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Previous studies on the impact of the COVID-19 pandemic on the mental health of health-care workers have relied on self-reported screening measures to estimate the point prevalence of common mental disorders. Screening measures, which are designed to be sensitive, have low positive predictive value and often overestimate prevalence. We aimed to estimate prevalence of common mental disorders and post-traumatic stress disorder (PTSD) among health-care workers in England using diagnostic interviews.We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders. The recruitment period for the diagnostic interviews was between March 1, 2021 and Aug 27, 2021. Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD.The screening sample contained 23 462 participants: 2079 participants were excluded due to missing values on the GHQ-12 and 11 147 participants due to missing values on the PCL-6. 243 individuals participated in diagnostic interviews for common mental disorders (CIS-R; mean age 42 years [range 21-70]; 185 [76%] women and 58 [24%] men) and 94 individuals participated in diagnostic interviews for PTSD (CAPS-5; mean age 44 years [23-62]; 79 [84%] women and 15 [16%] men). 202 (83%) of 243 individuals in the common mental disorders sample and 83 (88%) of 94 individuals in the PTSD sample were White. GHQ-12 screening caseness for common mental disorders was 52·8% (95% CI 51·7-53·8). Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14·3% (10·4-19·2), population prevalence of depression was 13·7% (10·1-18·3), and combined population prevalence of generalised anxiety disorder and depression was 21·5% (16·9-26·8). PCL-6 screening caseness for PTSD was 25·4% (24·3-26·5). Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7·9% (4·0-15·1).The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention.UK Medical Research Council; UCL/Wellcome; Rosetrees Trust; NHS England and Improvement; Economic and Social Research Council; National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the Maudsley and King's College London (KCL); NIHR Protection Research Unit in Emergency Preparedness and Response at KCL.

ObjectivesTo determine how workplace experiences of NHS staff varied by ethnic group during the COVID-19 pandemic and examine how these experiences are associated with mental and physical health at the time of the study.MethodsAn online Inequalities Survey was conducted by the TIDES study (Tackling Inequalities and Discrimination Experiences in health Services) in collaboration with NHS CHECK. This Inequalities Survey collected measures relating to workplace experiences (such as personal protective equipment (PPE), risk assessments, redeployments, and discrimination) as well as mental health, and physical health from NHS staff working in the 18 trusts participating with the NHS CHECK study between February and October 2021 (N=4622).ResultsRegression analysis revealed that staff from Black and Mixed/Other ethnic groups had greater odds of experiencing workplace harassment (adjusted odds ratio (AOR) = 2.43 [1.56-3.78] and 2.38 [1.12-5.07], respectively) and discrimination (AOR = 4.36 [2.73-6.96], and 3.94 [1.67-9.33], respectively) compared to White British staff. Staff from black ethnic groups also had greater odds than White British staff of reporting PPE unavailability (AOR = 2.16 [1.16-4.00]). Such workplace experiences were associated with negative physical and mental health outcomes, though this association varied by ethnicity. Conversely, understanding employment rights around redeployment, being informed about, and having the ability to inform redeployment decisions were associated with lower odds of poor health outcomes.ConclusionsStructural changes to the way staff from ethnically minoritised groups are supported, and how their complaints are addressed by leaders within the NHS are urgently required to address racism and inequalities in the NHS.Policy implicationsMaintaining transparency and implementing effective mechanisms for addressing poor working conditions, harassment, and discrimination is crucial in the NHS. This can be achieved through appointing a designated staff member, establishing a tracking system, and training HR managers in identifying and handling reports of racial discrimination. Incorporating diversity and inclusion considerations into professional development activities and providing staff with opportunities to actively participate in decision-making can also benefit their health. The NHS Workforce Race Equality Standard may need to broaden its scope to assess race equality effectively.

