life.

Background Depression is common in people with dementia, and negatively affects quality of life. Aims This paper aims to evaluate the cost-effectiveness of an intervention for depression in mild and moderate dementia caused by Alzheimer's disease over 12 months (PATHFINDER trial), from both the health and social care and societal perspectives. Method A total of 336 participants were randomised to receive the adapted PATH intervention in addition to treatment as usual (TAU) (n = 168) or TAU alone (n = 168). Health and social care resource use were collected with the Client Service Receipt Inventory and health-related quality-of-life data with the EQ-5D-5L instrument at baseline and 3-, 6- and 12-month follow-up points. Principal analysis comprised quality-adjusted life-years (QALYs) calculated from the participant responses to the EQ-5D-5L instrument. Results The mean cost of the adapted PATH intervention was estimated at £1141 per PATHFINDER participant. From a health and social care perspective, the mean difference in costs between the adapted PATH and control arm at 12 months was −£74 (95% CI −£1942 to £1793), and from the societal perspective was −£671 (95% CI −£9144 to £7801). The mean difference in QALYs was 0.027 (95% CI −0.004 to 0.059). At £20 000 per QALY gained threshold, there were 74 and 68% probabilities of adapted PATH being cost-effective from the health and social care and societal perspective, respectively. Conclusions The addition of the adapted PATH intervention to TAU for people with dementia and depression generated cost savings alongside a higher quality of life compared with TAU alone; however, the improvements in costs and QALYs were not statistically significant.

Background Physical health conditions are more common in individuals with autism. Some, like epilepsy, have considerable evidence supporting their increased prevalence, but many diseases lack literature to make strong conclusions. Aims To investigate the prevalence of physical health comorbidities in autism. Method We undertook a nested cross-sectional study, using a sample from the National Centre for Mental Health database. It included participants from England and Wales who reported a clinician-made diagnosis of autism (n = 813), and a control sample without autism or mental illness (n = 2781). Participants had provided a medical history at enrolment. Analysis was carried out by binomial logistic regressions controlling for age, gender, smoking status, and antipsychotic and mood stabiliser use. A subanalysis of individuals with concurrent intellectual disability (n = 86) used binomial logistic regression with the same control variables. Results Many physical health conditions were significantly more common in autism. Sixteen out of 28 conditions showed increased odds, with the highest odds ratios observed for liver disease, chronic obstructive pulmonary disease, kidney disease, osteoporosis and rheumatoid arthritis. A subanalysis demonstrated a similar pattern of physical health in individuals with autism with and without concurrent intellectual disability. Some conditions, including osteoporosis, hyperthyroidism, head injury and liver disease, had larger odds ratios in individuals with concurrent intellectual disability. Conclusions Physical health conditions occur more commonly in individuals with autism, and certain conditions are further increased in those with concurrent intellectual disability. Our findings contribute to prior evidence, including novel associations, and suggest that people with autism are at greater risk of physical health problems throughout adulthood.

Background Severe mental illness (SMI), which includes schizophrenia, schizoaffective disorder and bipolar disorder, has profound health impacts, even in the elderly. Aims To evaluate relative risk of hospital admission and length of hospital stay for physical illness in elders with SMI. Method To construct a population-based retrospective cohort observed from April 2007 to March 2016, data from a case registry with full but de-identified electronic health records were retrieved for patients of the South London and Maudsley NHS Foundation Trust, the single secondary mental healthcare service provider in south-east London. We compared participants with SMI aged >60 years old with the general population of the same age and residing in the same areas through data linkage by age-, sex- and fiscal-year-standardised admission ratios (SARs) for primary diagnoses at hospital discharge. Furthermore, we compared the duration of hospital stay with an age-, sex- and cause-of-admission-matched random group by linear regression for major causes of admission. Results In total, records for 4175 older people with SMI were obtained, relating to 10 342 admission episodes, showing an overall SAR for all physical illnesses of 5.15 (95% CI: 5.05, 5.25). Among the top causes of admission, SARs ranged from 3.87 for circulatory system disorders (ICD-10 codes: I00–I99) to 6.99 for genitourinary system or urinary conditions (N00–N39). Specifically, the diagnostic group of ‘symptoms, signs and findings, not elsewhere classified’ (R00–R99) had an elevated SAR of 6.56 (95% CI: 6.22, 6.90). Elders with SMI also had significantly longer hospital stays than their counterparts in the general population, especially for digestive system illnesses (K00–K93), after adjusting for confounding. Conclusions Poorer overall physical health and specific patterns were identified in elders with SMI.

