Various psychotherapies are available for individuals with obsessive-compulsive disorder (OCD). However, the comparative effectiveness and acceptability of these therapies remain unclear. To examine the comparative effectiveness and acceptability of different psychotherapies for OCD. A living database of psychological interventions for OCD was utilised, and randomised controlled trials comparing psychotherapies with each other/control groups were included. Pairwise and network meta-analyses were conducted using a random-effects model. Comparative standardised mean differences (SMDs) were pooled for effectiveness in reducing OCD symptom severity post-treatment. Relative risks were calculated for acceptability. Sensitivity analyses were conducted by repeating the main analyses while controlling for specific variables to test the robustness of the findings. A total of 68 controlled trials (76 comparisons, 4019 patients) were included, involving 7 psychotherapeutic approaches. All psychotherapies were significantly more effective than both waitlist (SMD -1.40 to -0.96) and pill placebo (SMD -1.44 to -1.00). Except for mindfulness-based therapy, all approaches were more effective than both care-as-usual (SMD -0.98 to -0.67) and psychological placebo (SMD -0.95 to -0.63). Sensitivity analyses excluding outliers, studies with comorbidities, comparisons with waitlist controls and comparisons supported by only a single study, as well as analyses restricted to adults with OCD, yielded results consistent with the main analyses. When restricted to studies rated as low risk of bias, all therapies except mindfulness-based therapy and the inference-based approach remained significantly more effective than waitlist. No significant differences were found among psychotherapies regarding effectiveness and acceptability. Psychotherapies are similarly effective and acceptable for treating OCD. However, these findings should be interpreted with caution due to limited statistical power, substantial heterogeneity and a high risk of bias across many included studies. More methodologically rigorous research is needed to validate and strengthen the current evidence base.
Real-world evidence on pharmacotherapy for bipolar disorder remains limited; in particular, the effectiveness of combination therapies that are widely used in clinical practice has not been systematically assessed. To assess the effectiveness of mono- and combination therapy with mood stabilisers and antipsychotics in preventing psychiatric hospitalisation. This population-based cohort study used a within-individual design and data from the National Database of Health Insurance Claims and Specific Health Check-ups of Japan. Patients aged ≥20 years, with a primary diagnosis of bipolar disorder treated in psychiatric settings between 1 April 2013 and 31 March 2022, were included. Follow-up continued until 31 May 2023. Exposures included monotherapy with mood stabilisers or antipsychotics, and combination therapy involving (a) lithium plus another mood stabiliser or (b) lithium, valproate or lamotrigine plus a commonly prescribed antipsychotic. The primary outcome was time to psychiatric hospitalisation. Adjusted hazard ratios (aHRs) with 95% confidence intervals were estimated using stratified Cox regression. Among 315 046 patients (median follow-up 7.1 years), 83 621 (26.5%) experienced psychiatric hospitalisation. Monotherapy with lithium (aHR 0.67 [0.66-0.68]), valproate (aHR 0.71, 95% CI 0.70-0.73), lamotrigine (aHR 0.72, 95% CI 0.69-0.75) and carbamazepine (aHR 0.74, 95% CI 0.70-0.78) was associated with reduced hospitalisation compared with non-use of any mood stabilisers. Antipsychotic monotherapy with 15 agents, including aripiprazole (aHR 0.73, 95% CI 0.70-0.75) and zotepine (aHR 0.74, 95% CI 0.69-0.79), was also associated with reduced risk compared with non-use of any antipsychotics. Combination therapy with lithium plus carbamazepine (aHR 0.73, 95% CI 0.64-0.83), zotepine (aHR 0.82, 95% CI 0.72-0.93), aripiprazole (aHR 0.87, 95% CI0.82-0.92) or valproate (aHR 0.92, 95% CI 0.87-0.97) was associated with further reductions in hospitalisation risk compared with lithium monotherapy. This large, population-based study showed that monotherapy and combination therapy with mood stabilisers and antipsychotics varied in their effectiveness in preventing psychiatric hospitalisation. These findings may inform treatment decisions in the clinical management of bipolar disorder.
