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Post-traumatic stress disorder (PTSD) is a risk factor for suicidality (suicidal ideation, and suicide attempt). This study described the prevalence of suicidality amongst a representative sample of individuals with PTSD and the association between suicidality and receipt of five PTSD treatments.We analysed deidentified data for patients being treated for PTSD at Camden and Islington NHS Foundation Trust between 2009 and 2017 obtained via the Clinical Record Interactive Search tool. We described the sample's sociodemographic and clinical characteristics and used stepwise logistic regression to investigate the association between suicidality and receipt of four, specific PTSD treatments: psychotherapy, antidepressant/antianxiety medication, antipsychotics, benzodiazepines. We used Cox proportional hazards regression to investigate the association between suicidality and hospital/crisis team admission.Of 745 patients diagnosed with PTSD, 60% received psychotherapy and 66% received psychotropic medication. Those who reported suicidality (6%) were no more likely than those who did not to be prescribed antidepressant/antianxiety medication, but were more likely to receive antipsychotics (AOR = 2.27, 95% CI 1.15 - 4.47), benzodiazepines (AOR 2.28, 95% CI 1.17 - 4.44), psychotherapy (AOR 2.60, 95% CI 1.18 - 5.73) and to be admitted to hospital/crisis team (AOR 2.84, 95% 1.82 - 4.45).In this sample, patients with PTSD and suicidality were more likely to receive psychiatric medication, psychotherapy and psychiatric admission than those who were not suicidal. Overall patients were more likely to receive psychotropic medication than psychotherapy. Adherence to clinical guidelines is important in this population to improve treatment outcomes and reduce the risk of suicide.KEY POINTSNICE guidelines recommend psychological therapy be first line treatment for PTSD, yet we identified that fewer people diagnosed with PTSD received therapy compared to psychotropic medication.Patients with suicidality were more likely to receive antipsychotics and benzodiazepines, yet not antidepressant/antianxiety medication although given that suicidality is characteristic of severe depression, it might be assumed from stepped care models that antidepressant/antianxiety medication be prescribed before antipsychotics.The high proportion of patients prescribed antipsychotics suggests a need for better understanding of psychosis symptoms among trauma-exposed populations.Identifying which combinations of symptoms are associated with suicidal thoughts could help tailor trauma-informed approaches to discussing therapy and medication.

Objective To use data from electronic health records (EHRs) to describe the demographic, clinical and functional correlates of childhood sexual abuse (CSA) in patients with severe mental illness (SMI), and compare their clinical outcomes (admissions and receipt of antipsychotic medications) to those of patients with no recorded history of CSA. Methods We applied a string‐matching technique to clinical text records of 7000 patients with SMI (non‐organic psychotic disorders or bipolar disorder), identifying 619 (8.8%) patients with a recorded history of CSA. Data were extracted from both free‐text and structured fields of patients’ EHRs. Results Comorbid diagnoses of major depressive disorder, post‐traumatic stress disorder and personality disorders were more prevalent in patients with CSA. Positive psychotic symptoms, depressed mood, self‐harm, substance use and aggression were also more prevalent in this group, as were problems with relationships and living conditions. The odds of inpatient admissions were higher in patients with CSA than in those without (adjusted OR = 1.95, 95% CI: 1.64–2.33), and they were more likely to have spent more than 10 days per year as inpatients (adjusted OR = 1.32, 95% CI: 1.07–1.62). Patients with CSA were more likely to be prescribed antipsychotic medications (adjusted OR = 2.48, 95% CI: 1.69–3.66) and be given over 75% of the maximum recommended daily dose (adjusted OR = 1.72, 95% CI: 1.44–2.04). Conclusion Data‐driven approaches are a reliable, promising avenue for research on childhood trauma. Clinicians should be trained and skilled at identifying childhood adversity in patients with SMI, and addressing it as part of the care plan.

Background Antipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions (ADRs). Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2 + antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of ADRs: QT interval prolongation, hyperprolactinaemia, and increased body weight [body mass index (BMI) ⩾ 25]. Methods We extracted anonymised EHR data. Patients aged 16 + receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively. Results We identified 35 409 observations of antipsychotic prescribing among 13 391 patients. Compared with antipsychotic monotherapy, APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% CI 1.87–3.24) and of registering a BMI > 25 (adjusted odds ratio 1.75; 95% CI 1.33–2.31) in the period following the APP prescribing. Conclusions Our observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity.

Background Characteristics and outcomes of patients presenting to Emergency Departments (EDs) have been under-examined. This paper describes the characteristics and risk of repeat suicidality amongst patients presenting to EDs with (1) suicidal ideation and (2) self-harm, compared to (3) controls in mental health crisis. Methods The Clinical Record Interactive Search tool identified 2211 patients who presented to three London EDs with suicidal ideation or self-harm, and 1108 control patients. All patients received a full psychosocial assessment. Chi-squared tests examined group characteristics. Cox regression models assessed the risk of re-presentation with suicidal ideation or self-harm within one year. Results There were a higher proportion of females and individuals under the age of 25 in the self-harm group. Patients presenting with suicidal ideation or self-harm were more likely to be white, live in more deprived areas, and less likely to receive a psychiatric diagnosis within one year compared to controls. Risk of repeat suicidality within one year was 3–4 times higher in those with baseline suicidal ideation (adjusted HR = 3.66, 95% CI 2.44–5.48) or self-harm (HR = 3.53 95% CI 2.47–5.04) compared to controls. Limitations To be included patients needed to have a full psychosocial assessment. Incomplete records meant 21.4% of the sample was excluded. This will have introduced bias which might confound observed associations. Conclusion Individuals presenting with either suicidal ideation or self-harm have similar risk for re-presentation within one year. Both groups would benefit from personalised risk management plans and active follow-up to reduce the risk of repeat suicidal behaviour.

BackgroundAntipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions. Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2+ antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of adverse drug reactions: QT interval prolongation, hyperprolactinaemia, and increased body weight (body mass index [BMI] ≥ 25).MethodsWe extracted anonymised EHR data. Patients aged 16+ receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively.ResultsWe identified 35,409 observations of antipsychotic prescribing among 13,391 patients. APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% C.I. 1.87-3.24) and of having a BMI > 25 (adjusted odds ratio 1.75; 95% C.I. 1.33-2.31) in the period following the APP prescribing.ConclusionsOur observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity.

OBJECTIVES Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants. METHODS Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis. RESULTS We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses. CONCLUSIONS There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.

We aimed to investigate whether daily fluctuations in mental health-relevant Twitter posts are associated with daily fluctuations in mental health crisis episodes. We conducted a primary and replicated time-series analysis of retrospectively collected data from Twitter and two London mental healthcare providers. Daily numbers of ‘crisis episodes’ were defined as incident inpatient, home treatment team and crisis house referrals between 2010 and 2014. Higher volumes of depression and schizophrenia tweets were associated with higher numbers of same-day crisis episodes for both sites. After adjusting for temporal trends, seven-day lagged analyses showed significant positive associations on day 1, changing to negative associations by day 4 and reverting to positive associations by day 7. There was a 15% increase in crisis episodes on days with above-median schizophrenia-related Twitter posts. A temporal association was thus found between Twitter-wide mental health-related social media content and crisis episodes in mental healthcare replicated across two services. Seven-day associations are consistent with both precipitating and longer-term risk associations. Sizes of effects were large enough to have potential local and national relevance and further research is needed to evaluate how services might better anticipate times of higher risk and identify the most vulnerable groups.

Objective Mining the data contained within Electronic Health Records (EHRs) can potentially generate a greater understanding of medication effects in the real world, complementing what we know from Randomised control trials (RCTs). We Propose a text mining approach to detect adverse events and medication episodes from the clinical text to enhance our understanding of adverse effects related to Clozapine, the most effective antipsychotic drug for the management of treatment-resistant schizophrenia, but underutilised due to concerns over its side effects. Material and methods We used data from de-identified EHRs of three mental health trusts in the UK (>50 million documents, over 500,000 patients, 2835 of which were prescribed Clozapine). We explored the prevalence of 33 adverse effects by age, gender, ethnicity, smoking status and admission type three months before and after the patients started Clozapine treatment. Where possible, we compared the prevalence of adverse effects with those reported in the Side Effects Resource (SIDER). Results Sedation, fatigue, agitation, dizziness, hypersalivation, weight gain, tachycardia, headache, constipation and confusion were amongst the highest recorded Clozapine adverse effect in the three months following the start of treatment. Higher percentages of all adverse effects were found in the first month of Clozapine therapy. Using a significance level of (p< 0.05) our chi-square tests show a significant association between most of the ADRs and smoking status and hospital admission, and some in gender, ethnicity and age groups in all trusts hospitals. Later we combined the data from the three trusts hospitals to estimate the average effect of ADRs in each monthly interval. In gender and ethnicity, the results show significant association in 7 out of 33 ADRs, smoking status shows significant association in 21 out of 33 ADRs and hospital admission shows the significant association in 30 out of 33 ADRs. Conclusion A better understanding of how drugs work in the real world can complement clinical trials.

Background Response to antidepressants in major depressive disorder is variable and determinants are not well understood or used to design clinical trials. We aimed to understand these determinants. Methods Supported by Innovative Medicines Initiative, as part of a large public-private collaboration (NEWMEDS), we assembled the largest dataset of individual patient level information from industry sponsored randomized placebo-controlled trials of antidepressant drugs in adults with MDD. We examined patient and trial-design-related determinants of outcome as measured by change on Hamilton Depression Scale or Montgomery–Asberg Depression Rating Scale in 34 placebo-controlled trials (drug, n = 8260; placebo, n = 3957). Results While it is conventional for trials to be 6–8 weeks long, drug-placebo differences were nearly the same at week 4 as at week 6 and with lower dropout rates. At the multivariate level, having any of these attributes was significantly associated with greater drug vs. placebo differences on symptom improvement: female, increasing proportion of patients on placebo, centers located outside of North America, centers with low placebo response (regardless of active treatment response) and using randomized withdrawal designs. Limitations Data on compounds that failed were not available to us. Findings may not be relevant for new mechanisms of action. Conclusions Proof of concept trials can be shorter and efficiency improved by selecting enriched populations based on clinical and demographic variables, ensuring adequate balance of placebo patients, and carefully selecting and monitoring centers. In addition to improving drug discovery, patient exposure to placebo and experimental treatments can be reduced.

Aims and methodTo identify temporal and demographic trends in referrals made to psychiatric liaison services. Routine clinical data from 16 105 individual referrals from three central London accident and emergency (A&E) departments to psychiatric liaison services from 2012 to 2014 were obtained and analysed using the Clinical Record Interactive Search (CRIS).ResultsReferrals from A&E to psychiatric liaison services increased 16% over the 3-year study period. There were fewer referrals to psychiatric liaison services in winter months compared with other seasons. There were fewer referrals to psychiatric liaison services over the weekend compared with weekdays (average 15.4 daily weekday referrals v. 13.2 weekend, z = 5.1, P < 0.001), and weekend referrals were slightly less likely to result in admission to psychiatric hospital (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01).Clinical implicationsPsychiatric staffing in A&E and inpatient psychiatric wards requires planning to meet temporal and regional variations in the pattern of demand.Declaration of interestNone.