ObjectivesThe COVID-19 pandemic has disrupted the social and working lives of many. Past studies have highlighted worsening mental health during the pandemic, but often rely on small samples or infrequent follow-up. This study draws on fortnightly assessments from a large occupational cohort to describe differing trajectories of mental health between April 2020 and April 2021 and individual characteristics associated with these trajectory types.MethodsKing’s College London Coronavirus Health and Experiences of Colleagues at King’s is an occupational cohort study at a large university in London, UK. Participants (n=2241) completed online questionnaires fortnightly between April 2020 and April 2021. Symptoms of anxiety and depression were assessed using Generalised Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9).ResultsOn average, participants reported low levels of anxiety and depression (GAD-7 and PHQ-9 scores of 0–9, consistent with ‘none’, ‘minimal’ or ‘mild’ symptoms) throughout the year, with symptoms highest in April 2020 and decreasing over the summer months when no lockdown measures were in place. However, we observed more severe and variable symptoms among subgroups of participants. Four trajectory types for anxiety and depression were identified: ‘persistent high severity’ (6%–7% of participants), ‘varying symptoms, opposing national cases’ (4%–8%), ‘varying symptoms, consistent with national cases’ (6%–11%) and ‘persistent low severity’ (74%–84%). Younger age, female gender, caring responsibilities and shielding were associated with higher severity trajectory types.ConclusionsThese data highlight differing individual responses to the pandemic and underscore the need to consider individual circumstances when assessing and treating mental health. Aggregate trends in anxiety and depression may hide greater variation and symptom severity among subgroups.

PurposeThe health and well-being of healthcare staff came into focus during the coronavirus disease-2019 (COVID-19) pandemic as already strained workforces responded to new and additional challenges. Organisational support services made efforts to adapt staff support provision. However, most literature and recommendations are centred on surveys of medical and clinical staff. The present study included staff across clinical and non-clinical workforces within a mental health trust over the course of the COVID-19 pandemic to date, and aimed to understand workforces' access to and experiences of organisational support.Design/methodology/approachThe current study was a qualitative one using convenience and purposive sampling. Semi-structured individual and group interviews were conducted using a topic guide. Reflexive thematic analysis was used in a phenomenological framework to analyse data.Findings35 staff, broadly representative of the trust workforce, were recruited. Six global themes summarised the experiences of staff in relation to work practices, personal well-being and support access over the first year of the COVID-19 pandemic: COVID-19 disease, interpersonal relationships, individual considerations, change, working environment and support.Practical implicationsThe findings from the study have implications for organisational support provisions for healthcare workers and the dissemination of these services.Originality/valueAcknowledging the multi-various experiences of different workforces within National Healthcare Service organisations and how these change over time will facilitate innovative changes to staff support provision.

AimTo understand how student nurse experiences on clinical placement, within NHS hospitals, differ for ethnic minority and White British groups.DesignA qualitative thematic analysis with an inductive approach.MethodsData from semi-structured interviews with 21 London (United Kingdom) hospital-based student nurses were examined using thematic analysis. Participants were interviewed as part of theTackling Inequalities and Discrimination Experiences in health Services(TIDES) study and asked about their experiences during clinical placement.ResultsFive main themes were identified: 1) Role of mentors, 2) Discrimination and unfair treatment, 3) Speaking up/out, 4) Career progression, and 5) Consequences of adverse experiences. All themes were linked, with the social dynamics and workplace environment (referred to as ‘ward culture’) providing a context that normalises mistreatment experienced by nursing students. Students from ethnic minority backgrounds reported racism as well as cultural and/or religious microaggressions. While being valued for their race and ethnicity, White British students also experienced discrimination and inequity due to their age, sex, gender, and sexual orientation. Students from both White British and ethnic minority groups acknowledged that being treated badly was a barrier to career progression. Ethnic minority students also noted that the lack of diverse representation within senior nursing positions discouraged career progression within the UK National Health Service (NHS).ConclusionThese initial experiences of inequality and discrimination are liable to shape a student’s perspective of their profession and ability to progress within nursing. The NHS is responsible for ensuring that student nurses’ developmental opportunities are equal, irrespective of ethnicity.ImpactWard culture is perpetuated through the action of others to normalise mistreatment and concurrently disadvantage ethnic minority students making them feel unvalued, which in turn impacts both staff retention and career progression within the NHS. Training assessors should be aware of the existing culture of discrimination within clinical placements and work to eradicate it.