Background The grief of relatives of patients who died of COVID-19 in an intensive care unit (ICU) has exacted an enormous toll worldwide. Aims To determine the prevalence of probable prolonged grief disorder (PGD) at 12 months post-loss and beyond. We also sought to examine circumstances of the death during the COVID-19 pandemic that might pose a heightened risk of PGD, and the associations between probable PGD diagnosis, quality of life and social disconnection. Method We conducted an observational, cross-sectional multicentre study of the next of kin of those who died of COVID-19 between March 2020 and December 2021. Participants were recruited from ICUs in South-East London. The Prolonged Grief Disorder Scale (PG-13-R), Quality-of-Life Scale (QOLS) and Oxford Grief-Social Disconnection Scale (OG-SD) were used. Results A total of 73 relatives were recruited and assessed, all of them over a year after their loss. Twenty-five (34.2%; 95% CI 23.1–45.4%) relatives of patients who died in the ICU met the criteria for PGD. Those who met the criteria had significantly worse quality of life (QOLS score mean difference 26; 95% CI 17–34; P < 0.001) and endorsed greater social disconnection (OG-SD score means difference 41; 95% CI 27–54; P < 0.001). Conclusions The findings suggest that rates of PGD are elevated among relatives of patients who died of COVID-19 in the ICU. This, coupled with worse quality of life and greater social disconnection experienced by those meeting the criteria, suggests the need to attend to the social deprivations and social dysfunctions of this population group.

Background Adult attention-deficit hyperactivity disorder (ADHD) clinics are in their infancy in Ireland and internationally. There is an urgent need for clinical evaluation of these services. Until now, clinical outcomes have relied mainly on functional scales and/or quality of life. However, adult ADHD is a longstanding disorder with many comorbidities. Although medication for ADHD symptoms can have immediate effects, co-occurring problems may take considerably longer to remediate. Aims To present the psychometrics of a short outcome measure of key clinical areas including symptoms. Method The ADHD Clinical Outcome Scale (ACOS), developed by the authors, is a clinician-rated scale and was administered in consecutive adults attending an ADHD clinic. A modified version was completed by the participant. A second clinician independently administered the scale in a subsample. ACOS consists of 15 items rated on a Likert scale. Two self-report scales, the Adult ADHD Quality of Life Questionnaire (AAQoL) and Weiss Functional Impairment Rating Scale (WFIRS), were also administered. Results The mean age of 148 participants was 30.1 years (s.d. = 9.71), and 81 were female (54.7%). The correlation for interrater reliability was r = 0.868, and that between the participant and clinician versions was r = 0.663. The intraclass correlation coefficient for the internal consistency was 0.829, and the correlations for concurrent validity with total AAQoL and WFIRS scores were r = −0.573 and r = 0.477, respectively. Factor analysis revealed four factors: (a) attentional/organisational problems; (b) hyperactivity/impulsivity; (c) comorbidities; and (d) alcohol/drug use, self-harm and tension in relationships. Conclusions The psychometrics of the ACOS are promising, and the inclusion of typically co-occurring clinical domains makes it suitable for use as a clinician-rated outcome measure in every contact with patients attending adult ADHD clinics.

Background The prospective association between sleep duration and the development of late-life depressive symptomology is unclear. Aims To investigate sleep duration from midlife to late life in relation to risk of depressive symptoms in late life. Method A total of 14 361 participants from the Singapore Chinese Health Study were included in the present study. Daily sleep duration was self-reported at baseline (mean age of 52.4 years; 1993–98), follow-up 2 (mean age of 65.2 years; 2006–10) and follow-up 3 (mean age of 72.5 years; 2014–16) interviews. Depressive symptoms were evaluated using the Geriatric Depression Scale at follow-up 3 interviews. Modified Poisson regression models were performed to estimate relative risks and 95% confidence intervals of late-life depressive symptoms in relation to sleep duration at baseline and the two follow-up interviews. Results Compared with sleeping 7 h per day, a short sleep duration of ≤5 h per day at baseline (i.e. midlife) was related to a higher risk of depressive symptoms (relative risk 1.10, 95% CI 1.06–1.15), and this risk was not affected by subsequent prolongation of sleep. Conversely, a long sleep duration of ≥9 h per day at baseline was not related to risk of depressive symptoms. At follow-up 3 (i.e. late life), both short sleep (relative risk 1.20, 95% CI 1.16–1.25) and long sleep (relative risk 1.12, 95% CI 1.07–1.18) duration were cross-sectionally associated with depressive symptoms. Conclusion Short sleep duration in midlife, regardless of subsequent prolongation, is associated with an increased risk of depression in late life. Contrariwise, both short and long sleep duration in late life co-occur with depressive symptoms.

Background Domestic abuse is a significant risk factor for self-harm and suicide. A large proportion of people presenting to healthcare services following self-harm have experienced domestic abuse. In the UK, routine enquiry for domestic abuse is recommended for people who present having self-harmed, but evidence indicates that this is not happening. Aims An exploratory qualitative study to explore liaison psychiatry staff experiences of asking about domestic abuse, including the barriers and challenges to asking. Method Semi-structured qualitative interviews with active adult liaison psychiatry staff in the UK. Recruitment was via online platforms and professional networks. A reflexive thematic analysis of the narratives was carried out. Results Fifteen participants were interviewed across a variety of disciplines (ten nurses, four doctors, one social worker). The generated themes include the following: asking about domestic abuse – the tension between knowing and doing; ‘delving deeper’ and the fear of making things worse; the entanglement of shame, blame and despondency; domestic abuse was different from other clinical problems (mental illness/substance misuse); and biases, myths and misassumptions guiding practice. Participants indicated the need for better training and education, and clear protocols for eliciting and acting on disclosures. Conclusion There is a clear need to improve the support offered to victim-survivors of domestic abuse who self-harm and present to healthcare services. National implementation of education and training to better equip liaison psychiatry teams with the skills and knowledge to sensitively support victim-survivors of domestic abuse is required.