BackgroundPotentially modifiable risk factors for developing dementia have been identified. However, risk factors for increased mortality in patients with diagnosed dementia are not well understood. Identifying factors that influence prognosis would help clinicians plan care and address unmet needs.AimsTo investigate diagnosed depression and sociodemographic factors as predictors of mortality in patients with dementia in UK secondary clinical care services.MethodWe conducted a cohort study of patients with a dementia diagnosis in an electronic health records database in a UK National Health Service mental health trust.ResultsIn 3374 patients with 10 856 person-years of follow-up, comorbid depression was not associated with mortality (adjusted hazard ratio 0.94; 95% CI 0.71–1.24). Single patients had higher mortality than those who were married (adjusted hazard ratio 1.25; 95% CI 1.03–1.50). Patients of Asian ethnicity had lower mortality rates than White British patients (adjusted hazard ratio 0.50; 95% CI 0.34–0.73).ConclusionsClinically diagnosed depression does not increase mortality in patients with dementia. Patients who are single are a potential high-mortality risk group. Lower mortality rates in Asian patients with dementia that have been reported in the USA also apply in the UK.Declaration of interestNone.

AimsTo describe characteristics of adults with intellectual disability (ID) and/or autism spectrum disorder (ASD) accessing care in one mental health Trust.To explore factors associated with in-patient admission/risk of re-admission within 12 months of discharge.BackgroundThere is concern that adults with intellectual disability and those with autism spectrum disorder are frequently admitted to mental health hospitals. The evidence from NHS datasets suggests that this remains a significant issue and is associated with personal, social and economic costs.MethodAdults (≥ 18 years) with ICD-10 diagnosis of “mental retardation” and/or autism who had accessed care in the Camden and Islington Foundation Trust were identified using the Clinical Record Interactive Search (CRIS). The identification process was validated through cross checking of free text in the electronic clinical notes. We compared demographic and clinical characteristics and service use, including length of admission, of 315 individuals with ASD and 339 with ID (with or without ASD). Logistic regression was used to explore factors associated with in-patient admission and re-admission within 12 months of discharge.ResultA greater proportion of adults with ID (with or without ASD) had a diagnosis of psychosis, substance misuse, or dementia whereas diagnosis of anxiety disorder was greater in those with ASD. Antipsychotics and other psychotropics were twice as likely to be prescribed for the ID ± group. Admission to psychiatric in-patient care was greater in those with ID ± ASD (adjusted OR 4.00, 95% confidence interval (CI) 2.41-6.63), men (aOR 2.28, 95%CI 1.39-3.75), younger adults (aOR 0.98, 95%CI 0.97-1.00), and in those with a diagnosis of schizophrenia spectrum disorder (aOR 5.08, 95%CI 3.00-8.61), affective disorder (aOR 2.23, 95%CI 1.29-3.83), personality disorder (aOR 1.94, 95%CI 1.02-3.68), and record of previous inpatient admission (aOR 2.18, 95%CI 1.17-4.05). Having ASD alone was associated with a greater risk of re-admission within one year of discharge, although this difference was not statistically significant (aOR 0.70, 95% CI 0.32-1.52). Comorbid diagnoses of affective disorder or personality disorder were the only significant associations with re-admission (aOR 3.11, 95%CI 1.34-7.23 and aOR 8.28, 95%CI 2.85-24.04, respectively).ConclusionThese findings provide the first longitudinal investigation into the acute care pathway for adults with ID and/or ASD in the NHS. Replication in other trusts is now needed to inform “at risk of admission” registers and guide targeted interventions to prevent admission.

Background The ways in which traumatic stress symptoms unfold under situations of ongoing threat and trauma exposure are poorly understood. The current study aims to identify traumatic stress symptom trajectories during conflict, as well as potential risk factors. Methods Experience sampling methods were used to study traumatic stress symptoms during the 2014 Israel-Gaza conflict in 100 Israeli civilians exposed to rocket fire. Summary reports of traumatic symptoms were made twice-daily for 30 days via mobile phone. Results Latent class growth analysis revealed four distinct classes (low, reducing, moderate, and high) characterised by their trajectory of traumatic stress symptoms during the conflict. Female gender, not being in a relationship, and higher prior trauma exposure were identified as potential risk factors. Limitations Data were not collected in the early phase of the conflict, the sample was relatively small, and only traumatic stress symptoms were investigated as outcomes. Conclusions This study identified heterogeneous traumatic stress symptom trajectories among civilians during a conflict, with different subgroups showing distinct response patterns over time, associated with various risk factors. Investigating responses to ongoing trauma, and identifying predictors of different stress symptom trajectories has clinical implications for the targeted delivery of interventions. Further exploration of heterogeneous trajectories could potentially elucidate mechanisms that drive resilience and recovery, including in situations of ongoing exposure such as during conflict.

Previous studies have found associations between low cognitive ability and later completed suicide. The aim of this study was to examine the association between cognitive ability and social functioning in adolescence, and later completed suicide in a large population-based longitudinal study. Data from the Israeli Draft Board Register for 634,655 Israeli male adolescents aged 16 and 17 was linked to a causes-of-death data registry, with a mean follow-up of 10.6 years for completed suicide. Our results show that in males without a psychiatric diagnosis, both low (adjusted HR=1.51, 95% CI: 1.19-1.92) and high (adjusted HR=1.36, 95% CI: 1.04-1.77) cognitive ability, and very poor (adjusted HR=2.30, 95% CI: 1.34-3.95) and poor (adjusted HR=1.64, 95% CI: 1.34-2.07) social functioning were associated with increased risk for later completed suicide; however positive predictive values were low (PPVs=0.09% and 0.10%, for low cognitive ability and very poor or poor social functioning, respectively). No association between cognitive ability or social functioning and risk for suicide was found in males with a psychiatric diagnosis. These data do not support the clinical utility of screening for such potential predictors.