ObjectivesTo study the overall disease prevalence, and associations between demographic, socioeconomic, psychosocial, and health-related factors, and self-reporting one or more long-term health conditions (LTCs) in a working-age inner-city population.DesignCross-sectional household-based survey with a follow-up timepoint.SettingSouth-East London Community Health survey data.Participants893 adults aged 16–64 years living in Lambeth and Southwark, London.Outcome measuresPrevalence estimates of individual and multiple LTCs. Multinomial logistic regression was used to analyse the association of demographic, socioeconomic, psychosocial and health-related indicators with having one and multiple LTCs at two timepoints.ResultsMore than one third of participants reported at least one LTC, with the most prevalent being musculoskeletal conditions and asthma. The prevalence of one LTC at both timepoints was 20.6% and 21.4%, and of multimorbidity was 14.0% and 16.4%. At both timepoints, the 35–44 age group showed the largest increase in prevalence of one LTC compared with the preceding age group (16–34). After adjusting for age and gender, small social networks and a larger number of stressful life events were associated with increased risk of having both one and multiple LTCs. The risk of multimorbidity was greater than for initial LTCs for small social networks (3.8 (95% CI: 1.8 to 7.8) compared with 2.0 (95% CI: 1.0 to 3.9)), and three to five stressful life events (3.0 (95% CI: 1.7 to 5.3) compared with 1.5 (95% CI 1.0 to 2.2)).ConclusionsIn this study, the prevalence of multimorbidity increased more than the prevalence of one LTC between the two timepoints, indicating a progression of the overall disease prevalence over time. The 35–44 age group showed the greatest increase in the number of initial LTCs which support health-promotion interventions targeting younger age groups. Focusing on increasing social support networks and treating the psychological impact of stressful life events may also be of benefit.

ObjectivesThis study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April–June) of the COVID-19 pandemic in the UK.MethodsPreliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale.ResultsAnalyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one’s moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse.ConclusionsOur findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.

ObjectiveTo examine variations in impact of the COVID-19 pandemic on the mental health of all types of healthcare workers (HCWs) in England over the first 17 months of the pandemic.MethodWe undertook a prospective cohort study of 22,501 HCWs from 18 English acute and mental health NHS Trusts, collecting online survey data on common mental disorders (CMDs), depression, anxiety, alcohol use, and PTSD, from April 2020 to August 2021. We analysed these data cross-sectionally by time period (corresponding to periods the NHS was under most pressure), and longitudinally. Data were weighted to better represent Trust population demographics.ResultsThe proportion of those with probable CMDs was greater during periods when the NHS was under most pressure (measured by average monthly deaths). For example, 55% (95%CI 53%, 58%) of participants reported symptoms of CMDs in April-June 2020 versus 47% (95%CI 46%, 48%) July-October 2020. Contrary to expectation, there were no major differences between professional groups (i.e. clinical and non-clinical staff). Younger, female, lower paid staff, who felt poorly supported by colleagues/managers, and who experienced potentially morally injurious events were most at risk of negative mental health outcomes.ConclusionAmong HCWs, the prevalence of probable CMDs increased during periods of escalating pressure on the NHS, suggesting staff support should be increased at such points in the future, and staff should be better prepared for such situations via training. All staff, regardless of role, experienced poorer mental health during these periods, suggesting that support should be provided for all staff groups.Key messagesWhat is already known on this topicExisting evidence about the mental health of healthcare workers (HCWs) through the COVID-19 pandemic comes mainly from cross-sectional studies using unrepresentative convenience samples, typically focussing on clinical staff rather than all HCWs. Such studies show high prevalence of symptoms of mental disorders, but the strength of this evidence is uncertain.What this study addsUsing a defined sampling frame, with longitudinal, weighted data, we show that during periods of greater pressure on the NHS (as indicated by average monthly national COVID-19 death rates), prevalence of mental disorder symptoms increased, and, importantly, that this effect was seen in non-clinical as well as clinical staff.How this study might affect research, practice or policyThese findings indicate that provision of support for HCWs should not only focus on those providing clinical care, but also on non-clinical staff such as porters, cleaners, and administrative staff, and additional support should be provided during higher pressure periods. Better preparation of staff for such situations is also suggested.

BackgroundCommon mental disorders (CMD), such as depression and anxiety, are an important cause of morbidity, economic burden and public mental health need. The UK Improving Access to Psychological Therapies (IAPT) programme is a national effort to reduce the burden and impact of CMD, available since 2008.AimsTo examine ethnic and migration-related differences in use of IAPT-based psychological treatment using a novel epidemiological dataset with linkage to de-identified IAPT records.MethodData from a psychiatric morbidity survey of two South East London boroughs (2008–2010) were individually-linked to data on IAPT services serving those boroughs. We used Poisson regression to estimate association between ethnicity and migration status (including years of UK residence), with rate of subsequent use of psychological treatment.ResultsThe rate of psychological treatment use was 14.4 cases per thousand person years [cases/1000 pyrs, 95% confidence intervals (95% CI) 12.4, 16.7]. There was strong statistical evidence that compared to non-migrants, migrants residing in the UK for less than 10 years were less likely to use psychological treatment after adjustment for probable sociodemographic predictors of need, life adversity, and physical/psychiatric morbidity at baseline [rate ratio (RR) 0.4 (95% CI 0.20, 0.75]. This difference was not explained by migration for asylum/political reasons, or English language proficiency, and was evident for both self- and GP referrals.ConclusionsLower use of IAPT among recent migrants is unexplained by sociodemographics, adversity, and baseline morbidity. Further research should focus on other individual-level and societal barriers to psychological treatment use among recent migrants to the UK, including in categories of intersecting migration and ethnicity.