Formal thought disorder (FTD) is a highly disabling transdiagnostic feature that impedes communication and social ties. Progress in understanding and treating FTD has been hampered by the uncertainties in its assessment. We examined if a short 3-5min assessment of transcribed speech can capture the latent dimensions and network structure of FTD and predict functional outcomes. In a transdiagnostic sample (N = 666) with a single longitudinal follow-up over 3-12 months (n = 244), we administered the short form of the Thought and Language Index to measure eight individual features of FTD. We determined the baseline factor structure of FTD, its temporal invariance at follow-up, and the predictive validity of FTD dimensions on the global single-item Social and Occupational Functioning Assessment Scale scores at baseline and follow-up. We identified the most influential and putative primary phenomena within the FTD syndrome, using network analysis. Factor analyses revealed a stable three-factor model of FTD: impoverishment (poverty of speech, weakening of goal), loosening (looseness, illogicality) and peculiarities (peculiar words, peculiar sentences), with excellent fit (Comparative Fit Index: 0.997, root mean square error of approximation: 0.040) and metric invariance over time. Impoverishment and peculiarities predicted functioning at baseline and 3-12 months later (cross-sectional: β = -0.196, p < 0.001 and β = -0.298, p = 0.001, respectively; longitudinal: β = -0.201, p = 0.037 and β = -0.336, p = 0.042, respectively). Looseness and poverty of speech were putative primary features influencing other FTD phenomena. Weakening of goal and peculiar sentences were the most connected phenomena. By integrating latent variable and network approaches, we provide a unified, empirically grounded framework to interpret FTD assessed using a brief speech task. We report a replicable three-dimensional structure, identify central symptoms that may maintain the FTD syndrome, and the specific dimensions that influence functional disability. These findings clarify the prognostically valuable features of FTD for future mechanistic and interventional research.
Depression is often accompanied by multisystem comorbidities, but the time trajectories of these comorbidities remain unclear. We aimed to define the temporal sequence of comorbidity accrual relative to depression diagnosis, and examine how this trajectory differs in recurrent depression. A total of 32 953 individuals with depression were identified in the UK Biobank cohort, including 2402 with recurrent depression. The time between diagnosis of depression or recurrent depression and ten common comorbidities was established to determine the temporal order and rate of comorbidity diagnosis in relation to depression, based on the sequence of recorded diagnostic events. We further stratified the cohort by polygenic risk score, gender, age and history of antidepressant or antihypertensive medication use. The study included 32 953 participants (mean age at diagnosis 52.6 years; 63.1% female). Hypertension and dorsopathies preceded depression diagnosis by a median of 2.6 years (interquartile range (IQR) -7.0 to 0.0) and 1.0 year (IQR -5.0 to 2.0), respectively. Alzheimer's disease and obesity emerged after diagnosis at medians of 2.5 years (IQR 0.0-5.0) and 0.8 years (IQR -2.0 to 3.0). High genetic risk was associated with an earlier onset of pre-depression cardiometabolic conditions, with hypertension occurring 2.8 years before diagnosis in individuals with a high polygenic risk score compared with 2.3 years in individuals with a low polygenic risk score. Crucially, individuals with recurrent depression exhibited a profoundly different trajectory, with most comorbidities manifesting many years after the index diagnosis. Stratification by medication history indicated that antihypertensive drug use was associated with an earlier recorded diagnosis of cardiometabolic conditions, whereas antidepressant use was linked to a later diagnosis of neurodegenerative diseases. These findings identify three critical windows for intervention and reveal a distinct, delayed comorbidity trajectory in recurrent depression. This underscores the need for long-term, integrated surveillance strategies tailored to depression subtype and treatment history.