Summary Background Crisis resolution and home treatment teams (CRTs) offer an alternative to hospital admission for patients undergoing mental health crises in the UK. Few studies have been done to examine predictors of relapse and readmission after contact with CRTs. Methods We used the Clinical Record Interactive Search to identify all patients receiving care from CRTs in two National Health Service (NHS) mental health trusts in London: Camden and Islington NHS Foundation Trust and South London and Maudsley NHS Foundation Trust. We used Cox regression models to examine rates and predictors of admission to acute mental health services within 1 year of contact with CRTs. Sex, age, ethnicity, marital status, social deprivation, severity of psychopathology, duration of index CRT episode, first contact with services, and diagnosis were extracted and examined as predictors of admission. Findings Between Jan 1, 2008, and Aug 31, 2014, 17 666 patients were treated by CRTs—8759 patients in the Camden and Islington trust and 8907 patients in the South London and Maudsley trust. 53·9 patients per 100 person-years (95% CI 52·1–55·8) in Camden and Islington and 51·3 patients per 100 person-years (95% CI 49·6–53·1) in South London and Maudsley were admitted to acute services within 1 year of seeing the CRT. In both cohorts, non-affective psychotic disorders (adjusted hazard ratio [HR] 1·25, 95% CI 1·09–1·44 in Camden and Islington; 1·27, 1·17–1·38 in South London and Maudsley) and age older than 65 years (1·18, 1·01–1·37 in Camden and Islington; 1·32, 1·12–1·56 in South London and Maudsley) were associated with increased risk of admission, whereas first contact with services (0·57, 0·52–0·62 in Camden and Islington; 0·69, 0·63–0·75 in South London and Maudsley), anxiety disorders (0·81, 0·69–0·96 in Camden and Islington; 0·77, 0·67–0·87 in South London and Maudsley), and longer index CRT episodes (adjusted HR per day 0·996, 0·994–0·998 in Camden and Islington; 0·989, 0·987–0·991 in South London and Maudsley) were associated with reduced risk of admission. Interpretation Past use of mental health services and a diagnosis of non-affective psychosis, which are markers of severity of mental illness, and older age, which is a marker of chronicity, are all risk factors for future relapse after interactions with CRTs. These findings might help clinicians and policy makers to offer more targeted and cost-effective services to reduce relapse rates. Funding None.

Summary Trends in detention under the Mental Health Act 1983 in two major London secondary mental healthcare providers were explored using patient-level data in a historical cohort study between 2007–2008 and 2016–2017. An increase in the number of detention episodes initiated per fiscal year was observed at both sites. The rise was accompanied by an increase in the number of active patients; the proportion of active patients detained per year remained relatively stable. Findings suggest that the rise in the number of detentions reflects the rise of the number of people receiving secondary mental healthcare.

Introduction: Although important to cognitive neuropsychiatry and theories of delusions, Capgras delusion has largely been reported in single case studies. Bell et al. [2017. Uncovering Capgras delusion using a large scale medical records database. British Journal of Psychiatry Open, 3(4), 179–185] previously deployed computational and clinical case identification on a large-scale medical records database to report a case series of 84 individuals with Capgras delusion. We replicated this approach on a new database from a different mental health service provider while additionally examining instances of violence, given previous claims that Capgras is a forensic risk. Methods: We identified 34 additional cases of Capgras. Delusion phenomenology, clinical characteristics, and presence of lesions detected by neuroimaging were extracted. Results: Although most cases involved misidentification of family members or partners, a notable minority (20.6%) included the misidentification of others. Capgras typically did not present as a monothematic delusion. Few cases had identifiable lesions with no evidence of right-hemisphere bias. There was no evidence of physical violence associated with Capgras. Conclusions: Findings closely replicate Bell et al. (2017). The majority of Capgras delusion phenomenology conforms to the “dual route” model although a significant minority of cases cannot be explained by this framework.

Case management services for people with serious mental illness are generally found to be effective, but controlled and randomized studies assessing such services are scarce. The aim of the present study was to assess the effectiveness of a new strengths-based case management (SBCM) service in Israel, using a randomized controlled approach. The sample consisted of 1276 individuals with serious mental illness, who consume psychiatric rehabilitation services (PRS) in the community, and were randomly assigned to receive or not to receive the SBCM service in addition to treatment-as-usual PRS. Quality of life, goal setting and attainment, unmet needs, self-efficacy, interpersonal relationships, symptom severity, and service utilization were assessed by clients at onset and after 20 months. Results show that SBCM participants improved in self-efficacy, unmet needs, and general quality of life, and set more goals than the control group. SBCM participants also consumed fewer services at follow-up. Results suggest that SBCM services are effective in helping individuals with serious mental illness set personal goals and use PRS in a better and more focused manner.

OBJECTIVE: Data suggest that adherence to religious beliefs is associated with lower rates of suicide. A number of mediating factors have been hypothesized to explain this association, including enhanced social support, less substance abuse, and lower rates of psychopathology. METHOD: We utilized data from a two-phase population-based, epidemiological study of mental disorders among young Jewish Israel born in a 10-year birth-cohort conducted in the 1980s. This study included data on religiosity and suicidal behaviour. Twenty-five years thereafter, mortality data were obtained from a national vital statistics registry. RESULTS: Rates of suicidal ideation were similar among secular, partially observant, and religious subjects (9.4%, 6.7%, and 6.2%, respectively; adjusted OR for linear trend: 0.80, 95% CI: 0.58-1.09). Rates of suicide attempts were significantly lower among religious subjects (2.4%, 2.5%, and 0.4% for secular, partially observant, and religious, respectively; adjusted OR for linear trend: 0.62, 95% CI: 0.43-0.88). Of the 4914 subjects, eight died by suicide: Seven of them were secular and one was partially observant (χ(2) = 2.52, P = 0.09). There were no differences in social functioning or rates of psychopathology among the study groups. CONCLUSION: Religiosity has a protective effect against suicide attempts, which is independent of social functioning, psychopathology, and substance use.© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Language: en