BackgroundThe COVID-19 pandemic has highlighted the impact work can have on healthcare workers and the importance of staff support services. Rapid guidance was published to encourage preventive and responsive support for healthcare workers.AimsTo understand mental healthcare staff's help-seeking behaviours and access to support at work in response to the COVID-19 pandemic, to inform iterative improvements to provision of staff support.MethodWe conducted a formative appraisal of access to support and support needs of staff in a National Health Service mental health trust. This involved 11 semi-structured individual interviews using a topic guide. Five virtual staff forums were additional sources of data. Reflexive thematic analysis was used to identify key themes.ResultsPeer-based, within-team support was highly valued and sought after. However, access to support was negatively affected by work pressures, physical distancing and perceived cultural barriers.ConclusionsHealthcare organisations need to help colleagues to support each other by facilitating open, diverse workplace cultures and providing easily accessible, safe and reflective spaces. Future research should evaluate support in the evolving work contexts imposed by COVID-19 to inform interventions that account for differences across healthcare workforces.

Background Few data are available on the pattern of use of fit notes issued in secondary care settings. Aims To evaluate the pattern and quality of e-fit notes issued in an NHS Trust. Methods Anonymized data on patients admitted to Guy’s and St Thomas’ NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes. Results A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were ‘not fit’ for work, whilst 156 (19%) advised that they ‘may be fit’ for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the ‘may be fit’ e-fit notes issued, 91/114 (80%) were related to the functional ability of patients. Conclusions Our study suggests that doctors in secondary care are more willing to use the ‘may be fit’ option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

ObjectivesIntroduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.MethodsData were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.ResultsIn a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.ConclusionsFor the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

ObjectivesTo describe the process and outcomes of a data linkage between electronic secondary mental healthcare records from the South London and Maudsley (SLaM) NHS Foundation Trust with benefits records from the Department for Work and Pensions (DWP). We also describe the mental health and benefit profile of patients who were successfully linked.DesignA deterministic linkage of routine records from health and welfare government service providers within a secure environment.Setting and participantsAdults aged≥18 years who were referred to or accessed treatment at SLaM services between January 2007 and June 2019, including those who were treated as part of Improving Access to Psychological Therapies (IAPT) services between January 2008 and June 2019 (n=448 404). Benefits data from the DWP from January 2005 to June 2020.Outcome measuresThe linkage rate and associated sociodemographic, diagnostic and treatment factors. Recorded primary psychiatric diagnosis based on International Classification of Diseases (ICD)-10 codes and type of benefit receipt.ResultsA linkage rate of 92.3% was achieved. Women, younger patients and those from ethnic minority groups were less likely to be successfully linked. Patients who had subsequently died, had a recorded primary psychiatric diagnosis, had also engaged with IAPT and had a higher number of historical postcodes available were more likely to be linked. Overall, 83% of patients received benefits at some point between 2005 and 2020. Benefit receipt across the psychiatric diagnosis spectrum was high, over 80% across most ICD-10 codes.ConclusionsThis data linkage is the first of its kind in the UK demonstrating the use of routinely collected mental health and benefits data. Benefit receipt was high among patients accessing SLaM services and varied by psychiatric diagnosis. Future areas of research are discussed, including exploring the effectiveness of interventions for helping people into work and the impact of benefit reforms.

ObjectivesSickness absence is strongly associated with poor mental health, and mental disorders often go untreated. In this population-based cohort study, we identified people receiving fit notes from their general practitioner (GP) and determined access to mental health treatment stratified by health complaint and demographic variables.DesignLongitudinal study of health records.SettingPrimary care and secondary mental health care in the borough of Lambeth, South London. Forty-five GP practices in Lambeth and the local secondary mental healthcare trust.ParticipantsThe analytical sample included 293 933 working age adults (16–60 years) registered at a Lambeth GP practice between 1 January 2014 and 30 April 2016.Primary and secondary outcome measuresThree indicators of mental healthcare in the year after first fit note were antidepressant prescription, contact with Improving Access to Psychological Therapy (IAPT) services and contact with secondary mental health services.Results75% of people with an identified mental health condition at first fit note had an indicator of mental healthcare in the following year. Black Caribbean and Black African groups presenting with mental disorders were less likely to have a mental healthcare indicator compared with White British groups.ConclusionsThe majority of those with an identified mental health need receive some treatment in the year following a fit note; however, our results suggest Black African and Black Caribbean groups with an identified mental healthcare need have less complete access compared to the White British group.