Health anxiety, characterised by excessive worry about having or acquiring a serious illness, significantly impacts mental health and well-being. Determining which psychological interventions and components should be considered as first-line treatments requires robust evidence. This study aimed to evaluate the efficacy of various psychological interventions and their essential components in managing health anxiety. A comprehensive search was conducted across multiple academic databases, including PubMed, Embase, PsyINFO, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials, with updates until 16 January 2025. Randomised clinical trials investigating the efficacy of psychological interventions among adults with substantial levels of health anxiety were included. We employed random-effects network meta-analysis for treatment comparison, and component network meta-analysis to assess the impacts of key therapeutic elements. A total of 35 trials involving 3263 participants (67% female; mean age 37 years, s.d. = 6) were analysed. The results revealed significant effects for several therapies, including cognitive-behavioural therapy (CBT), exposure therapy, acceptance and commitment therapy, metacognitive therapy, and mindfulness-based cognitive therapy, as well as behavioural stress management, compared with a waiting list control. However, cognitive bias modification, imagery therapy and short-term psychodynamic psychotherapy did not show significant effects. Component analysis indicated that exposure and response prevention, cognitive restructuring and mindfulness were linked to improved treatment outcomes. Both CBT and third-wave CBT are reasonable first-line choices for managing health anxiety. Effective CBT packages for health anxiety should integrate key components such as exposure and response prevention, cognitive restructuring and mindfulness.
People with severe mental illness (SMI) are more likely to develop long-term physical health conditions compared with those without SMI, contributing to an inequality in life expectancy. Chronic kidney disease (CKD) is a growing global health concern set to be the fifth leading cause of life-years lost by 2040. Although people with SMI may have a higher risk of CKD, there is limited research exploring the relationship between CKD and SMI. This review aimed to examine the prevalence, incidence and risk of CKD among people with SMI. We searched Medline, Embase, PsycINFO, CINAHL, Scopus and Web of Science for epidemiological research reporting the prevalence of CKD (of any stage according to Kidney Disease Improving Global Outcomes guidelines) among people with SMI. Records were imported into Covidence and screened by two reviewers. Meta-analyses were conducted using random-effects models to examine the prevalence, incidence and risk of CKD among people with SMI. Forty-eight studies were included in the review. The pooled prevalence of CKD was 8% in studies of people with SMI (95% CI 5%, 18%) and was highest in studies focused only on participants with bipolar disorder (95% CI 0.15 (0.06, 0.26)). The pooled incidence rate of CKD was 26.83 cases (95% CI 18.66, 38.58) per 1000 person-years. People with SMI had significantly higher odds of CKD compared with those without SMI (odds ratio 2.33 [95% CI 1.70, 3.21]). People with SMI are at a significantly higher risk of having CKD compared with those without SMI. Although psychiatric medication and high rates of diabetes may play a role, the drivers of this inequality are under-researched.
Receipt of violence (victimisation) is associated with a higher risk of severe mental illness and with worse illness severity; however, associations with routine clinical outcomes are less clear. To investigate associations between victimisation and subsequent clinical outcomes in people presenting with severe mental illness, using a south London health records data resource. Data were extracted for 16 372 patients presenting between January 2007 and October 2022, aged 18+ years and receiving diagnoses of schizophrenia-related disorders, mania or bipolar disorder. Recorded victimisation and subtype (any, physical, domestic or sexual) were ascertained via natural language processing from the first 3 months of the record following presentation. Cox regression models were deployed to investigate subsequent risk of mental health emergency care assessment, crisis intervention, in-patient care, Mental Health Act (MHA) detention and mortality. Poisson regression models investigated the numbers of attended healthcare events and antipsychotic agents received. Covariates included sociodemographic characteristics and clinical status (service receipt, medication, symptom profile). All victimisation exposures were associated with a higher risk of all outcomes, apart from mortality and number of antipsychotics, following adjustment for sociodemographic factors, and with emergency assessment (hazard ratio for any victimisation 1.17, 95% CI 1.09-1.27), in-patient/MHA detention (hazard ratio 1.32, 95% CI 1.06-1.65/1.82, 95% CI 1.31-2.55) and higher numbers of attended events (incidence rate ratio 1.17, 95% CI 1.16-1.19) following full adjustment. Associations were similar for subtypes of victimisation and exposures, and between men and women following sociodemographic adjustment, but the associations were slightly weaker for women following full adjustment. Experiences of violence, to the extent to which patients report their experiences and these are recorded, are risk factors for worse outcomes in severe mental illness, only partly accounted for by clinical status around the time of presentation. More systematic ascertainment and recording of victimisation needs to be considered if interventions are to be appropriately targeted.