Background On 15 March 2019, a white supremacist gunman sequentially attacked two mosques in Christchurch, New Zealand, killing 51 people aged from 3 to 77 years and bullet-injuring 40 more. Approximately 250 people survived the atrocity, and many more family and community members have been directly or indirectly affected. Aim To develop an understanding of the personal experiences of some of those affected, including effects on daily life and well-being, in the 18–30 months following the attacks. Method Qualitative thematic analysis of semi-structured interviews with 21 men and women from September 2020 to August 2021 was performed. Participants were drawn from a larger quantitative study and included injured, bereaved, witnesses, family members and those from the wider Muslim community in Christchurch. Results Four superordinate themes were identified: being overwhelmed in the midst of chaos; experiencing silent and enduring impact; living similarly, but differently; and gaining meaning and growth. These themes captured ongoing distress inclusive of physical symptoms, family and community relationship dynamics and connectedness, secondary stressors, and diversity in coping and growth. For most, the centrality of Islam as a faith tradition was woven throughout. Conclusion Consistent with previous literature, post-trauma reactions were pervasive and varied. This appeared to be compounded by secondary stressors in this cohort, such as sociopolitical circumstances, demographic diversity, the COVID-19 pandemic and justice processes. Findings also revealed a strong spiritual thread in the experiences of this minority faith community, shedding light on a complex interaction between recovery and post-traumatic growth.

Background The Republic of Cyprus has recorded the greatest increase in suicide mortality among Eastern Mediterranean countries, with an average annual increase of 5.1% in 2000–2019. Aims To investigate trends in suicide mortality rates between 2004 and 2020 in the Republic of Cyprus, with a focus on age, gender and suicide methods. Method Suicide deaths (ICD-10 taxonomy, including ‘undetermined’ code) and population denominators were obtained from the National Mortality Registry and Statistical Office, respectively. Directly standardised (European Standard) mortality rates were calculated for four gender and age groups. Annual change was estimated using Poisson regression models with interaction terms to assess differential trends over different time periods. Results There were 560 suicide deaths; these were four times more frequent in men, and approximately 80% were classified as ‘violent’ for both genders. The male suicide rate doubled from 4–5 to 9–10 per 100 000, mostly before 2012, representing a 9% annual change (rate ratio = 1.09, 95% CI 1.03, 1.15; P = 0.002). From 2013, the trend reversed (effect modification P < 0.001) with a 4% annual decrease (95% CI −9%, 1%). Declines were not uniform across all age groups; rates in males aged 45–64 years continued to rise, surpassing the previously high rate in males aged 25–44 years. Rates in females declined from 4–5 per 100 000 to 2–3 over the study period. Overall, the male-to-female suicide rate ratio was 5.33 (95% CI 3.46, 8.19) in 2017–2020, compared with 2.73 (1.88, 3.95) in 2004–2008. Conclusion Although suicide rates remain relatively low, the gender differential has widened in the Republic of Cyprus. Further analysis of trends in relation to unemployment and other socioeconomic indicators is warranted.

Background Although there is now substantial evidence on the acute impacts of the COVID-19 pandemic on anxiety disorders, the long-term population impact of the pandemic remains largely unexplored. Aims To quantify a possible longitudinal population-level impact of the pandemic by projecting the prevalence of anxiety disorders through 2030 among men and women aged up to 95 years in Germany under scenarios with varying impacts of the pandemic on the incidence of anxiety disorders. Method We used a three-state illness–death model and data from the Global Burden of Disease Study to model historical trends of the prevalence and incidence of anxiety disorders. The German population projections determined the initial values for projections. The COVID-19 incidence rate data informed an additional incidence model, which was parameterised with a wash-in period, delay, wash-out period, incidence increase level and decay constant. Results When no additional increase in the incidence during the pandemic waves during 2020–2022 was assumed, it was estimated that 3.86 million women (9.96%) and 2.13 million men (5.40%) would have anxiety disorders in 2030. When increases in incidence following pandemic waves were assumed, the most extreme scenario projected 5.67 million (14.02%) women and 3.30 million (8.14%) men with the mental disorder in 2030. Conclusions Any increased incidence during the pandemic resulted in elevated prevalence over the projection period. Projection of anxiety disorder prevalence based on the illness–death model enables simulations with varying assumptions and provides insight for public health planning. These findings should be refined as trend data accumulate and become available.

Climate change is responsible for marked increases in the frequency and severity of bush/wildfires, resulting in more people exposed to such events with long-term subclinical psychiatric symptoms. This editorial calls for immediate action to implement comprehensive and novel approaches to treating these conditions and preventing them from developing into more severe disorders.