BackgroundCo-occurrence of common mental disorders (CMD) with psychotic experiences is well-known. There is little research on the public mental health relevance of concurrent psychotic experiences for service use, suicidality, and poor physical health. We aim to: (1) describe the distribution of psychotic experiences co-occurring with a range of non-psychotic psychiatric disorders [CMD, depressive episode, anxiety disorder, probable post-traumatic stress disorder (PTSD), and personality dysfunction], and (2) examine associations of concurrent psychotic experiences with secondary mental healthcare use, psychological treatment use for CMD, lifetime suicide attempts, and poor self-rated health.MethodsWe linked a prospective cross-sectional community health survey with a mental healthcare provider database. For each non-psychotic psychiatric disorder, patients with concurrent psychotic experiences were compared to those without psychotic experiences on use of secondary mental healthcare, psychological treatment for CMD, suicide attempt, physical functioning, and a composite multimorbidity score, using logistic regression and Cox regressions.ResultsIn all disorders except for anxiety disorder, concurrent psychotic experiences were accompanied by a greater odds of all outcomes (odds ratios) for a unit change in composite multimorbidity score ranged between 2.21 [95% confidence interval (CI) 1.49–3.27] and 3.46 (95% CI 1.52–7.85). Hazard ratios for secondary mental health service use for non-psychotic disorders with concurrent psychotic experiences, ranged from 0.53 (95% CI 0.15–1.86) for anxiety disorders with psychotic experiences to 4.99 (95% CI 1.22–20.44) among those with PTSD with psychotic experiences.ConclusionsCo-occurring psychotic experiences indicate greater public mental health burden, suggesting psychotic experiences could be a marker for future preventive strategies improving public mental health.

ObjectivesExplore inequalities in risk factors, mental and physical health morbidity in non-pregnant women of reproductive age in contact with mental health services and how these vary per ethnicity.DesignRetrospective cohort study.SettingData from Lambeth DataNet, anonymised primary care records of this ethnically diverse London borough, linked to anonymised electronic mental health records (‘CRIS secondary care database’).ParticipantsWomen aged 15–40 years with an episode of secondary mental health care between January 2008 and December 2018 and no antenatal or postnatal Read codes (n=3817) and a 4:1 age-matched comparison cohort (n=14 532).Main outcome measuresPreconception risk factors including low/high body mass index, smoking, alcohol, substance misuse, micronutrient deficiencies and physical diagnoses.ResultsWomen in contact with mental health services (whether with or without severe mental illness (SMI)) had a higher prevalence of all risk factors and physical health diagnoses studied. Women from minority ethnic groups were less likely to be diagnosed with depression in primary care compared with white British women (adjusted OR 0.66 (0.55–0.79) pConclusionsOur results challenge the perspective that regular monitoring of physical health in primary care should be exclusively encouraged in people with a l diagnosis. The striking differences in multimorbidity for women in contact with mental health services and those of ethnic minority groups emphasise a need of integrative models of care.

ObjectivesThe fit note replaced the sick note in the UK in 2010, with the aim of improving support for patients requiring sickness absence, yet there has been very little research into fit note use. This study aims to describe number of fit notes by condition, to improve our understanding of patterns of fit note use in primary care. Previous fit note research has relied on extracting diagnoses directly from fit notes, rather than extracting information from clinical records. In this paper, we extract information from clinical records to explore demographic factors and conditions associated with number of fit notes issued.DesignThis is a longitudinal study of clinical data. We analysed individual-level anonymised data from general practitioner consultations, including demographic information and condition recorded at first fit note. The latter encompassed diagnoses, individual symptoms and psychosocial issues.SettingA database called Lambeth DataNet, containing electronic clinical records on 326 415 adults (ages 16–60) from all 45 general practices within the London Borough of Lambeth from 1 January 2014 to 30 April 2017.ParticipantsOur analytical sample contained 40 698 people with a condition recorded at first fit note.Primary outcome measurePredicted number of fit notes in the period January 2014–April 2017ResultsOf all studied diagnostic groups, mental illness had the highest predicted number of fit notes (n=3.3; 95% CI: 3.1 to 3.4) after controlling for demographic factors and long-term conditions. The highest predicted number of fit notes for any condition subgroup was among patients presenting for drug and/or alcohol misuse (n=4.5; 95% CI: 4.1 to 4.8).ConclusionsFor the first time, we show drug and/or alcohol misuse at first fit note are associated with the highest number of fit notes. Research is needed to understand the trajectories of individuals at highest risk of long-term sickness absence, in particular, people presenting with drug and/or alcohol misuse.