Internet-based interventions vary with respect to the level of support provided, and the impact of support levels on outcomes has been unclear. To evaluate the relative effectiveness and acceptability of support levels in internet-based cognitive-behavioural therapy (iCBT) for depression. This network meta-analysis included randomised controlled trials of stand-alone iCBT for adults with elevated levels of depressive symptoms, identified via systematic searches of PubMed, EMBASE, PsycINFO and the Cochrane Library (1 January 2025). The primary outcome was post-intervention effectiveness. The secondary outcome was study drop-out risk. Risk of bias was assessed with Cochrane RoB-2. A frequentist random-effects model was conducted (preregistered at https://osf.io/amw4r). We included 141 trials with 169 comparisons (n = 32 197). iCBT with therapeutic support had the greatest effect in terms of reducing depressive symptoms compared with care-as-usual (g = 0.42; 95% CI: 0.30 to 0.55). Such interventions outperformed offers with minimal coaching (encouragement only; g = 0.19, 95% CI: 0.03-0.35) and technical support (g = 0.27, 95% CI: 0.08-0.45) but had similar effects to those with full coaching (i.e. standardised feedback), automated support, on-demand support or no support. Interventions providing technical support represented the least effective iCBT format and were not statistically superior to care as usual (g = 0.15, 95% CI: -0.02 to 0.33). For acceptability, iCBT with minimal coaching showed the lowest drop-out rate (risk ratio = 1.13, (95% CI: 0.88-1.46), whereas technical support showed the highest (risk ratio = 1.6, 95% CI: 1.21-2.15). With pre-intervention human contact, all support levels were similarly effective; without it, therapeutic support outperformed other types of support (g = 0.32-0.68) and drop-out risks increased. Low-intensity supported iCBT can be as effective as therapist-guided iCBT when initial human contact is present. Evidence regarding the potential harms of no-human support is needed before implementation.
An estimated 5% of cases of first-episode psychosis are due to rare and sometimes reversible causes that can be identified through diagnostic investigations that are currently less common in psychiatry, e.g. lumbar puncture, specialised brain imaging and genetic testing. The current clinical practice of the use of such technologies, however, raises several challenging ethical questions. Drawing on our multidisciplinary perspective spanning psychiatry, neurology, philosophy, neuroscience, sociology and medical ethics from three countries, we identify emerging ethical issues in the diagnosis of rare causes of psychosis. We group challenges thus: (a) diagnostic justice, (b) moral responsibility and (c) unintended consequences of diagnostic work-up. Justice challenges surrounded the role of (a) 'luck', (b) social capital and (c) prior psychiatric diagnoses in determining access to work-up. Moral responsibility challenges surround the extent to which (a) clinicians are expected to know the red flags and work-up for rare or ultra-rare causes; and (b) those running health systems should enable knowledgeable clinicians to provide the requisite work-up. Challenges related to unintended consequences include the risk of pursuing work-up of rare causes to reinforce (a) psychiatric exceptionalism and (b) paternalistic decision-making that doesn't allow space for patient preferences. Finally, we reflect on unresolved issues and future directions.
Attention-deficit hyperactivity disorder (ADHD) is increasingly recognised as a social identity as well as a medical diagnosis. Social identity theory suggests that group identification can benefit self-esteem, well-being and mental health, but little is known about ADHD social identification or preferred terminology in English. We aimed to measure ADHD social identification and preferred terminology in a sample of adults with ADHD in the UK and to understand whether ADHD social identification is related to improved self-esteem, well-being and mental health. Three hundred and nineteen adults with ADHD in the UK participated. They were aged between 18 and 73 years and 59% were female. Participants completed self-report measures of ADHD social identification, self-esteem, well-being, anxiety, depression, terminology preferences, medication use and sources of learning about ADHD. Descriptive statistics were used to identify the percentage of participants who preferred ADHD-first versus person-first terminology. Pre-registered serial mediation models tested hypothesised pathways from ADHD identification to mental health via self-esteem and well-being. Further analyses examined associations between terminology preferences, medication use and sources of learning about ADHD. ADHD identification was not significantly correlated with self-esteem, anxiety or depression. Most participants (77%) preferred person-first terminology ('person with ADHD'). Higher ADHD identification was associated with identity-first language preference and medication use. Social media was the only source of learning about ADHD related to higher ADHD identification. In mediation models, ADHD identification was not associated with self-esteem or well-being; however, a subcomponent of ADHD social identification - satisfaction - was indirectly related to better mental health via self-esteem and well-being. These cross-sectional findings indicated that ADHD identification did not show the hypothesised protective associations with mental health. Preferences for person-first terminology suggest ADHD is not always central to identity. Longitudinal and qualitative studies are needed to clarify causal relationships and clinical implications.