Background Research on schizophrenia and life expectancy has mainly focused on premature mortality. Aims This study investigates factors associated with longevity in patients with schizophrenia receiving long-term care and identifies shared traits among these individuals. Method A retrospective cross-sectional study analysing the clinical records of 138 patients with schizophrenia who died between 2015 and 2017 in a psychiatric long-term care facility was conducted. Longevity was defined by life tables drawn from the national health database. Variables were compared between longevity and control groups to determine predictors of longer lifespans. Cluster analysis was employed to identify shared traits among individuals with longevity. Causes of death by age were compared. Results In the long-term care setting, of the 138 participants, 45 were in the longevity group. This group had more males, lower antipsychotic doses, but more mobility issues. Significant predictors of longevity included older age at onset, longer length of stay, lower activities of daily living scores and a hypertension diagnosis. Cluster analysis revealed two patterns, suggesting that poorer health indicators did not necessarily lead to shorter lives. Fatalities caused by pneumonia were associated with a higher age, compared to those from cancer and choking. Conclusions Addressing modifiable risk factors enhances life expectancy in patients with schizophrenia, especially for males, while the age at onset may play a significant role. An integrated long-term care model with close monitoring and timely provision of mental and general healthcare may help extend lifespans. Further research is needed to balance long-term residential care and community-based care for elderly patients with schizophrenia.

Background People with severe mental illness (SMI) have worse physical health than the general population. There is evidence that support from volunteers can help the mental health of people with SMI, but little evidence regarding the support they can give for physical health. Aims To evaluate the feasibility of an intervention where volunteer ‘Health Champions’ support people with SMI in managing their physical health. Method A feasibility hybrid randomised controlled trial conducted in mental health teams with people with SMI. Volunteers delivered the Health Champions intervention. We collected data on the feasibility of delivering the intervention, and clinical and cost-effectiveness. Participants were randomised by a statistician independent of the research team, to either having a Health Champion or treatment as usual. Blinding was not done. Results We recruited 48 participants: 27 to the intervention group and 21 to the control group. Data were analysed for 34 participants. No changes were found in clinical effectiveness for either group. Implementation outcomes measures showed high acceptability, feasibility and appropriateness, but with low response rates. No adverse events were identified in either group. Interviews with participants found they identified changes they had made to their physical health. The cost of implementing the intervention was £312 per participant. Conclusions The Health Champion intervention was feasible to implement, but the implementation of the study measures was problematic. Participants found the intervention acceptable, feasible and appropriate, and it led them to make changes in their physical health. A larger trial is recommended, with tailored implementation outcome measures.

This editorial discusses a study by Day and colleagues, in which the authors investigated the prevalence of resolution of alcohol and other drug problems in the UK and compared people who resolved their problems with and without treatment.

Background Rates of acute mental health presentations in youth were increasing pre-pandemic internationally. Longitudinal studies following COVID-19 attest to ongoing deterioration in youth mental health, recognising adverse unintended consequences following public health restrictions. Aims To examine whether the initial post-COVID-19 increase in mental health presentations persisted following the reclassification of COVID-19 to endemic status, accompanied by the removal of most restrictions. Method All referrals to paediatric liaison psychiatry (PLP) between January 2018 and December 2022 in a Dublin tertiary children's hospital were included in the study. An interrupted time series analysis with autoregressive integrated moving average models was conducted, examining referrals with respect to different phases of COVID-19 and application of public health restrictions. Results Some 1385 referrals to PLP were received over the 5-year study. There was a significant decrease in PLP referrals immediately post-COVID-19, followed by a significant and sustained increase as the pandemic progressed and moved to endemic status. Public health restriction phases had a unique effect on those presenting with suicidal ideation, with a significant increase in the number of referrals. There was no effect of restrictions on other clinical profiles. Conclusions Increased referrals for youth with mental health difficulties, reported during the COVID-19 pandemic, persisted into the early endemic stage, after COVID-19 public health restrictions ceased. Specific impacts of restrictions on suicidal ideation referrals require further study. Investment in child and adolescent mental health services remains a priority, and future pandemic response strategies need to examine unintended consequences of any enforced public health measure.

Background Data on associations between inflammation and depressive symptoms largely originate from high income population settings, despite the greatest disease burden in major depressive disorder being attributed to populations in lower-middle income countries (LMICs). Aims We assessed the prevalence of low-grade inflammation in adults with treatment-resistant depression (TRD) in Pakistan, an LMIC, and investigated associations between peripheral C-reactive protein (CRP) levels and depressive symptoms. Method This is a secondary analysis of two randomised controlled trials investigating adjunctive immunomodulatory agents (minocycline and simvastatin) for Pakistani adults with TRD (n = 191). Logistic regression models were built to assess the relationship between pre-treatment CRP (≥ or

Background Having social support improves one's health outcomes and self-esteem, and buffers the negative impact of stressors. Previous studies have explored the association between social support and brain activity, but evidence from task-dependent functional connectivity is still limited. Aims We aimed to explore how gradually decreasing levels of social support influence task-dependent functional connectivity across several major neural networks. Method We designed a social support task and recruited 72 young adults from real-life social groups. Of the four members in each group, one healthy participant (18 participants in total) completed the functional magnetic resonance imaging (fMRI) scan. The fMRI task included three phases with varying levels of social support: high-support phase, fair phase and low-support phase. Functional connectivity changes according to three phases were examined by generalised psychophysiological interaction analysis. Results The results of the analysis demonstrated that participants losing expected support showed increased connectivity among salience network, default mood network and frontoparietal network nodes during the fair phase compared with the high-support phase. During the low-support phase, participants showed increased connectivity among only salience network nodes compared with the high-support phase. Conclusions The results indicate that the loss of support was perceived as a threat signal and induced widespread increased functional connectivity within brain networks. The observation of significant functional connectivity changes between fair and high-support phases suggests that even a small loss of social support from close ones leads to major changes in brain function.