Background: There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias. Aims: To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide. Method: We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years. Results: Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ± 2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide. Conclusion: In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Background Consistent evidence suggests that there is an association between childhood trauma and psychotic disorders. Exposure to childhood trauma among people with severe mental illness (SMI) is associated with a range of negative outcomes, including exacerbation of symptoms, higher rates of readmission and relapse, poorer levels of social and vocational functioning, substance use and self-harm (Grubaugh et al., 2011). We aimed to identify people with SMI and a history of CSA as recorded in electronic health records in a large mental healthcare provider in the UK, describe the clinical and functional characteristics these patients and compare their clinical outcomes (admissions, medication) to those of patients with no recorded history of CSA. Methods Data for this study were obtained from Camden & Islington NHS Foundation Trust using the Clinical Record Interactive Search (CRIS) tool. CRIS is an application developed to enable routinely collected electronic health records to be used in research. C&I NHS FT is a large mental health provider serving a geographic catchment area of two inner-city London boroughs, and approximately 470,000 residents. For purposes of this study we identified patients with an ICD-10 diagnosis of F20-F29 or F30-31 with at least one year of follow-up. We searched text records (clinical notes and documents) for keywords associated with CSA, using an iterative process of inclusion and exclusion rules. We then tested the positive predictive value of this search. We compared the demographic, clinical and functional characteristics of patients with and without a history of CSA using chi square tests. Next, we used logistic regression models to examine the outcomes of inpatient admission and receipt of antipsychotic medication among the study population. Results We identified 7,000 patients with SMI, of which 619 (8.8%) hade a recorded history of CSA. Patients with a recorded history of CSA were more likely to be female (63.8% vs. 43.3%), single (76.9% vs. 66.5%), of white ethnic origin (66.4% vs. 54.3%) than their counterparts without CSA. There was no difference in the distribution of social deprivation between the groups. Major depressive disorder, posttraumatic stress disorder and personality disorders were all more prevalent in patients with CSA (13.4% vs. 7.6%, 4.7% vs. 1.4%, and 22.0% vs. 5.8%, respectively). Higher rates of moderate-severe psychotic symptoms, depressed mood, self-harm, substance use and aggression were also evident in this group, as were problems with relationships and accommodation. There was a 2-fold increase in the odds of inpatient admissions in patients with a history of CSA than in those without (adjusted OR=1.95, 95% CI: 1.64–2.33), and they were more likely to have spent at least 10 days a year as inpatients (adjusted OR=1.32, 95% CI: 1.07–1.62). Similarly, patients with a history of CSA were more likely to be prescribed antipsychotic medication (adjusted OR=2.48, 95% CI: 1.69–3.66), and more likely to be given over 75% of the maximum recommended dose (adjusted OR=1.72, 95% CI: 1.44–2.04). Discussion The current study used routinely recorded data from electronic health records to identify a history of childhood sexual abuse in patients with SMI. Consistent with previous findings, the study demonstrated that exposure to childhood trauma is associated with negative clinical and functional outcomes in these patients. Clinicians working with patients with SMI should be trained and skilled at assessing childhood adversity, and addressing such adversity in the clinical setting.

Objectives: Qualitative studies suggest that people from UK minority ethnic groups with dementia access health services later in the illness than white UK-born elders but there are no large quantitative studies investigating this. We aimed to investigate inter-ethnic differences in cognitive scores and age at dementia diagnosis.Methods: We used the Clinical Record Interactive Search (CRIS) applied to the electronic health records of two London mental health trusts to identify patients diagnosed with dementia between 2008 and 2016. We meta-analysed mean Mini Mental State Examination (MMSE) and mean age at the time of diagnosis across Trusts for the most common ethnic groups, and used linear regression models to test these associations before and after adjustment for age, sex, Index of Multiple Deprivation and marital status. We also compared percentage of referrals for each ethnic group with catchment Census distributions.Results: Compared to White patients (N=9380), unadjusted mean MMSE scores were lower in Asian (-1.25; 95% CI -1.79, -0.71; N=642) and Black patients (-1.82, 95% CI -2.13, -1.52; N=2008) as was mean age at diagnosis (Asian patients: -4.27 (-4.92, -3.61); Black patients -3.70 (-4.13, -3.27) years). These differences persisted after adjustment. In general, ethnic group distributions in referrals did not differ substantially from those expected in the catchments. Conclusions: People from Black and Asian groups were younger at dementia diagnosis and had lower MMSE scores than White referrals.

We assessed in vivo symptom courses of early psychological responses during war and investigated the influence of exposure, gender, and a prior diagnosis of severe mental illness (SMI).Participants were 181 highly exposed individuals from the general population and community psychiatric rehabilitation centers. A 30-day twice-daily Internet-smartphone-based intensive assessment two weeks into the 2014 Israel-Gaza war estimated peritraumatic symptom clusters, sense of threat, negative emotions and cognitions, and siren exposure during two periods that varied in exposure level. Piecewise growth curve modeling procedures were performed.We found different courses for most variables, gender, and SMI status. Women were more reactive two weeks into the war but reduced their reactivity level at a faster pace than males, reaching lower symptom levels one month later. Women's courses were characterized by arousal, negative emotionality, sense of threat, and reactivity to siren exposure. No-SMI men had a stable course followed by a significant reduction in arousal, negative emotions, avoidance, and perceived threat during a "return to routine" lower-level intensity period of the war. Individuals with SMI had higher reactivity levels at study onset; but while women with SMI improved over time, men with SMI worsened. SMI reactivity was characterized by negative cognitions, intrusions, and avoidance.Early reactions during prolonged exposure to war are variable, dynamic, and affected by exposure context. Symptoms, emotions, and cognitions develop differentially over time and are affected by gender and mental health status. The identification of various early stress courses should inform primary intervention strategies.