Major depression is a common and disabling disorder, and individuals with subthreshold depression represent a key at-risk group. We previously demonstrated that specific cognitive behavioural therapy (CBT) skills training delivered via a smartphone app (behavioural activation, cognitive restructuring, problem solving, assertion training and behavioural therapy for insomnia) improved depressive symptoms for up to 26 weeks. To evaluate the long-term effects (up to 50 weeks) of CBT skills and their combinations for preventing major depressive episodes and reducing the total burden of depression (TBD). Participants were adults from the general population with subthreshold depression. A master protocol trial with four 2 × 2 factorial trials was used to randomise 3280 participants to one of nine intervention arms or a self-check control group. The primary outcome was time to onset of major depression by week 50. Hazard ratios for the interventions ranged from 0.52 (95% CI: 0.29-0.94) to 0.63 (95% CI: 0.36-1.10), with behavioural activation + assertion training showing the greatest preventive effect (number needed to treat: 23.3 (95% CI: 12.2 to 250)), followed by behavioural therapy for insomnia, behavioural activation + behavioural therapy for insomnia and cognitive restructuring. All interventions reduced TBD scores compared with control, with behavioural activation + cognitive restructuring exhibiting the largest reduction. Effect sizes at week 50 ranged from -0.34 to -0.07 and behavioural activation + cognitive restructuring was the most effective. No serious adverse events were reported. The current findings indicated that specific CBT skills - particularly behavioural activation +assertion training , behavioural activation + cognitive restructuring and behavioural therapy for insomnia - effectively prevented the onset of depression and reduced the TBD at 50 weeks. Given its brevity, portability, accessibility and scalability, smartphone-based CBT is promising as a preventive intervention.
Restrictive interventions are used in the treatment of some people with severe mental disorders such as psychosis - including psychiatric intensive care unit (PICU) admission, seclusion and restraint. Early Intervention in Psychosis (EIP) service input may improve outcomes in psychosis, but it is unclear whether specific components of EIP care reduce the need for restrictive practice. To examine associations between EIP care components, demographic characteristics and restrictive interventions. We conducted a retrospective cohort study of 14 874 people who used EIP services in England, using linked data from the National Clinical Audit of Psychosis and the Mental Health Services Data Set. We examined associations between EIP components and time to PICU admission (primary outcome) alongside seclusion/physical restraint/injected chemical restraint/requests for police assistance (secondary outcomes), using multilevel Cox regression, adjusting for demographic factors and clustering by service. Higher hazards of restrictive interventions were observed among men, younger people and several minority ethnic groups. Individuals eligible for clozapine who were not offered it (hazard ratio 1.51, 95% CI 1.20-1.91) or refused it (hazard ratio 1.46, 95% CI 1.02-2.10) had higher hazards of PICU admission than those not eligible, whereas those who were eligible for clozapine and received it did not. There was weaker evidence of similar effects on hazards of physical restraint and seclusion. Receipt of CBT for psychosis was associated with reduced hazards of PICU admission (hazard ratio 0.80, 95% CI 0.67-0.95) and physical restraint (hazard ratio 0.68, 95% CI 0.47-0.98). Substance use was associated with increased hazards of PICU admission and requests for police assistance, although substance use interventions appeared to partially mitigate this. Marked demographic disparities exist in the use of restrictive practice. Specific EIP care components may be associated with reductions. Strengthening evidence-based EIP provision and addressing structural inequalities may support progress towards less coercive and more equitable care.
This paper investigates the epistemic, affective and ethical power of images in psychiatric care, building on Binswanger's existential morphologies. It argues that images occupy an intermediate space between sensation and concept, offering a path to reflection while preserving contact with lived experience. Unlike abstract conceptual thought, images are fluid, metamorphic forms of sensation that serve as co-produced figures of understanding in the therapeutic encounter, mediating between patient and clinician. Crucially, the paper advocates an 'and-both' framework: concepts are vital for communication between clinicians, but images are indispensable for engaging with the patient's lived world. However, images are vulnerable to degeneration - from imagination to persuasion, and from living symbol to rigid cliché or delusion. The vitality of care rests on keeping these images alive, dialogical and open to transformation. A psychiatry grounded in imaginal thinking evolves beyond mere classification into a poetics of recognition, where healing arises from the shared creation of meaning between two embodied presences.
Hyperbolic tapering is increasingly recommended for the gradual reduction of psychiatric drugs to minimise withdrawal symptoms, yet available formulations rarely accommodate the small dose regimens required. To evaluate whether pharmaceutical manipulation strategies - as proposed in clinical guidelines for hyperbolic tapering - can produce progressively smaller haloperidol doses with adequate accuracy and precision. Strategies included whole and split tablets, liquid dispensed via dropper or dosing syringe, diluted solutions and tablet suspension, applied under controlled laboratory conditions. Haloperidol was used as a model, following an exponential 10% dose reduction schedule from 5 to 0 mg, generating multiple tapering steps that mirrored real-world scenarios. Drug content was quantified by high-performance liquid chromatography and interpreted according to an adapted pharmacopoeial criterion. All strategies yielded mean doses within 90-110% of expected values, demonstrating satisfactory accuracy and reproducibility. Variability was higher with tablet splitting, drop-based measurements and tablet suspension (relative standard deviation of 8.0%), whereas the use of whole tablets, dosing syringe and diluted liquid improved precision (relative standard deviation of 3.3%). These findings demonstrate the technical feasibility of achieving progressively smaller doses through standardised manipulation strategies, providing experimental support for hyperbolic tapering in clinical practice. Although off-label, such approaches currently offer the only practical means for safe dose reduction in the absence of smaller dose formulations, highlighting a regulatory gap between product design and clinical needs. Aligned with clinical guidelines, our findings support manipulation strategies as a practical and reliable component of individualised dose reduction in psychiatric care.
Selective serotonin reuptake inhibitors (SSRIs) are limited by inadequate response in a significant proportion of patients, slow onset, minimal cognitive benefit and side-effects. Preclinical studies suggest selective serotonin 4 receptor (5-HT4R) agonists may produce faster antidepressant effects via distinct mechanisms; however, there has been no experimental research in clinical populations to date. To test whether the novel 5-HT4R partial agonist PF-04995274 produces early behavioural and neural changes in emotional cognition similar to SSRIs in patients with unmedicated major depressive disorder (MDD). In a double-blind, placebo-controlled trial, 90 participants with MDD were randomised to 7 days of PF-04995274 (15 mg), citalopram (20 mg) or placebo. Emotional processing was assessed using a behavioural facial expression recognition task and functional magnetic resonance imaging (fMRI) of implicit emotional face processing (days 6-9). Observer- and self-reported symptoms of depression were also measured at baseline and study end. As anticipated, citalopram reduced relative accuracy and increased relative reaction time to identify negative faces, with corresponding changes in neural activity (reduced left amygdala activation to emotional faces and valence-specific shifts in cortical regions). In contrast, PF-04995274 produced no change in behavioural negative bias or amygdala activity but increased medial-frontal cortex activation across valences. While this was not a clinical trial, both active treatments demonstrated an early treatment response with reduced observer-rated depression severity relative to placebo; PF-04995274 also reduced self-reported depression, state anxiety and negative affect. PF-04995274 did not show the typical antidepressant profile of negative bias reductions observed with citalopram. Instead, it was associated with distinct increased medial-frontal activation during an emotional faces task, coupled with preliminary evidence of early clinical improvement, suggesting a potential alternative pathway for antidepressant effects. Findings support further clinical trials of 5-HT4R agonists and investigation of pro-cognitive and mood effects. NCT03516604.
Many children and young people (CYP) with significant mental health difficulties face barriers to accessing care from mental health services, impacting their clinical outcomes and recovery. Sociodemographic and socioeconomic factors may contribute to inequalities in access and outcomes. To investigate the roles of sociodemographic, socioeconomic and clinical factors in influencing access to services, receipt of clinical care or diagnoses and clinical outcomes. Using data from a large, nationally representative, randomised controlled trial in England (STADIA), 1225 children aged 5-17 years and with emotional difficulties referred to child and adolescent mental health services (CAMHS) were followed up over 18 months post-referral to investigate predictors of referral acceptance, receipt of care and their clinical outcomes. Older CYP (for each 1-year increase in age, odds ratio 1.07, 95% CI: 1.02, 1.11) and those living in the least deprived neighbourhoods (deprivation index, least versus most deprived quintile: odds ratio 1.60, 95% CI: 1.05, 2.43) were more likely to have their referral accepted by CAMHS. Clinical severity (i.e. scoring above cut-off for symptoms and/or impact) was not associated with receipt of a clinical diagnosis or treatment/intervention. At 12-month post-referral, 61% met mental health 'caseness' criteria (v. 67% at baseline). CYP living in less deprived neighbourhoods had better clinical outcomes at 12-month follow-up (least versus most deprived quintile: odds ratio 0.49, 95% CI: 0.30, 0.81, for meeting caseness criteria, i.e. the presence of clinically significant symptoms and impairment). Females were more likely than males to have clinically significant levels of depression at 12-month follow-up (odds ratio 1.77, 95% CI: 1.28, 2.45). There appear to be sociodemographic and socioeconomic inequalities in access to care and outcomes for clinically referred CYP with emotional mental health difficulties, with limited improvements in clinical outcomes 1 year following referral to CAMHS. CYP living in more deprived areas and younger children appear less likely to receive help, hampering earlier intervention efforts even in help-seeking populations.
Explanatory frameworks for mental disorders influence stigmatisation and clinical attitudes. Mechanistic biological explanations often yield negative effects on prognostic optimism and empathy. Evolutionary framings might reduce stigma, but this has rarely been tested empirically. To experimentally test whether a brief educational intervention presenting an evolutionary explanation of anxiety, compared with a genetic explanation, would influence clinicians' attitudes in directions consistent with anti-stigma goals. In this pre-registered, multi-site, cluster-randomised trial, 171 practising mental health clinicians across the UK and Ireland were randomised by session to receive a 30 min educational presentation on either evolutionary or genetic explanations for anxiety. Pre- and post-session questionnaires assessed clinicians' optimism regarding patient recovery, perceived efficacy of psychosocial interventions, expected patient willingness to share diagnosis and seek help and perceived usefulness of the information. Data were analysed using Bayesian cumulative ordinal regression models. In line with pre-registered hypotheses, clinicians rated evolutionary explanations as substantially more useful for patients (odds ratio 5.05, 95% credible interval [2.46, 10.28], latent standard deviation shift 1.07) and for clinicians (odds ratio 3.10, 95% credible interval [1.62, 5.81], latent standard deviation shift 0.76) compared with genetic explanations. Evolutionary explanations also resulted in higher anticipated public willingness to seek psychiatric help (odds ratio 1.79, 95% credible interval [0.93, 3.35]) and share a diagnosis (odds ratio 1.62, 95% credible interval [0.88, 2.97]); optimism about patient recovery (odds ratio 1.58, 95% credible interval [0.71, 3.46]); perceived effectiveness of psychosocial interventions (odds ratio 1.62, 95% credible interval [0.84, 3.10]); and belief in the functional usefulness of negative emotions (β = 0.25 s.d., 95% credible interval [0.01, 0.49]). These effects were driven by both positive pre-post effects of evolutionary education and negative pre-post effects of genetic education compared with pre-education baseline. Exploratory analysis showed further anti-stigma effects. Framing anxiety through an evolutionary lens substantially improved clinicians' attitudes on various measures of stigmatisation compared with genetic explanations, and was rated as highly useful for both clinicians and patients.
People with affective psychotic disorders often face diagnostic delays and presentations are under-recognised at first contact with early intervention services (EIS). Despite their clinical significance, most research and service models for first-episode psychosis (FEP) have focused on non-affective psychoses. We sought to clarify the relative prevalence of affective psychoses in EIS. A systematic review and random-effects meta-analysis of observational studies reporting proportion of affective psychotic disorders among individuals presenting to EIS with FEP was conducted. Eligible studies included treated FEP populations diagnosed using DSM/ICD criteria. Searches were conducted in Web of Science, Medline and PsycINFO (inception to July 2025). The primary outcome was pooled proportion of affective psychotic disorders. Heterogeneity was assessed using Q-statistics and I2-statistics. Meta-regressions examined potential moderators, including urbanicity, national income level and geographical region. Eighty-three studies (N = 30 946; mean age 24.95 years; 34.78% female) were included. Random-effects pooled proportion was 18.0% (95% CI 15.4-20.6; 95% prediction interval 3.6-39.4%; I2 = 95.6%). Schizoaffective disorder represented 7.4% (k = 49; 95% CI 5.8-9.2). Schizophrenia was the most frequent diagnosis, with a pooled proportion of 45.5% (k = 79; 95% CI 40.3-50.7). Meta-regression analyses identified that affective psychoses were less common in Asia and more common in North America compared with Europe. Higher urbanicity was also associated with increased prevalence. Associations with national income level (NIL) were limited by small subgroup sizes. Affective psychotic disorders constitute a meaningful subgroup within EIS. This suggests better screening, targeted treatments and adaptive service models of care.
Media coverage of suicide can influence population suicide rates. While reports of suicide deaths are often associated with increased suicides (Werther effect), stories of survival may be associated with reductions (Papageno effect). On 11 September 2024, news outlets widely reported musician Jon Bon Jovi intervening to stop a woman's suicide attempt in Tennessee. To assess whether this highly publicised intervention was associated with contemporaneous reductions in suicide deaths in Tennessee and 19 comparison states. We conducted quasi-Poisson time-series analyses of monthly suicide deaths from 2014 to 2024, adjusting for macroeconomic indicators and seasonality. To ensure geographic and temporal specificity, we employed a two-stage validation framework including temporal placebo testing (116 iterations) and comparison across 19 states (60 subgroups, by total and gender) using Benjamini-Hochberg false discovery rate (FDR) correction. In Tennessee, a significant reduction in suicide mortality occurred in September 2024 (risk ratio 0.78; percentile: 0.9%). The effect was most robust among Tennessean males (risk ratio 0.74), at the 0.9th percentile of the historical distribution. This was the only subgroup among 60 examined to maintain statistical significance after FDR adjustment (p < 0.001). No significant deviation was observed among Tennessean females or within comparison states after multiple testing corrections. This study provides the first evidence of a Papageno effect following a widely publicised, real-life survival story. The localised impact suggests a local exposure and/or resonance factor, while the male-specific reduction may reflect identification with the male intervener (i.e. Bon Jovi). Survival narratives may represent an underutilised opportunity for suicide prevention and warrant further study and should be integrated into responsible media reporting guidelines.
Burnout arises from prolonged, unresolved work-related stress and adversely affects professional performance and overall well-being. Resident doctors and medical students are particularly vulnerable because of the demands of balancing clinical, academic and related responsibilities. This study aimed to assess self-reported burnout and related stressors among UK resident doctors and medical students, and estimate the economic impact of burnout-related absenteeism among resident doctors. Self-report questionnaires assessing burnout and related stressors were distributed to UK resident doctors and medical students. A total of 2793 responses were received: 1439 (51.5%) from resident doctors and 1354 (48.5%) from medical students. Economic losses from absenteeism were calculated with a human capital approach. Burnout was reported by 70% (n = 1008) of resident doctors and 65.7% (n = 889) of medical students. Notably, 56.8% (n = 573) and 79.3% (n = 705) of resident doctors and medical students affected by burnout, respectively, were unaware of available support services. Relocation stress (85.1% of residents and 62.6% of students), financial stress (53.9% of residents and 57.8% of students) and poor work-life balance (32.1% of residents and 20.7% of students) were commonly reported. The annual economic burden of absenteeism related to burnout among resident doctors was estimated to reach £251.5 million. Burnout among UK resident doctors and medical students may reflect a combination of underlying factors, including financial strain, relocation stress and difficulties with work-life balance. These findings underscore the need for targeted interventions that support well-being and address financial and relocation challenges, which may, in turn, help prevent burnout and improve retention within the medical workforce. Reducing burnout and associated stressors may also help lessen its economic impact, allowing resources to be redirected towards patient care.