Background Literature emphasises the importance of identifying and intervening in the adoption of unhealthy lifestyle behaviours (ULBs) during adolescence at an early stage, to mitigate their long-term detrimental effects. Among the possible associated factors contributing to ULBs, attention-deficit hyperactivity disorder (ADHD) has been shown to play an important role. However, little is known about ADHD subclinical manifestations. Aims The present study aimed to bridge the gap in the literature and shed light on the relationship between subclinical ADHD and early adoption of ULBs during adolescence. Through a clinimetric approach, prevalence of ULBs, severity of ADHD symptoms and psychosocial factors (i.e. allostatic overload, abnormal illness behaviour, quality of life, psychological well-being) were investigated among adolescents. The associations between different degrees of ADHD, ULBs and psychosocial factors were also explored. Method This multicentre cross-sectional study involved 440 adolescents (54.5% females; mean age 14.21 years) from six upper secondary schools. Participants completed self-report questionnaires on sociodemographic characteristics, ULBs, ADHD symptoms and psychosocial factors. Results The most common ULBs were energy drinks/alcohol consumption and problematic smartphone use. Of the sample, 22% showed subclinical ADHD and 20.2% showed clinical ADHD. The subclinical ADHD group showed several ULBs (i.e. altered mindful eating, impaired quality of sleep, problematic technology use) and psychosocial factors, akin to those of ADHD group and different from peers without ADHD symptoms. Conclusions Since subclinical ADHD manifestation is associated with ULBs, similarly to clinical ADHD, identifying subthreshold symptoms during adolescence is crucial, as it could improve health-related outcomes in adulthood across different domains.

Background Medications with anticholinergic properties are associated with a range of adverse effects that tend to be worse in older people. Aims To investigate medication regimens with high anticholinergic burden, prescribed for older adults under the care of mental health services. Method Clinical audit of prescribing practice, using a standardised data collection tool. Results Fifty-seven trusts/healthcare organisations submitted data on medicines prescribed for 7915 patients: two-thirds (66%) were prescribed medication with anticholinergic properties, while just under a quarter (23%) had a medication regimen with high anticholinergic burden (total score ≥3 on the anticholinergic effect on cognition (AEC) scale). Some 16% of patients with a diagnosis of dementia or mild cognitive impairment were prescribed medication regimens with a high anticholinergic burden, compared with 35% of those without such diagnoses. A high anticholinergic burden was mostly because of combinations of commonly prescribed psychotropic medications, principally antidepressant and antipsychotic medications with individual AEC scores of 1 or 2. Conclusions Adults under the care of older people's mental health services are commonly prescribed multiple medications for psychiatric and physical disorders; these medication regimens can have a high anticholinergic burden, often an inadvertent consequence of the co-prescription of medications with modest anticholinergic activity. Prescribers for older adults should assess the anticholinergic burden of medication regimens, assiduously check for adverse anticholinergic effects and consider alternative medications with less anticholinergic effect where indicated. The use of a scale, such as the AEC, which identifies the level of central anticholinergic activity of relevant medications, can be a helpful clinical guide.

Background Although clozapine is the most effective antipsychotic for people with treatment-resistant schizophrenia (TRS), only 40% of people with TRS respond, and there is limited evidence for augmentation agents. Cannabidiol (CBD) reduces positive symptoms in individuals with schizophrenia, but no trials have specifically examined its efficacy in those with clozapine-resistant schizophrenia. Aims To examine the clinical efficacy of CBD augmentation in people with clozapine-resistant schizophrenia. Method This is a 12-week randomised, placebo-controlled, double-blind, parallel-group trial (registration number: ACTRN12622001112752). We will recruit 88 individuals with clozapine-resistant schizophrenia, randomised (1:1) to 1000 mg daily CBD versus placebo. Eligible individuals will be aged between 18 and 64 years, fulfil DSM-IV criteria for schizophrenia or schizoaffective disorder, have a total PANSS (Positive and Negative Syndrome Scale) score ≥60, have received oral clozapine for at least 18 weeks and have a clozapine level of >350 ng/mL. Interim analyses will be conducted at 25, 50 and 75% recruitment; these will also provide an opportunity to reallocate participants dependent on conditional power. The primary endpoint will be the difference in PANSS positive scores at the end of week 12. Secondary endpoints include depression, anxiety, sleep, quality of life, alcohol consumption, change in weight and metabolic syndrome components, and neurocognitive measures, as well as safety and tolerability. Discussion Novel treatments for clozapine-resistant schizophrenia are urgently needed. If found to be effective, CBD may have a role as a novel and safe adjunct to clozapine.