Appendix 1. Association between clinical and demographic characteristics and the mini-mental state examination at death, using only scores recorded within one year of death. Appendix 2. Flow diagram of study patient inclusion/exclusion. (DOCX 41 kb)

Suicide is a major cause of death among individuals with eating disorders. This study examined risk of suicide among females with eating disorders based on population-based military data. Data on diagnoses of eating disorders from the pre-induction screening for psychopathology and diagnoses assigned during military service were merged with data on later suicide from the nationwide Israeli Death Registry. We identified 1,356 females with eating disorders and compared their risk of suicide to a population-based control group of females without eating disorders over a mean follow-up period of 8.5 ± 5.34 years. Females with eating disorders had a higher rate of suicide (0.22 %, n = 3) compared to females without eating disorders (0.03 %, n = 166). Having a moderate–severe eating disorder was associated with increased risk of suicide (RR = 12.50, 95 % CI = 3.86–38.09), whereas none of the females diagnosed as having a mild eating disorder died by suicide. Females with moderate–severe eating disorders are at risk of suicide and should be monitored for suicidal intent.

BackgroundThe base rate of transition from subthreshold psychotic experiences (the exposure) to clinical psychotic disorder (the outcome) in unselected, representative and non-help-seeking population-based samples is unknown.MethodA systematic review and meta-analysis was conducted of representative, longitudinal population-based cohorts with baseline assessment of subthreshold psychotic experiences and follow-up assessment of psychotic and non-psychotic clinical outcomes.ResultsSix cohorts were identified with a 3–24-year follow-up of baseline subthreshold self-reported psychotic experiences. The yearly risk of conversion to a clinical psychotic outcome in exposed individuals (0.56%) was 3.5 times higher than for individuals without psychotic experiences (0.16%) and there was meta-analytic evidence of dose–response with severity/persistence of psychotic experiences. Individual studies also suggest a role for motivational impairment and social dysfunction. The evidence for conversion to non-psychotic outcome was weaker, although findings were similar in direction.ConclusionsSubthreshold self-reported psychotic experiences in epidemiological non-help-seeking samples index psychometric risk for psychotic disorder, with strong modifier effects of severity/persistence. These data can serve as the population reference for selected and variable samples of help-seeking individuals at ultra-high risk, for whom much higher transition rates have been indicated.

Borderline intellectual functioning is defined by the DSM IV as an IQ range that is between one to two standard deviations below the mean (71

BackgroundPrevious studies have found that patients with schizophrenia are more likely to be violent than the general population. The aim of this study was to investigate the association between schizophrenia and violent crime in the Israeli population.MethodUsing the Israeli Psychiatric Hospitalization Case Registry we identified 3187 patients with a discharge diagnosis of schizophrenia. For each proband we identified parents and siblings, and gender- and age-matched controls for patients, parents and siblings. Information on violent crimes was obtained from police records.ResultsPatients with schizophrenia were at increased risk for violent crimes compared with controls [odds ratio (OR) 4.3, 95% confidence interval (CI) 3.8–4.9], especially women (OR 9.9, 95% CI 6.2–15.7). Risk for violent crimes was higher among patients with co-morbid substance misuse than in patients without such co-morbidity (OR 5.1, 95% CI 4.2–6.3).ConclusionsThe results of this study suggest that increased risk of violence is part of the clinical picture of schizophrenia and needs to be recognized as a legitimate, essential, aspect of clinical management.

Outcomes in RCT's of antipsychotic medications are often examined using last observation carried forward (LOCF) and mixed effect models (MMRM), these ignore meaning of non-completion and thus rely on questionable assumptions. We tested an approach that combines into a single statistic, the drug effect in those who complete trial and proportion of patients in each treatment group who complete trial. This approach offers a conceptually and clinically meaningful endpoint. Composite approach was compared to LOCF (ANCOVA) and MMRM in 59 industry sponsored RCT's. For within study comparisons we computed effect size (z-score) and p values for (a) rates of completion, (b) symptom change for complete cases, which were combined into composite statistic, and (c) symptom change for all cases using last observation forward (LOCF). In the 30 active comparator studies, composite approach detected larger differences in effect size than LOCF (ES=.05) and MMRM (ES=.076). In 10 of the 49 comparisons composite lead to significant differences (p≤.05) where LOCF and MMRM did not. In 3 comparisons LOCF was significant, in 2 MMRM lead to significant differences whereas composite did not. In placebo controlled trials, there was no meaningful difference in effect size between composite and LOCF and MMRM when comparing placebo to active treatment, however composite detected greater differences than other approaches when comparing between active treatments. Composite was more sensitive to effects of experimental treatment vs. active controls (but not placebo) than LOCF and MMRM thereby increasing study power while answering a more relevant question.

SummaryWhat is already known about this subject Low IQ is associated with high BMI in childhood. There are inconsistent findings on the association between low SES and high BMI. Youth with low IQ have been reported to have poorer health behaviors, such as poor nutrition and less physical activity. What this study adds Low IQ is significantly associated with obesity for both male and female adolescents, though more strongly for female adolescents. Physical activity has a mediating effect on the association between low IQ and obesity among both male and female adolescents, though more strongly for male adolescents. The association between low IQ and obesity is strongest among adolescents from high SES backgrounds. Background Previous studies have shown an association between low intelligence quotient (IQ), high body mass index and low socioeconomic status (SES). Objectives This study examined the cross-sectional association between IQ and obesity, exploring the roles of gender, SES and physical activity in this association. Methods Subjects were 235 663 male and 169 259 female adolescents assessed by the Israeli military draft board. Results Low IQ was significantly associated with increased odds of obesity among male (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.36–1.52) and female adolescents (OR = 1.61, 95% CI = 1.51–1.73); this association was significantly stronger among female adolescents. Sobel tests indicated that physical activity had a significant mediating effect on this association for male and female adolescents, although more strongly for male adolescents. Dividing the sample according to SES, the association between low IQ and obesity was strongest in the high SES group (male adolescents: OR = 1.26, 95% CI = 1.10–1.43, female adolescents: OR = 1.61, 95% CI = 1.38–1.89), even when controlling for physical activity. Conclusions The findings suggest that low IQ is associated with increased odds of obesity, particularly in female adolescents and in adolescents with high SES. Physical activity has a mediating effect on this association, although more strongly for male than for female adolescents. Public health measures on decreasing obesity might focus on these groups.