ObjectivesThis study reports preliminary findings on the prevalence of, and factors associated with, mental health and wellbeing outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK.MethodsPreliminary cross-sectional data were analysed from a cohort study (n=4,378). Clinical and non-clinical staff of three London-based NHS Trusts (UK), including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire (GHQ-12). Secondary outcomes are probable anxiety (GAD-7), depression (PHQ-9), Post-Traumatic Stress Disorder (PTSD) (PCL-6), suicidal ideation (CIS-R), and alcohol use (AUDIT). Moral injury is measured using the Moray Injury Event Scale (MIES).ResultsAnalyses showed substantial levels of CMDs (58.9%, 95%CI 58.1 to 60.8), and of PTSD (30.2%, 95%CI 28.1 to 32.5) with lower levels of depression (27.3%, 95%CI 25.3 to 29.4), anxiety (23.2%, 95%CI 21.3 to 25.3), and alcohol misuse (10.5%, 95%CI, 9.2 to 11.9). Women, younger staff, and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one’s moral code) was strongly associated with increased levels of CMDs, anxiety, depression, PTSD symptoms, and alcohol misuse.ConclusionsOur findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.HighlightsWhat is already known about this subject?Large-scale population studies report increased prevalence of depression, anxiety, and psychological distress during the COVID-19 pandemic.Evidence from previous epidemics indicates a high and persistent burden of adverse mental health outcomes among healthcare workers.What are the new findings?Substantial levels of probable common mental disorders and post-traumatic stress disorder were found among healthcare workers.Groups at increased risk of adverse mental health outcomes included women, nurses, and younger staff, as well as those who reported higher levels of moral injury.How might this impact on policy or clinical practice in the foreseeable future?The mental health offering to healthcare workers must consider the interplay of demographic, social, and occupational factors.Additional longitudinal research that emphasises methodological rigor, namely with use of standardised diagnostic interviews to establish mental health diagnoses, is necessary to better understand the mental health burden, identify those most at risk, and provide appropriate support without pathologizing ordinary distress responses.

For personality disorder (PD), it is unknown whether additional psychiatric conditions increases their risk of self-harm. We thus performed a retrospective cohort study, using data from secondary mental healthcare in South London, linked to Hospital Episodes Statistics in England to identify self-harm admissions. Adults with diagnosed PD, followed up in a 6-year period, were involved (N=7,475). Cox regression was used to model the risk of self-harm admissions, with comorbid depression, substance use disorders (SUD), severe mental illness (SMI), anorexia nervosa (AN) and bulimia nervosa (BN) as primary exposures, with sociodemographics considered as confounders. In multivariable analyses, comorbid SUD (adjusted HR=1.66; 95%CI: 1.45, 1.90), depressive disorder (1.25; 1.09, 1.44), AN (1.63; 1.10, 2.39) and BN (1.65; 1.09, 2.51) were positively associated with increased risks of hospitalisation due to self-harm. However, negative association was found for comorbid SMI. The findings highlight the importance of assessing and treating comorbid psychiatric disorders in PD.

BackgroundResearch on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population.MethodsLambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017.ResultsWe found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73–12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60–4.87), chronic pain and depression (HR 4.14; 95% CI 3.69–4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36–4.95).ConclusionsOur results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

Background Research on sickness absence has typically focused on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. Methods Lambeth Datanet is a primary care database which collects individual level data on GP consultations, prescriptions, Quality and Outcomes Framework (QOF) diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326,415 people’s records covering a 40-month period from January 2014 to April 2017. Results We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and depression (HR 4.0; 95% CI 3.4–4.6), followed by chronic pain and depression (HR 3.9; 95% CI 3.5–4.4) and cardiac condition and depression (HR 3.9; 95% CI 3.2–4.7). Conclusion Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability in the population. The findings highlight the importance of multi-morbidity, particularly comorbid depression, as the leading cause of disability among working age adults.

ObjectivesThe fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the ‘maybe fit’ for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem.MethodsStudies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.ResultsThirteen papers representing seven studies met inclusion criteria. In the largest study, ‘maybe fit’ for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. ‘Maybe fit’ recommendations were made in 8.5%–10% of fit notes received by primary care patients in employment, and in 10%–32% of patients seen by GPs trained in the Diploma in Occupational Medicine. ‘Maybe fit’ was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the ‘maybe fit’ option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment.ConclusionsFit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.