Background Inflammation is increasingly recognised as a fundamental component of the pathophysiology of major depressive disorder (MDD), with a variety of inflammatory biomarkers playing pivotal roles. These markers are closely linked to both the severity of symptoms and the responsiveness to treatments in MDD. Aims This scoping review aims to explore the scientific literature investigating the complex relationships between inflammatory biomarkers and depression, by identifying new studies and critical issues in current research. Method Following the PRISMA Extension for Scoping Reviews guidelines, we systematically searched databases including PubMed, Scopus, PsycINFO, Open Grey and Cochrane Library. Our search focused on articles published from 1 January 2020 to 1 May 2024. We included studies evaluating inflammatory biomarkers in adult patients with MDD, utilising observational and randomised controlled trial designs, and review studies. Results Our analysis examined 44 studies on the complex interplay between inflammation and its multiple effects on MDD. Significant associations between specific inflammatory biomarkers and depression severity were found, requiring cautious interpretation. We also highlight several methodological limitations in the current studies, which warrant caution in directly applying these findings to clinical practice. However, identified methodologies show potential for using these biomarkers as diagnostic tools or therapeutic targets, including anti-inflammatory interventions. Conclusions The findings emphasise the need for sophisticated, integrative research to understand inflammation's role in MDD. Future studies should identify specific biomarker panels for diagnosing depression and bridging peripheral biomarker measurements with central neuroinflammatory processes, leading to better diagnostic and treatment strategies.

Background The cardiorespiratory effect in mental illnesses has recently received much attention. However, the cardiovascular and pulmonary effects of mood disorders have not been clearly demonstrated. Aims This study aims to compare individuals with mood disorders and healthy people in terms of exercise capacity, functionality, respiratory muscle strength, pulmonary function, dyspnoea and physical activity level. Method This cross-sectional study involved 30 patients with mood disorders and 35 age- and gender-matched healthy individuals. Exercise capacity (6-Minute Walk Test (6MWT), 3-Minute Step Test (3MST)), functionality (vertical jump test, functional reach test), respiratory parameters (respiratory muscle strength, pulmonary function test), dyspnoea (Modified Medical Research Council Dyspnoea Scale) and physical activity level (Short-Form International Physical Activity Questionnaire (IPAQ)) were evaluated. Results 6MWT results (P < 0.001) and functional test scores (vertical jump test, P = 0.006; functional reach test, P < 0.001) were significantly lower, and heart rate recovery after 3MST (P < 0.001) was higher in mood disorder patients. Although patients' respiratory parameters were lower than healthy individuals, only measured and predicted respiratory muscle strength (P < 0.001), peak expiratory flow rate litres (P < 0.001), forced vital capacity predicted (P = 0.010) and forced expiratory volume in 1 s predicted (P = 0.002) values were statistically significantly different. Dyspnoea with activities was higher in patients (P < 0.001). Patients spent more time sitting (IPAQ, P < 0.001), but overall physical activity levels were similar between the two groups (P > 0.05). Conclusions Patients with mood disorders had decreased exercise capacity and pulmonary function, lower functionality scores and respiratory muscle strength, and increased dyspnoea. Exercise-based rehabilitation protocols are recommended for the management of risk factors affecting the mood disorder patients' cardiorespiratory status.

Background Patients with schizophrenia die decades earlier than the general population. Among the factors involved in this mortality gap, evidence suggests a telomere length shortening in this clinical population, which is associated with premature ageing. Recent studies support the use of strength-based training exercise programmes to maintain, or even elongate, telomere length in healthy elderly populations. However, studies aiming at modifying telomere length in severe mental illnesses, such as schizophrenia, are still very scarce. Aims To investigate the effect of a strength-based physical exercise programme on the telomere length of individuals with schizophrenia. Method We propose a pragmatic, randomised controlled trial including 40 patients aged ≥18 years, with a stable diagnosis of schizophrenia, attending the Complejo de Rehabilitación Psicosocial (CRPS, Psychosocial Rehabilitation Centre) in Salamanca, Spain. These patients will be randomly assigned (1:1) to either receive the usual treatment and rehabilitation programmes offered by CRPS (treatment-as-usual group) or these plus twice weekly sessions of an evidence-based, strength-based training exercise programme for 12 weeks (intervention group). The primary outcome will be effect on telomere length. Secondary outcomes will include impact on cognitive function, frailty and quality of life. Results We expect to show the importance of implementing strength-based physical exercise programmes for patients with schizophrenia. We could find that such programmes induce biological and genetic changes that may lengthen life expectancy and decrease physical fragility. Conclusions We anticipate that our trial findings could contribute to parity of esteem for mental health, reducing premature ageing in patients with severe mental illnesses, such as schizophrenia.