Background Negative symptoms are an important target for intervention in schizophrenia. There is lack of clarity in defining appropriate patients for negative symptom trials. While regulators, drug developers and academics have expressed positions in this regard, the implications of these definitions are not yet tested in large-scale trials and there is no consensus. Objectives We examined the extent to which various operational criteria for inclusion in negative symptoms in schizophrenia clinical trials can impact patient selection and examined the effectiveness of second generation antipsychotics (SGAs) in patients with various degrees of negative symptoms. Method Using anonymized patient data from AstraZeneca, Janssen Pharmaceuticals, Eli Lilly, Lundbeck, and Pfizer from 20 placebo-controlled trials of SGAs in schizophrenia from the NewMeds repository, we applied different criteria for negative symptoms: prominent, predominant, and EMA criteria, which require predominant and core negative symptoms to be present and examined the impact of these on inclusion and outcome. Results Operational criteria for negative symptoms in trials vary greatly in their inclusion of patients from “typical” trial samples. Of the patients in our studies, 8.1% and 62.3% met criteria for prominent negative symptoms, 10.2% to 50.2% met criteria for predominant negative symptoms and 7.6% to 40.0% met EMA criteria at baseline. After 6 weeks of active treatment, 8% and 33.1% of patients met criteria for prominent residual negative symptoms and 14.9% to 65% met criteria for prominent and 12.2% to 45.5% met EMA criteria. Patients with predominant or prominent negative symptoms showed marked improvement on second generation antipsychotics. Conclusions Applying various operational criteria for selecting patients for negative symptoms trials provides a great variability in percentage of suitable patients calling into question the extent to which some definitions may be overly narrow.

BACKGROUND: The prevalence and manifestation of posttraumatic stress symptoms in young children may differ from that observed in adults. This study examined sociodemographic, familial, and psychosomatic correlates of posttraumatic stress disorder (PTSD) among preschool children and their mothers who had been exposed to ongoing missile attacks in the Gaza war. METHODS: One hundred and sixty-seven mothers of preschoolers (aged 4.0-6.5 years) were interviewed regarding PTSD and psychosomatic symptomatology of their children, as well as their own reactions to trauma. RESULTS: Fourteen mothers (8.4%) and 35 children (21.0%) screened positive for PTSD. Sociodemographic characteristics were not associated with PTSD among mothers or children. Among children, the only significant risk factor was having a mother with PTSD (OR = 12.22, 95% CI 2.75-54.28). Compared to children who did not screen positive for PTSD, those who did screen positive displayed significantly higher rates of psychosomatic reactions to trauma, most notably constipation or diarrhea (OR = 4.36, 95% CI 1.64-11.60) and headaches (OR = 2.91, 95% CI 1.07-7.94). CONCLUSIONS: Results of this study add to the burgeoning literature on child PTSD, emphasizing the important role of maternal anxiety and the psychosomatic reactions associated with exposure to ongoing traumatic experiences in young children. Language: en

Research has shown higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness (SMI). The aim of this study was to assess the prevalence of traumatic events and full and partial PTSD among people with SMI and their associations with trauma-related cognitions and depressive symptoms. A total of 122 persons with SMI were assessed for trauma exposure and PTSD. A subsample of 40 participants, 20 with PTSD and 20 without PTSD, were randomly selected, and their posttraumatic cognitions and depressive symptoms were assessed. The prevalence of traumatic events was 90%, and 19% met full diagnostic criteria for PTSD, and 20% had partial PTSD. The people with PTSD had more depressive symptoms and negative cognitions. PTSD in SMI is highly prevalent and underdiagnosed.

Introduction Previous research has identified several risk factors that are strongly associated with suicidal behavior in patients with severe depression. However, the effects of area-level characteristics on suicidal ideation and attempt in this population remain unclear. Methods The Clinical Record Interactive Search (CRIS) database was used to identify 2587 patients with severe depression who received secondary mental health services from the Camden & Islington NHS Foundation Trust. Stepwise multivariable logistic regression models were used to examine associations between socio-demographic characteristics, clinical variables, area-level measures, and suicidal ideation and attempt as separate outcomes. Results Both suicidal ideation and attempts were common among this cohort of severely depressed individuals (70.5% and 37.7%, respectively). While several individual socio-demographic and clinical characteristics were associated with both outcomes, particularly past psychiatric admission (suicidal ideation: adjusted OR=2.86, 95% CI: 2.26–3.62; suicide attempt: adjusted OR=4.00, 95% CI: 3.30–4.89), neither social deprivation nor ethnic density (measured at the area-level) was associated with risk for either outcome. Limitations Data were not collected specifically for research purposes and hence information on some potential confounders was not available. Additionally, information was restricted to individuals who accessed secondary mental health services in a defined catchment area and period. The study therefore does not take into account individuals who did not access mental health services. Conclusions The variation in risk for suicidal ideation and attempt among severely depressed individuals is explained by differences in individual socio-demographic and clinical characteristics, most notably past psychiatric admission and substance misuse, and not by area-level measures.

Context: It has been suggested that attenuated psychotic symptoms (APSs) reported by people who do not have psychotic disorders signal risk for later severe mental illness. Objective: To investigate this suggestion using follow-up assessments of hospitalization for clinical diagnoses of nonaffective psychotic and other psychiatric disorders. Design: Longitudinal cohort study of self-reported APSs with outcome assessment of severe mental illness obtained through linkage with a national hospitalization case registry. Setting: Israel. Participants: A stratified full probability sample of 4914 persons aged 25 to 34 years who were screened for psychopathology in the 1980s. Main Outcome Measure: Subsequent psychiatric hospitalization was ascertained using the psychiatric hospitalization registry, with a mean follow-up of 24 years. Results: After removing subjects with diagnosable psychotic disorders at baseline, 57.2% of the remaining sample reported at least 1 weak (infrequent) APS and 14.3% reported at least 1 strong (frequent) APS in the year preceding the assessment. Self-reported APSs predicted risk of later hospitalization for nonaffective psychotic disorders, mostly during the 5 years after baseline (adjusted odds ratio=4.31; 95% CI, 2.21-8.41; positive predictive value=1.27%; population attributable risk fraction=33%). Also, APSs increased the risk of later hospitalization for other psychiatric disorders, albeit to a lesser extent (adjusted odds ratio=2.21; 95% CI, 1.02-4.82). Conclusions: Self-reported APSs signal risk for later nonaffective psychotic disorders but are not clinically useful as predictors. The difference between these population-based data and the high-risk literature in terms of the positive predictive value (1% vs 10%, respectively) and the time window of transition (5 years vs 12 months, respectively) can be attributed to the selective enrichment strategies that produce high-risk samples.

Background Psychiatric hospitalization registries are utilized to investigate the incidence and prevalence of schizophrenia for both research and administrative purposes. The assumption behind this is that most individuals with schizophrenia will be hospitalized at least once in their life-time. Method In an epidemiological survey conducted in the 1980s, a population-based sample (n = 4914) of Israel-born individuals then aged 25–34 were screened in the community, and 29 (0.6%) were subsequently diagnosed by psychiatrists using SADS/RDC criteria. Twenty four years later we linked data from the epidemiological survey with the Israeli National Psychiatric Hospitalization Registry. Results Twenty seven of the 29 individuals (93%) diagnosed with schizophrenia in the survey were identified in the hospitalization registry with the same diagnosis. Fifty-two (1.0%) participants not diagnosed during the survey with schizophrenia were identified in the psychiatric hospitalization registry 24 years later with schizophrenia. The majority of them were diagnosed with other psychiatric disorders in the survey. If all diagnoses of schizophrenia are accepted at face value, the lifetime prevalence rate would be 1.8% for this cohort. Conclusion The overwhelming majority of individuals diagnosed with schizophrenia at ages 25–34 in an epidemiological survey were present in the Psychiatric Hospitalization Registry. However, the assessment of life-time rates of schizophrenia at these ages is problematic because some future cases are asymptomatic, others have premorbid non-psychotic disorders, while in others it is difficult to differentiate between affective disorders and schizophrenia. Availability of psychiatric services and hospitalization policy must be considered when generalizing these findings to other countries.

To examine variations in rates of inpatient suicide and clinical risk factors for this phenomenon.The National Israeli Psychiatric Hospitalization Case Registry was used to study inpatient suicide. Clinical risk factors for inpatient suicide were examined in a nested case control design.Between 1990 and 2013 there were 326 inpatient suicides, at an average of one inpatient suicide per 1614 admissions. A significant decline in rates of suicide per admission over time (p0.001) was associated with a reduced number of beds (p0.001) and a decline in nationwide suicide rates (p=0.001). Clinical risk factors for inpatient suicide were: affective disorders (OR=5.95), schizoaffective disorder (OR=5.27), schizophrenia (OR=3.82), previous suicide attempts (OR=2.59), involuntary hospitalization (OR=1.67), and more previous hospitalizations (OR=1.16,). A multivariate model with sensitivity of 27.3% and specificity of 95.3% for inpatient suicide, showed a positive predictive value of 0.4%.The absolute number and rates of inpatient suicide per admission have decreased over time, probably due to the decreased number of beds lowering total time at risk. Patients with affective and psychotic disorders and with previous suicide attempts have the greatest risk of inpatient suicide. However, clinical characteristics do not enable identification of patients who are at risk for suicide.

There have been very few prospective studies of death by suicide in the general population. Rather, studies of suicide have generally used psychological autopsies, a method that has the potential weakness of recall bias.To examine correlates of death by suicide among a community-based nonclinical sample prospectively assessed years before death by suicide.We analyzed data from an epidemiological study of a 10-year birth cohort (n = 4,914) conducted in Israel in the 1980s, with follow-up mortality data over 25 years.Eight participants died by suicide during follow-up (6/100,000 per year; mean follow-up to suicide = 18.3 ± 2.0 years), the majority of whom were rated as functioning relatively well at baseline. Male sex, psychiatric hospitalizations, major depressive disorder, and previous suicide attempts were associated with later suicide.In this nonclinical sample of persons assessed between ages 25 and 34, several correlates of suicide were identified, but the majority of persons who died by suicide were relatively high functioning at baseline. Major precursors of suicide may be more proximal factors of acute or chronic negative changes in life circumstances.

Objective The Scale for the Assessment of Negative Symptoms (SANS) is the most widely used instrument for measuring negative symptoms in schizophrenia. The validity of its factor structure has not been established. Congruence of the SANS and its subscales to the negative subscale of the Positive and Negative Symptom Scale (PANSS-N) and the Calgary Depression Scale for Schizophrenia (CDSS) were never explored. The current study revised SANS's structure and examined its correlations with the PANSS and the CDSS. Method Two-hundred and forty patients with schizophrenia with predominantly negative symptoms were analyzed. A principal component analysis was conducted for SANS. Spearman's correlations were conducted for SANS and PANSS-N, and for SANS and CDSS. Results Principal Component Analyses (PCA) of SANS revealed four factors, corresponding to the original SANS subscales with two exceptions: Item #13 (grooming and hygiene) loaded on the alogia factor rather than on its original affective flattening factor, and Item #4 (poor eye contact) did not load onto any factor. The total PANSS-N score showed a moderate correlation with the SANS and all of its subscales. The total CDSS score showed a low negative correlation with the total SANS score and with its avolition subscale. Conclusions Our results supported the validity of SANS's structure except for “poor eye contact” and “grooming end hygiene”. The moderate correlation between SANS and PANSS-N suggests that although they are not identical, they measure similar constructs. The low negative correlation between SANS and CDSS suggests that they measure different constructs.