Highlights • We find that people who have more adversity in childhood accumulate more trauma in later life. • The excess PTSD in people with childhood adversity may partially be explained by greater subsequent trauma exposure, but not by trauma severity or comorbid psychiatric disorder. • This suggests a specific relationship between childhood adversity and subsequent vulnerability to PTSD., Objective Only a minority of trauma-exposed individuals go on to develop post traumatic stress disorder (PTSD). Previous studies in high income countries suggest that maladaptive family functioning adversities (MFFA) in childhood may partially explain individual variation in vulnerability to PTSD following trauma. We test in a lower middle-income setting (Sri Lanka) whether: (1) MFFA is associated with trauma exposure; (2) MFFA moderates the association between exposure to trauma and later (a) PTSD (b) other psychiatric diagnoses; and (3) any association between MFFA and PTSD is explained by experiences of interpersonal violence, cumulative trauma exposure or comorbid psychopathology. Methods We conducted a population study of 3995 twins and 2019 singletons residing in Colombo, Sri Lanka. Participants completed the Composite International Diagnostic Interview, including nine traumatic exposures and a questionnaire on MFFA. Results 23.4% of participants reported exposure to MFFA. We found that (1) MFFA was strongly associated with trauma exposure (2) MFFA moderates the association between trauma exposure and both (a) PTSD and (b) other DSM psychiatric diagnosis. (3) This was not explained by interpersonal violence, cumulative trauma exposure or other psychopathology. Conclusions MFFA moderates the association between trauma and PTSD, and the association between trauma and non-PTSD psychopathology.

ObjectivesWe describe the development and initial validation of a new scale for measuring non-illness factors that are important in predicting occupational outcomes, called the NIPSA (non-illness predictors of sickness absence) scale.MethodsForty-two questions were developed which covered a broad range of potential non-illness-related risk factors for sickness absence. 682 participants in the South East London Community Health study answered these questions and a range of questions regarding both short-term and long-term sickness absence. Factor analysis was conducted prior to examining the links between each identified factor and sickness absence outcomes.ResultsExploratory factor analysis using the oblique rotation method suggested the questionnaire should contain 26 questions and extracted four factors with eigenvalues greater than 1: perception of psychosocial work environment (factor 1), perceived vulnerability (factor 2), rest-focused attitude towards recovery (factor 3) and attitudes towards work (factor 4). Three of these factors (factors 1, 2 and 3) showed significant associations with long-term sickness absence measures (pConclusionsThe NIPSA is a new tool that will hopefully allow clinicians to quickly assess for the presence of non-illness factors that may be important in predicting occupational outcomes and tailor treatments and interventions to address the barriers identified. To the best of our knowledge, this is the first time that a scale focused on transdiagnostic, non-illness-related predictors of sickness absence has been developed.

Background: Research on trauma and its impact on mental health typically relies on self-reports which can be influenced by recall bias and an individual's subjective interpretation of events. This study aims to compare responses on a checklist of life events with a trauma experience screening question, both of which assessed trauma experience retrospectively. Methods: A community sample of adults were asked about life events from a checklist before asking them whether they ever had a trauma experience, i.e. "an event that either puts them or someone close to them at risk of serious harm or death". Results: Less than half of the sample who reported at least one life event on the checklist that qualified as a trauma reported a trauma experience that they perceived put them or close others at risk of serious harm. Women responders, those reporting early life traumas, and a greater number of lifetime trauma events were more likely to report a trauma experience. Current symptoms of Common Mental Disorder did not account for differences in reporting of trauma experiences. Conclusions: Epidemiological approaches which require participants to make subjective judgement on the severity of the trauma experience will capture individual differences that we have shown are influenced by gender and previous trauma experience.

IntroductionOnly a minority of trauma-exposed individuals go on to develop post traumatic stress disorder (PTSD). Previous studies in high-income countries suggest that maladaptive family functioning adversities (MFFA) in childhood may partially ex-plain individual variation in vulnerability to PTSD following trauma. We test in a lower middle income setting (Sri Lanka) whether: (1) MFFA moderates the association between exposure to trauma and later (a) PTSD (b) other psychiatric diagnoses; (2) any moderation by MFFA is explained by experiences of interpersonal violence, cumulative trauma exposure or other psychopathology.MethodsWe conducted a population study of 3995 twins and 2019 singletons residing in Colombo, Sri Lanka. Participants completed the composite international diagnostic interview, including nine traumatic exposures and a questionnaire on MFFA.ResultsIn total, 23.4% of participants reported exposure to MFFA. We found that (1) MFFA moderates the association between trauma exposure and both (a) PTSD and (b) non-PTSD diagnosis. (2) This was not explained by interpersonal violence, cumulative trauma exposure or other psychopathology.ConclusionsIn our sample MFFA moderates the association between trauma and PTSD, and the association between trauma and non-PTSD psychopathology.