Background Psychoeducational interventions are a critical aspect of supporting adults with attention-deficit hyperactivity disorder (ADHD). The Understanding and Managing Adult ADHD Programme (UMAAP) is a six-session, group-based webinar intervention that incorporates psychoeducation with acceptance and commitment therapy. UMAAP relies on self-referrals and is facilitated by a charity, to promote accessibility. Aims The present study aimed to evaluate the feasibility of UMAAP and explore preliminary effectiveness. Method Adults with formally diagnosed or self-identified ADHD (n = 257) participated in an uncontrolled pre–post design. Feasibility was indicated by attendance, confidence in completing the home practice and satisfaction. Quality of life, psychological flexibility, self-acceptance and knowledge of ADHD were assessed at baseline, 1 week post-intervention and 3 months later, to explore preliminary effectiveness. Results Feasibility was demonstrated by the high attendance ratings and satisfaction with the intervention, although there was only moderate confidence in the ability to complete the home practices. Quality of life (mean increase 9.69, 95% CI 7.57–11.80), self-acceptance (mean increase 0.19, 95% CI 0.10–0.28) and knowledge of ADHD (mean increase 1.55, 95% CI 1.23–1.82) were significantly improved post-intervention. The effects were maintained at the 3-month follow-up. Psychological flexibility did not significantly change immediately post-intervention, but increased significantly at the 3-month follow-up (mean increase 0.42, 95% CI 0.26–0.58). Conclusions Overall, UMAAP is a feasible intervention for adults with ADHD. Findings highlighted the feasibility of delivering psychological interventions online in group settings, to increase access to support for adults with ADHD.

Background Personal independence payment (PIP) is a benefit that covers additional daily living costs people may incur from a long-term health condition or disability. Little is known about PIP receipt and associated factors among people who access mental health services, and trends over time. Individual-level data linking healthcare records with administrative records on benefits receipt have been non-existent in the UK. Aims To explore how PIP receipt varies over time, including PIP type, and its association with sociodemographic and diagnostic patient characteristics among people who access mental health services. Method A data-set was established by linking electronic mental health records from the South London and Maudsley NHS Foundation Trust with administrative records from the Department for Work and Pensions. Results Of 143 714 working-age patients, 37 120 (25.8%) had received PIP between 2013 and 2019, with PIP receipt steadily increasing over time. Two in three patients (63.2%) had received both the daily living and mobility component. PIP receipt increased with age. Those in more deprived areas were more likely to receive PIP. The likelihood of PIP receipt varied by ethnicity. Patients diagnosed with a severe mental illness had 1.48 odds (95% CI 1.42–1.53) of having received PIP, compared with those with a different psychiatric diagnosis. Conclusions One in four people who accessed mental health services had received PIP, with higher levels seen among those most likely in need, as indicated by a severe mental illness diagnosis. Future research using this data-set could explore the average duration of PIP receipt in people who access mental health services, and re-assessment patterns by psychiatric diagnosis.

Background People with psychosis experience worse cardiometabolic health than the same-aged general population. In New Zealand, Indigenous Māori experiencing psychosis have greater risk of cardiometabolic and other physical health problems. Aims To identify a cohort of adults accessing secondary mental health and addiction services in New Zealand, with a previous psychosis diagnosis as of 1 January 2018, and compare odds of hospital admission outcomes, mortality and receipt of cardiometabolic blood screening between Māori and non-Māori in the following 2 years. Method Crude and adjusted logistic regression models compared odds of hospital admission outcomes, mortality and receipt of cardiometabolic blood screening (lipids and haemoglobin A1c) between Māori and non-Māori, occurring between 1 January 2018 and 31 December 2019. Results A cohort (N = 21 214) of Māori (n = 7274) and non-Māori (n = 13 940) was identified. Māori had higher adjusted risk of mortality (odds ratio 1.26, 95% CI 1.03–1.54), and hospital admission with diabetes (odds ratio 1.64, 95% CI 1.43–1.87), cardiovascular disease (odds ratio 1.54, 95% CI 1.25–1.88) and any physical health condition (odds ratio 1.07, 95% CI 1.00–1.15) than non-Māori. Around a third of people did not receive recommended cardiometabolic blood screening, with no difference between Māori and non-Māori after covariate adjustment. Conclusions Māori experiencing psychosis are more likely to die and be admitted to hospital with cardiovascular disease or diabetes than non-Māori. Because of the higher cardiometabolic risk borne by Māori, it is suggested that cardiometabolic screening shortfalls will lead to worsening physical health inequities for Māori experiencing psychosis.

Background Pharmacological treatment options for patients with dementia owing to Alzheimer's disease are limited to symptomatic therapy. Recently, the US Food and Drug Administration approved the monoclonal antibody lecanemab for the treatment of amyloid-positive patients with mild cognitive impairment (MCI) and early Alzheimer´s dementia. European approval is expected in 2024. Data on the applicability and eligibility for treatment with anti-amyloid monoclonal antibodies outside of a study population are lacking. Aims This study examined eligibility criteria for lecanemab in a real-world memory clinic population between 1 January 2022 and 31 July 2023. Method We conducted a retrospective, single-centre study applying the clinical trial eligibility criteria for lecanemab to out-patients of a specialised psychiatric memory clinic. Eligibility for anti-amyloid treatment was assessed following the phase 3 inclusion and exclusion criteria and the published recommendations for lecanemab. Results The study population consisted of 587 out-patients. Two-thirds were diagnosed with Alzheimer's disease (probable or possible Alzheimer's disease dementia in 43.6% of cases, n = 256) or MCI (23%, n = 135), and 33.4% (n = 196) were diagnosed with dementia or neurocognitive disorder owing to another aetiology. Applying all lecanemab eligibility criteria, 11 (4.3%) patients with dementia and two (1.5%) patients with MCI would have been eligible for treatment with this compound, whereas 13 dementia (5.1%) and 14 (10.4%) MCI patients met clinical inclusion criteria, but had no available amyloid status. Conclusions Even in a memory clinic with a good infrastructure and sufficient facilities for dementia diagnostics, most patients do not meet the eligibility criteria for treatment with lecanemab.

Background A nationwide register-based cohort study from Finland including 48 124 incident benzodiazepines and related drug (BZDR) users aged 18–65 years who initiated use in 2006 and were not dispensed BZDRs during 2004–2005. The follow-up was 5 years or until death, whichever occurred first. Aims To investigate sociodemographic and clinical factors associated with high-dose use of BZDRs (i.e. Z-drugs) among new BZDR users. Method The temporal BZDR dose was calculated as a point estimate every 6 months after initiation as defined daily doses (DDDs) per day, based on the PRE2DUP method (an approach based on mathematical modelling of personal drug purchasing behaviours). Sociodemographic and clinical factors associated with dose categories were studied using multinomial logistic regression. Results During the 5-year follow-up, very high-dose BZDR use was observed in 7.4% (n = 3557) and medium high-dose use in 25.5% (n = 12 266) of the users (corresponding to ≥30 mg and 10–29 mg in diazepam equivalents, respectively). Very high-dose use was more common among men compared with women (10.9% versus 4.6%). Very high-dose use patterns were especially observed in younger age groups (18- to 25-year-olds). Compared with oxazepam, initiating BZDR use with clonazepam (adjusted odds ratio 3.86, 95% CI 3.24–4.60), diazepam (2.05, 1.78–2.36) or alprazolam (1.76, 1.52–2.03) was associated with increased odds for very high-dose use. Both medium high-dose and very high-dose BZDR use were associated with a lower level of education. In all, 58% of very high-dose use occurred in BZDR users who received their first prescription from general practitioners. Conclusions Clinicians should be aware of the dose escalation risk especially when prescribing diazepam, alprazolam or clonazepam for psychiatric indications. If BZDRs are needed, our findings suggest favouring oxazepam.

Background The World Health Organization and the Global Burden of Disease study estimate that almost 800 000 people die from suicide yearly. The role of non-traditional risk factors such as climate and high-altitude exposure are poorly understood. Aims This study aims to determine a potential relationship between altitude exposure and suicide rates among 221 cantons located at different altitudes ranging from 0 to 4300 m. Method We conducted an 11-year, country-wide, population-based analysis on age- and gender-standardised suicide rates in Ecuador, based on the official data from the National Institute of Statistics, using all available self-harm death codes (ICD-10 codes X60–X84). Results A total of 11 280 cases of suicide were reported during 2011–2021. Suicide rates were higher among men (11.48/100 000). In terms of elevation, suicide rates were significantly higher among people from high-altitude cantons (3.7/100 000) versus those from low-altitude cantons. When applying the International Society Mountain Medicine categorisation, suicide rates were significantly higher at moderate- (4.3/100 000), high- (3.6/100 000) and very-high-altitude cantons (4.4/100 000) when compared with low-altitude locations (2.5/100 000). Conclusions Ecuador is one of the few countries that has a vast range of cantons located at different altitudes. We found that living at higher elevations is positively associated with greater suicide rates. Although the rates are significantly greater as elevation increases, a clear linear relationship is not apparent, likely because of the interplay of socioeconomic factors, including urbanicity. The effect of chronic hypobaric hypoxia on mood cannot be ruled out, although the existence of causal mechanisms remains to be elucidated.

Background Poor air quality can both trigger and aggravate lung and heart conditions, as well as affecting child development. It can even lead to neurological and mental health problems. However, the precise mechanisms by which air pollution affect human health are not well understood. Aims To promote interdisciplinary dialogue and better research based on a critical summary of evidence on air quality and health, with an emphasis on mental health, and to do so with a special focus on bioaerosols as a common but neglected air constituent. Method A rapid narrative review and interdisciplinary expert consultation, as is recommended for a complex and rapidly changing field of research. Results The research methods used to assess exposures and outcomes vary across different fields of study, resulting in a disconnect in bioaerosol and health research. We make recommendations to enhance the evidence base by standardising measures of exposure to both particulate matter in general and bioaerosols specifically. We present methods for assessing mental health and ideal designs. There is less research on bioaerosols, and we provide specific ways of measuring exposure to these. We suggest research designs for investigating causal mechanisms as important intermediate steps before undertaking larger-scale and definitive studies. Conclusions We propose methods for exposure and outcome measurement, as well as optimal research designs to inform the development of standards for undertaking and reporting research and for future policy.