BackgroundThe fit note, introduced in England, Wales and Scotland in 2010, was designed to radically change the sickness certification process from advising on individuals’ inability to work to what they could do if adjustments were made available. Our review aimed to evaluate: (1) the percentage of fit notes utilizing the new “may be fit for work” option or advising on work adjustments, (2) the impact of the fit note on sickness absence and return to work, (3) demographic variation in fit note use.MethodsWe systematically searched in Embase, Cochrane CENTRAL, Pub Med, Worldcat, Ovid and PsychInfo from 1 Jan 2010–30 Nov 2016 for studies on working aged adults which included the search terms “fit note” or “fitnote”. Relevant abstracts were extracted and we assessed the quality of the papers and assessed bias using the modified Newcastle Ottawa Scale.ResultsNine papers met the inclusion criteria, four of which were based on the same cohort. Maybe fit notes made up just 6.6% of all fit notes. Work adjustments were most often recommended for patients who were less deprived, female and patients with physical health problems. Fit note advice for patients with physical health problems increased over time, but the opposite was seen for patients with mental health problems.ConclusionsFurther research needed to evaluate the use, impact and potential of the fit note, especially for patients with mental illness.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Background International studies indicate that the median prevalence of psychotic experiences in children is 7%. It has been proposed that environmental stress during pregnancy may affect the neurodevelopment of the foetus and lead to a vulnerability in the child to later stressors and psychopathology. Aim In this study we explore the relationship between environmental stress during pregnancy and psychotic experiences in children in the general population at 12 years. Methods We analysed a birth cohort of 5038 children from the Avon Longitudinal Study of Parents and Children. Environmental stress was measured as life event exposure. Data on life events were collected on women during their pregnancy, whilst psychotic experiences in the offspring were assessed at age 12. Results There was a weak association between maternal exposure to life events and psychotic experiences at twelve years (crude OR 1.10 95% CI 1.02–1.18) per quartile of life event score. This association was not reduced after adjustment for socio-economic status, family history of schizophrenia, maternal education or birth weight but after adjustment for maternal anxiety and depression and smoking in early pregnancy there was no longer any evidence for an association (OR 1.01 95% CI 0.93–1.10). Conclusion This study provides some evidence to suggest that stressful life events may affect child psychotic experiences through effects on maternal psychopathology, and possibly physiology, during pregnancy.

A 77-year-old Caucasian female presented with central chest pain and an electrocardiogram showing anterior and inferior ST segment elevation. The patient had discrepancy of the blood pressure measurement and unequal radial pulses of the upper limbs. Urgent CT thorax and aorta showed no evidence of aortic dissection, but it showed a large mass in the left lung lower lobe, which involved the adjacent structures including the left ventricular. The patient refused to have a bronchoscopy or any further investigations and was discharged to the community with palliative care support.

BACKGROUND: Psychotic symptoms are common in adolescents in the general population but it is unknown whether they are associated with poor social functioning. AIMS: To investigate whether adolescent psychotic symptoms are associated with poor social functioning measured by peer relationships. METHOD: Data from the Avon Longitudinal Study of Parents and Children cohort was used. Logistic regression was used to explore the relationship between psychotic symptoms at 12.9years detected using a semi-structured interview and poor social functioning at 13.2years using parent-reported peer problems from the Strengths and Difficulties Questionnaire. RESULTS: There was strong evidence (p

At the current level of membership examination fees at the Royal College of Psychiatrists, a resident in psychiatry who passes every part first time pays a total of £2136.[1][1] These costs are intended to cover only expenses rather than to generate profit, a message which many of us have accepted

BackgroundMoral injury is defined as the strong emotional and cognitive reactions following events which clash with someone’s moral code, values or expectations. During the COVID-19 pandemic, increased exposure to potentially morally injurious events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this.ObjectiveWe sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19.MethodsWe recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) (Nash et al., 2013) at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis.ResultsHCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients.ConclusionThese results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement.HighlightsClinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patientsHCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbanceMost HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress