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BackgroundThe neurocognitive deficits and other correlates of problem gambling are also observable in individuals with lower cognitive abilities, suggesting that a low IQ may be a determinant of problem gambling. There has been very little research into this possibility. This study aimed to investigate the characteristics associated with problem gambling in a large population-based study in England, with a particular focus on IQ.MethodThe Adult Psychiatric Morbidity Survey (APMS) 2007 comprised detailed interviews with 7403 individuals living in private households in England. Problem gambling was ascertained using a questionnaire based on DSM-IV criteria. Verbal IQ was estimated using the National Adult Reading Test (NART). Confounders included socio-economic and demographic factors, common mental disorders, impulsivity, smoking, and hazardous drug and alcohol use.ResultsMore than two-thirds of the population reported engaging in some form of gambling in the previous year, but problem gambling was rare [prevalence 0.7%, 95% confidence interval (CI) 0.5–1.0]. The odds of problem gambling doubled with each standard deviation drop in estimated verbal IQ [adjusted odds ratio (OR) 2.1, 95% CI 1.3–3.4, p = 0.003], after adjusting for other characteristics associated with problem gambling including age, sex, socio-economic factors, drug and alcohol dependence, smoking, impulsivity and common mental disorders. There was no strong relationship observed between IQ and non-problem gambling.ConclusionsPeople with lower IQs may be at a higher risk of problem gambling. Further work is required to replicate and study the mechanisms behind these findings, and may aid the understanding of problem gambling and inform preventative measures and interventions. [ABSTRACT FROM PUBLISHER]

BackgroundHappiness and higher intelligent quotient (IQ) are independently related to positive health outcomes. However, there are inconsistent reports about the relationship between IQ and happiness. The aim was to examine the association between IQ and happiness and whether it is mediated by social and clinical factors.MethodThe authors analysed data from the 2007 Adult Psychiatric Morbidity Survey in England. The participants were adults aged 16 years or over, living in private households in 2007. Data from 6870 participants were included in the study. Happiness was measured using a validated question on a three-point scale. Verbal IQ was estimated using the National Adult Reading Test and both categorical and continuous IQ was analysed.ResultsHappiness is significantly associated with IQ. Those in the lowest IQ range (70–99) reported the lowest levels of happiness compared with the highest IQ group (120–129). Mediation analysis using the continuous IQ variable found dependency in activities of daily living, income, health and neurotic symptoms were strong mediators of the relationship, as they reduced the association between happiness and IQ by 50%.ConclusionsThose with lower IQ are less happy than those with higher IQ. Interventions that target modifiable variables such as income (e.g. through enhancing education and employment opportunities) and neurotic symptoms (e.g. through better detection of mental health problems) may improve levels of happiness in the lower IQ groups. [ABSTRACT FROM PUBLISHER]

Background. Long-term physical conditions (LTCs) consume the largest share of healthcare budgets. Although common mental disorders (CMDs) and LTCs often co-occur, the potential impact of improved mental health treatment on severe disability and hospital admissions for physical health problems remains unknown. Method. A cross-sectional study of 7403 adults aged 16-95 years living in private households in England was performed. LTCs were ascertained by prompted self-report. CMDs were ascertained by structured clinical interview. Disability was assessed using questions about problems with activities of daily living. Population impact and potential preventive gain were estimated using population-attributable fraction (PAF), and conservative estimates were obtained using 'treated non-cases' as the reference group. Results. Of the respondents, 20.7% reported at least one LTC. The prevalence of CMDs increased with the number of LTCs, but over two-thirds (71.2%) of CMD cases in people with LTCs were untreated. Statistically significant PAFs were found for CMDs and recent hospital admission [13.5%, 95% confidence intervals (Cl) 6.6-20.0] and severe disability (31.3%, 95% Cl 27.1-35.2) after adjusting for LTCs and other confounders. Only the latter remained significant when using the most conservative estimate of PAF (21.8%, 95% Cl 14.0-28.9), and this was reduced only slightly when considering only participants with LTCs (18.5%, 95% Cl 7.9-27.9). Conclusions. Better treatments for CMDs in people with LTCs could achieve almost the same population health gain in terms of reducing severe disability as those targeted at the entire population. Interventions to reduce the prevalence of CMDs among people with LTCs should be part of routine medical care. [ABSTRACT FROM AUTHOR]

BackgroundEvidence for an effect of work stressors on common mental disorders (CMD) has increased over the past decade. However, studies have not considered whether the effects of work stressors on CMD remain after taking co-occurring non-work stressors into account.MethodData were from the 2007 Adult Psychiatric Morbidity Survey, a national population survey of participants ⩾16 years living in private households in England. This paper analyses data from employed working age participants (N=3383: 1804 males; 1579 females). ICD-10 diagnoses for depressive episode, generalized anxiety disorder, obsessive compulsive disorder, agoraphobia, social phobia, panic or mixed anxiety and depression in the past week were derived using a structured diagnostic interview. Questionnaires assessed self-reported work stressors and non-work stressors.ResultsThe effects of work stressors on CMD were not explained by co-existing non-work stressors. We found independent effects of work and non-work stressors on CMD. Job stress, whether conceptualized as job strain or effort–reward imbalance, together with lower levels of social support at work, recent stressful life events, domestic violence, caring responsibilities, lower levels of non-work social support, debt and poor housing quality were all independently associated with CMD. Social support at home and debt did not influence the effect of work stressors on CMD.ConclusionsNon-work stressors do not appear to make people more susceptible to work stressors; both contribute to CMD. Tackling workplace stress is likely to benefit employee psychological health even if the employee's home life is stressful but interventions incorporating non-work stressors may also be effective. [ABSTRACT FROM PUBLISHER]

BackgroundPsychiatric co-morbidity is complex and ubiquitous. Our aim was to describe the extent, nature and patterning of psychiatric co-morbidity within a representative sample of the adult population of England, using latent class analysis.MethodData were used from the 2007 Adult Psychiatric Morbidity Survey, a two-phase national household survey undertaken in 2007 comprising 7325 participants aged 16 years and older living in private households in England. The presence of 15 common mental health and behavioural problems was ascertained using standardized clinical and validated self-report measures, including three anxiety disorders, depressive episode, mixed anxiety depressive disorder, psychosis, antisocial and borderline personality disorders, eating disorders, post-traumatic stress disorder, attention deficit disorder, alcohol and drug dependencies, problem gambling and attempted suicide.ResultsA four-class model provided the most parsimonious and informative explanation of the data. Most participants (81.6%) were assigned to a non-symptomatic or ‘Unaffected’ class. The remainder were classified into three qualitatively different symptomatic classes: ‘Co-thymia’ (12.4%), ‘Highly Co-morbid’ (5.0%) and ‘Addictions’ (1.0%). Classes differed in mean numbers of conditions and impairments in social functioning, and these dimensions were correlated.ConclusionsOur findings confirm that mental disorders typically co-occur and are concentrated in a relatively small number of individuals. Conditions associated with the highest levels of disability, mortality and cost – psychosis, suicidality and personality disorders – are often co-morbid with more common conditions. This needs to be recognized when planning services and when considering aetiology. [ABSTRACT FROM PUBLISHER]

BackgroundThe association between poor mental health and poverty is well known but its mechanism is not fully understood. This study tests the hypothesis that the association between low income and mental disorder is mediated by debt and its attendant financial hardship.MethodThe study is a cross-sectional nationally representative survey of private households in England, Scotland and Wales, which assessed 8580 participants aged 16?74 years living in general households. Psychosis, neurosis, alcohol abuse and drug abuse were identified by the Clinical Interview Schedule???Revised, the Schedule for Assessment in Neuropsychiatry (SCAN), the Alcohol Use Disorder Identification Test (AUDIT) and other measures. Detailed questions were asked about income, debt and financial hardship.ResultsThose with low income were more likely to have mental disorder [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.68?2.59] but this relationship was attenuated after adjustment for debt (OR 1.58, 95% CI 1.25?1.97) and vanished when other sociodemographic variables were also controlled (OR 1.07, 95% CI 0.77?1.48). Of those with mental disorder, 23% were in debt (compared with 8% of those without disorder), and 10% had had a utility disconnected (compared with 3%). The more debts people had, the more likely they were to have some form of mental disorder, even after adjustment for income and other sociodemographic variables. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income (OR 6.0, 95% CI 3.5?10.3).ConclusionsBoth low income and debt are associated with mental illness, but the effect of income appears to be mediated largely by debt. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes.MethodCross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire. RESULTS: Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2. CONCLUSIONS: People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment. [ABSTRACT FROM AUTHOR]

Background. Well-being is an important determinant of health and social outcomes. Measures of positive mental health states are needed for population-based research. The 12-item General Health Questionnaire (GHQ-12) has been widely used in many settings and languages, and includes positively and negatively worded items. Our aim was to test the hypothesis that the GHQ-12 assesses both positive and negative mental health and that these domains are independent of one another.Method. Exploratory (EFA) and confirmatory (CFA) factor analyses were conducted using data from the British Household Panel Survey (BHPS) and the Health Survey for England (HSE). Regression models were used to assess whether associations with individual and household characteristics varied across positive and negative mental health dimensions. We also explored higher-level variance in these measures, between electoral wards.Results. We found a consistent, replicable factor structure in both datasets. EFA results indicated a two-factor solution, and CFA demonstrated that this was superior to a one-factor model. These factors correspond to 'symptoms of mental disorder' and 'positive mental health'. Further analyses demonstrated independence of these factors in associations with age, gender, employment status, poor housing and household composition. Statistically significant ward-level variance was found for symptoms of mental disorder but not positive mental health.Conclusions. The GHQ-12 measures both positive and negative aspects of mental health, and although correlated, these dimensions have some independence. The GHQ-12 could be used to measure positive mental health in population-based research. [ABSTRACT FROM AUTHOR]

Background. The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups.Method. A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin.Results. Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups.Conclusions. An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Structural characteristics of social networks such as primary group size have received less attention than measures of perceived social support. Previous research suggests that associations between social network size and later common mental disorder status may differ according to sex and initial mental state. METHOD: Adults participating in the 2000 British National Household Survey of psychiatric morbidity were randomly selected for follow-up 18 months later. The revised Clinical Interview Schedule (CIS-R) and the Interview Measure of Social Relations (IMSR) were administered at baseline and follow-up. Primary group size was defined as the total number of close relatives and friends. A four-level scale of common mental disorder was modelled with ordinal logistic regression, based on weighted data (n=2413). FINDINGS: After adjusting for confounders, a primary group size of three or less at time 1 predicted worse mental health at time 2. This effect was greatest in men who were initially non-cases at baseline (averaged odds 4.5) and in women who were initially cases at baseline (average odds 2.9). Primary group size at time 2 was significantly predicted by level of common mental disorder at time 1 in women but not in men. Thus, confounding by baseline disorder does not explain risk of developing poor mental health in socially isolated men. CONCLUSION: This study replicates the strong effects of primary group size on future mental health that emerge when men and women are studied separately and when subjects are categorized according to baseline mental health status. [ABSTRACT FROM AUTHOR]

Background. There is little population-based evidence on ethnic variation in the most common mental disorders (CMD), anxiety and depression. We compared the prevalence of CMD among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England using a standardized clinical interview.Method. Cross-sectional survey of 4281 adults aged 16-74 years living in private households in England. CMD were assessed using the Revised Clinical Interview Schedule (CIS-R), a standardized clinical interview.Results. Ethnic differences in the prevalence of CMD were modest, and some variation with age and sex was noted. Compared to White counterparts, the prevalence of CMD was higher to a statistically significant degree among Irish [adjusted rate ratios (RR) 2.09, 95% CI 1.16-2.95, p=0.02] and Pakistani (adjusted RR 2.38, 95% CI 1.25-3.53, p=0.02) men aged 35-54 years, even after adjusting for differences in socio-economic status. Higher rates of CMD were also observed among Indian and Pakistani women aged 55-74 years, compared to White women of similar age. The prevalence of CMD among Bangladeshi women was lower than among White women, although this was restricted to those not interviewed in English. There were no differences in rates between Black Caribbean and White samples.Conclusions. Middle-aged Irish and Pakistani men, and older Indian and Pakistani women, had significantly higher rates of CMD than their White counterparts. The very low prevalence of CMD among Bangladeshi women contrasted with high levels of socio-economic deprivation among this group. Further study is needed to explore reasons for this variation. [ABSTRACT FROM AUTHOR]

Background: About 25% of primary care attenders are 'somatic presenters'; individuals consulting for physically-attributed somatic symptoms in the presence of psychiatric morbidity. We tested the hypothesis that somatic presenters differed from psychological presenters on measures of personality ad childhood experience.Method: Case-control study of 'psychological presenter' and 'somatic presenters'.Results: Psychological presenter reported significantly greater insecurity in intimate relationships, and recalled their fathers as significantly less caring and more over-protective, than somatic presenters. These difference remained after adjusting for differences in the severity and duration of psychiatric symptoms.Conclusions: Personality and childhood experiences may be associated with specific types of adult illness behaviour, independent of associations with the prevalence of psychiatric disorder. [ABSTRACT FROM AUTHOR]

Background: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these., Aims: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare., Method: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts., Results: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities., Conclusions: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Background: Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission., Methods: Data from the 2010-2011 Mental Health Minimum Dataset ( N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density., Results: Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission., Conclusions: We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Children of mothers with serious mental health difficulties are at increased risk of developing mental health difficulties themselves in their own lifetime. Specialist interventions delivered in perinatal mental health services offer an opportunity to support the infant's development and long-term mental health. This review aimed to systematically evaluate the shared elements of successful perinatal mental health interventions that underpin improved outcomes for infants whose mothers experience perinatal mental health difficulties. Nine electronic databases were searched comprehensively for relevant controlled studies of perinatal mental health interventions, and a narrative synthesis undertaken to assess whether statistically significant benefits were noted. Sixteen studies, trialing 19 interventions, were analyzed using a narrative approach and grouped according to reported effectiveness. Eight interventions demonstrated significant improvements in infant outcomes and/or mother-infant relationship outcomes and were used to inform the analysis of the included interventions' components. While the interventions identified were diverse, there were common components which potentially underpin successful interventions for infants whose mothers are experiencing mental health difficulties, including: facilitation of positive Mother×Infant interactions; helping mothers to understand their infant's perspective or inner world; and the use of video feedback.

Background: NHS Psychiatric beds comprise mental illness and intellectual disability beds. Penrose hypothesised that the number of psychiatric in-patients was inversely related to prison population size., Aims: To ascertain whether the Penrose hypothesis held true in England between 1960 and 2018-2019., Method: A time-series analysis explored the association between total prison population and NHS psychiatric beds; this was also tested for the male and female prison populations, using non-psychiatric beds as a comparator. Associations were explored with time lags of up to 20 years. Linear regression was conducted to estimate the size of the effect of bed closures., Results: NHS psychiatric beds decreased 93% and the prison population increased 208%. A strong (r =-0.96) and highly significant negative correlation between these changes was found. Annual reduction in psychiatric bed numbers was associated with an increase in prison population, strongest at a lag of 10 years. The closure of mental illness and intellectual disability beds was associated with increases in female prisoners 10 years later. The only significant explanatory variable for the increase in male prison population was intellectual disability bed reduction., Conclusions: The Penrose hypothesis held true between 1960 and 2018-2019 in England: psychiatric bed closures were associated with increases in prison population up to 10 years later. For every 100 psychiatric beds closed, there were 36 more prisoners 10 years later: 3 more female prisoners and 33 more male prisoners. Our results suggest that the dramatic increase in the female prison population may relate to the closure of NHS beds.

Background: In the UK, acute mental healthcare is provided by in-patient wards and crisis resolution teams. Readmission to acute care following discharge is common. Acute day units (ADUs) are also provided in some areas., Aims: To assess predictors of readmission to acute mental healthcare following discharge in England, including availability of ADUs., Method: We enrolled a national cohort of adults discharged from acute mental healthcare in the English National Health Service (NHS) between 2013 and 2015, determined the risk of readmission to either in-patient or crisis teams, and used multivariable, multilevel logistic models to evaluate predictors of readmission., Results: Of a total of 231 998 eligible individuals discharged from acute mental healthcare, 49 547 (21.4%) were readmitted within 6 months, with a median time to readmission of 34 days (interquartile range 10-88 days). Most variation in readmission (98%) was attributable to individual patient-level rather than provider (trust)-level effects (2.0%). Risk of readmission was not associated with local availability of ADUs (adjusted odds ratio 0.96, 95% CI 0.80-1.15). Statistically significant elevated risks were identified for participants who were female, older, single, from Black or mixed ethnic groups, or from more deprived areas. Clinical predictors included shorter index admission, psychosis and being an in-patient at baseline., Conclusions: Relapse and readmission to acute mental healthcare are common following discharge and occur early. Readmission was not influenced significantly by trust-level variables including availability of ADUs. More support for relapse prevention and symptom management may be required following discharge from acute mental healthcare.

Background: For people in mental health crisis, acute day units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to crisis resolution teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly compared with those receiving CRT care alone., Aims: We aimed to investigate readmission rates, satisfaction and well-being outcomes for people using ADUs and CRTs., Method: We conducted a cohort study comparing readmission to acute mental healthcare during a 6-month period for ADU and CRT participants. Secondary outcomes included satisfaction (Client Satisfaction Questionnaire), well-being (Short Warwick-Edinburgh Mental Well-being Scale) and depression (Center for Epidemiologic Studies Depression Scale)., Results: We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312, 42%) across four National Health Service trusts/health regions. There was no statistically significant overall difference in readmissions: 21% of ADU participants and 23% of CRT participants were readmitted over 6 months (adjusted hazard ratio 0.78, 95% CI 0.54-1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4-3.5, P < 0.001) and well-being scores (1.3, 95% CI 0.4-2.1, P = 0.004), and lower depression scores (-1.7, 95% CI -2.7 to -0.8, P < 0.001), than CRT participants., Conclusions: Patients who accessed ADUs demonstrated better outcomes for satisfaction, well-being and depression, and no significant differences in risk of readmission, compared with those who only used CRTs. Given the positive outcomes for patients, and the fact that ADUs are inconsistently provided in the National Health Service, their value and place in the acute care pathway needs further consideration and research.

Background: People living with serious mental illness (SMI) experience debilitating symptoms that worsen their physical health and quality of life. Regular physical activity (PA) may bring symptomatic improvements and enhance wellbeing. When undertaken in community-based group settings, PA may yield additional benefits such as reduced isolation. Initiating PA can be difficult for people with SMI, so PA engagement is commonly low. Designing acceptable and effective PA programs requires a better understanding of the lived experiences of PA initiation among people with SMI., Methods: This systematic review of qualitative studies used the meta-ethnography approach by Noblit and Hare (1988). Electronic databases were searched from inception to November 2017. Eligible studies used qualitative methodology; involved adults (≥18 years) with schizophrenia, bipolar affective disorder, major depressive disorder, or psychosis; reported community-based group PA; and captured the experience of PA initiation, including key features of social support. Study selection and quality assessment were performed by four reviewers., Results: Sixteen studies were included in the review. We identified a "journey" that depicted a long sequence of phases involved in initiating PA. The journey demonstrated the thought processes, expectations, barriers, and support needs of people with SMI. In particular, social support from a trusted source played an important role in getting people to the activity, both physically and emotionally., Discussion: The journey illustrated that initiation of PA for people with SMI is a long complex transition. This complex process needs to be understood before ongoing participation in PA can be addressed. Registration-The review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) on 22/03/2017 (registration number CRD42017059948).

Background: The steep rise in the rate of psychiatric hospital detentions in England is poorly understood., Aims: To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions., Method: Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions., Results: Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers., Conclusions: Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Background: Mental illness and mental well-being are independent but correlated dimensions of mental health. Both are associated with social functioning (in opposite directions), but it is not known whether they modify the effects of one another. New treatment targets might emerge if improving mental well-being in people with serious mental illness improved functional outcomes independent of clinical status., Aims: To describe associations between mental well-being and functioning in people classified according to mental illness status., Method: Cross-sectional data from 5485 respondents to the Health Survey for England 2014 were analysed. Mental illness status (including whether diagnosed by a professional) was by self-report and grouped into four categories, including 'diagnosis of serious mental illness'. Mental well-being was measured using the Warwick-Edinburgh Mental Well-Being Scale, and functioning by items from the EQ-5D. Mental distress was assessed using General Health Questionnaire (GHQ-12) items. Associations were examined using moderated regression models with group membership as an interaction term., Results: Mental well-being score was associated with (higher) functioning score (P < 0.05). This association varied between mental illness groups, even after adjusting for age, gender, ethnicity, physical health and symptoms of mental distress (F(3) = 14.60, P < 0.001). The gradient of this association was greatest for those with diagnosed serious mental illness., Conclusions: Mental well-being was associated with higher functional status in people with mental illness, independent of the symptoms of mental distress and other confounders. The association was strongest in the diagnosed serious mental illness group, suggesting that mental well-being may be important in recovery from mental illness.

Background: In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare., Method: A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review., Results: Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care., Conclusions: A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Aims and methodTo compare rates of admission for different types of severe mental illness between ethnic groups, and to test the hypothesis that larger and more clustered ethnic groups will have lower admission rates. This was a descriptive study of routinely collected data from the National Health Service in England., Results: There was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates.Clinical implicationsOur findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression.Declaration of interestNone.

Background: Individual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment., Aims: To describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation., Method: Secondary analysis of 2010/11 data from the Mental Health Minimum Dataset., Results: Areas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20-39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant., Conclusions: Age structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas., (© The Royal College of Psychiatrists 2016.)

Background: Communication may be an influential determinant of inequality of access to, engagement with and benefit from psychiatric services., Aims: To review the evidence on interventions designed to improve therapeutic communications between Black and minority ethnic patients and clinicians who provide care in psychiatric services., Method: Systematic review and evidence synthesis (PROSPERO registration: CRD42011001661). Data sources included the published and the 'grey' literature. A survey of experts and a consultation with patients and carers all contributed to the evidence synthesis, interpretation and recommendations., Results: Twenty-one studies were included in our analysis. The trials showed benefits mainly for depressive symptoms, experiences of care, knowledge, stigma, adherence to prescribed medication, insight and alliance. The effect sizes were smaller for better-quality trials (range of d 0.18-0.75) than for moderate- or lower-quality studies (range of d 0.18-4.3). The review found only two studies offering weak economic evidence., Conclusions: Culturally adapted psychotherapies, and ethnographic and motivational assessment leading to psychotherapies were effective and favoured by patients and carers. Further trials are needed from outside of the UK and USA, as are economic evaluations and studies of routine psychiatric care practices., (© The Royal College of Psychiatrists 2015.)

Background: Mental well-being underpins many aspects of health and social functioning, and is economically important., Aims: To describe mental well-being in a general population sample and to determine the extent to which mental well-being and mental illness are independent of one another., Method: Secondary analysis of a survey of 7293 adults in England. Nine survey questions were identified as possible indicators of mental well-being. Common mental disorders (ICD-10) were ascertained using the Revised Clinical Interview Schedule (CIS-R). Principal components analysis was used to describe the factor structure of mental well-being and to generate mental well-being indicators., Results: A two-factor solution found eight out of nine items with strong loadings on well-being. Eight items corresponding to hedonic and eudaemonic well-being accounted for 36.9% and 14.3% of total variance respectively. Separate hedonic and eudaemonic well-being scales were created. Hedonic well-being (full of life; having lots of energy) declined with age, while eudaemonic well-being (getting on well with family and friends; sense of belonging) rose steadily with age. Hedonic well-being was lower and eudaemonic well-being higher in women. Associations of well-being with age, gender, income and self-rated health were little altered by adjustment for symptoms of mental illness., Conclusions: In a large nationally representative population sample, two types of well-being were distinguished and reliably assessed: hedonic and eudaemonic. Associations with mental well-being were relatively independent of symptoms of mental illness. Mental well-being can remain even in the presence of mental suffering.

Background: Mixed anxiety and depressive disorder (MADD) is common yet ill-defined, with little known about outcomes., Aims: To determine MADD outcomes over 1 year., Method: We recruited 250 adults attending seven London general practices with mild-moderate distress. Three groups were defined using a diagnostic interview: MADD, other ICD-10 psychiatric diagnosis, no psychiatric diagnosis. We assessed symptoms of distress (General Health Questionnaire-28), quality of life (12-item Short Form Health Survey), general practitioner (GP) diagnosis and consultation rate at baseline, 3 months and 1 year., Results: Two-thirds of participants with MADD had no significant psychological distress at 3 months (61%) or 1 year (69%). However, compared with those with no diagnosis, individuals had twice the risk of significant distress (incidence rate ratio 2.39, 95% CI 1.29-4.42) at 3 months but not 1 year, and persistently lower quality of life (mental health functioning). There was no significant difference in GP consultation rate/diagnosis., Conclusions: The majority with MADD improved, but individuals had an increased risk of significant distress at 3 months and a lower quality of life. As we cannot currently predict those with a poorer prognosis these patients should be actively monitored in primary care.

Background: Most evidence for associations between childhood adversity and adult mental illness is retrospective., Aims: To evaluate prospective evidence of associations between poor parent-child relationships and common psychiatric disorders in later life., Method: Systematic review of studies published between 1970 and 2008 including: (a) more than 100 participants; (b) measures of relationships in the home during childhood; (c) at least 10 years between assessment of exposures; and (d) measures of anxiety, depression, suicide, suicidal ideation or post-traumatic stress disorder (PTSD). Analysis was by narrative synthesis., Results: Twenty-three papers were identified reporting data from 16 cohorts. Abusive relationships predicted depression, anxiety and PTSD. Maternal emotional unavailability in early life predicted suicide attempts in adolescence. Results of studies investigating less severe relationship problems were suggestive but not conclusive of causal association, due partly to methodological heterogeneity., Conclusions: Given the prevalence and disabling nature of common psychiatric problems, these studies highlight the need to minimise harm associated with dysfunctional parent-child relationships.

Background: There is evidence that the prevalence of common mental disorders varies across Europe., Aims: To compare prevalence of common mental disorders in general practice attendees in six European countries., Method: Unselected attendees to general practices in the UK, Spain, Portugal, Slovenia, Estonia and The Netherlands were assessed for major depression, panic syndrome and other anxiety syndrome. Prevalence of DSM-IV major depression, other anxiety syndrome and panic syndrome was compared between the UK and other countries after taking account of differences in demographic factors and practice consultation rates., Results: Prevalence was estimated in 2,344 men and 4,865 women. The highest prevalence for all disorders occurred in the UK and Spain, and lowest in Slovenia and The Netherlands. Men aged 30-50 and women aged 18-30 had the highest prevalence of major depression; men aged 40-60 had the highest prevalence of anxiety, and men and women aged 40-50 had the highest prevalence of panic syndrome. Demographic factors accounted for the variance between the UK and Spain but otherwise had little impact on the significance of observed country differences., Conclusions: These results add to the evidence for real differences between European countries in prevalence of psychological disorders and show that the burden of care on general practitioners varies markedly between countries.

Background: Depression is prevalent, costly and often undertreated., Aims: To test the hypothesis that people with low socio-economic status are least likely to receive and adhere to evidence-based treatments for depression, after controlling for clinical need., Method: Individuals with an ICD-10 depressive episode in the past 12 months (n=866) were recruited from 7271 attendees in 36 general practices in England and Wales. Depressive episodes were identified using the 12-month Composite International Diagnostic Interview. Treatment receipt and adherence were assessed by structured interview, and rated using evidence-based criteria., Results: We identified 332 individuals (38.3%) who received and adhered to evidence-based treatment. There were few socio-economic differences in treatment allocation. Although those without educational qualifications were least likely to receive psychological treatments (OR = 0.55,95% CI 0.34-0.89, P = 0.02), this association was not statistically significant after adjusting for depression severity., Conclusions: We found no evidence of inverse care in the treatment of moderate and severe depression in primary care in England and Wales.

Background: Low socio-economic status is associated with a higher prevalence of depression, but it is not yet known whether change in socio-economic status leads to a change in rates of depression., Aims: To assess whether longitudinal change in socio-economic factors affects change of depression level., Method: In a prospective cohort study using the annual Belgian Household Panel Survey (1992-1999), depression was assessed using the Global Depression Scale. Socio-economic factors were assessed with regard to material standard of living, education, employment status and social relationships., Results: A lowering in material standard of living between annual waves was associated with increases in depressive symptoms and caseness of major depression. Life circumstances also influenced depression. Ceasing to cohabit with a partner increased depressive symptoms and caseness, and improvement in circumstances reduced them; the negative effects were stronger than the positive ones., Conclusions: The study showed a clear relationship between worsening socio-economic circumstances and depression.

Background: There is concern about the stigma of mental illness, but it is difficult to measure stigma consistently., Aims: To develop a standardised instrument to measure the stigma of mental illness., Method: We used qualitative data from interviews with mental health service users to develop a pilot scale with 42 items. We recruited 193 service users in order to standardise the scale. Of these, 93 were asked to complete the questionnaire twice, 2 weeks apart, of whom 60 (65%) did so. Items with a test-retest reliability kappa coefficient of 0.4 or greater were retained and subjected to common factor analysis., Results: The final 28-item stigma scale has a three-factor structure: the first concerns discrimination, the second disclosure and the third potential positive aspects of mental illness. Stigma scale scores were negatively correlated with global self-esteem., Conclusions: This self-report questionnaire, which can be completed in 5-10 min, may help us understand more about the role of stigma of psychiatric illness in research and clinical settings.

Background: Individuals in lower socio-economic groups have an increased prevalence of common mental disorders., Aims: To investigate the longitudinal association between socio-economic position and common mental disorders in a general population sample in the UK., Method: Participants (n=2406) were assessed at two time points 18 months apart with the Revised Clinical Interview Schedule. The sample was stratified into two cohorts according to mental health status at baseline., Results: None of the socio-economic indicators studied was significantly associated with an episode of common mental disorder at follow-up after adjusting for baseline psychiatric morbidity. The analysis of separate diagnostic categories showed that subjective financial difficulties at baseline were independently associated with depression at follow-up in both cohorts., Conclusions: These findings support the view that apart from objective measures of socio-economic position, more subjective measures might be equally important from an aetiological or clinical perspective.

Background: Some UK studies have reported an urban excess in the prevalence of the most common mental disorders of anxiety and depression., Aims: To investigate rural/non-rural differences in the onset and maintenance of episodes of common mental disorders, after adjusting for the characteristics of respondents and their households., Method: A12-month cohort study of 7659 adults aged 16-74 years living in 4338 private households, nested within 626 electoral wards in England, Wales and Scotland. Common mental disorders were assessed using the General Health Questionnaire (GHQ). Electoral wards were characterised by Office for National Statistics classification and by population density. Data were analysed using multilevel statistical modelling., Results: Rural residents had slightly better mental health than non-rural counterparts. The effects of geographical location on the mental health of participants were neither significantly confounded nor modified by socio-economic status, employment status or household income., Conclusions: There are small but statistically significant differences in rates of common mental disorders between urban and rural residents. Quantifying between-place differences using population density alone risks missing important contextual effects on mental health.

Background: There is little geographical variation in the prevalence of the common mental disorders. However, there is little longitudinal research., Aims: To estimate variance in rates of common mental disorders at individual, household and electoral ward levels prospectively., Method: A 12-month cohort study of 7659 adults aged 16-74 years in 4338 private households, in 626 electoral wards. Data were collected as part of the British Household Panel Survey. Common mental disorders were assessed using the 12-item General Health Questionnaire (GHQ). Ward-level socio-economic deprivation was measured using the Carstairs index., Results: Less than 1% of total variance, in onset and maintenance of common mental disorders and change in GHQ score between waves, occurred at ward level. However, 12% of variance, which is a statistically significant difference, was found at household level (a much smaller geographical unit) and this difference remained after further analyses., Conclusions: Ward level socio-economic deprivation does not influence the onset and maintenance of common mental disorders in Britain but local factors at the household level do. Reasons for this remain unclear.

Background: Stigma defines people in terms of some distinguishing characteristic and devalues them as a consequence., Aims: To describe the relationship of stigma with mental illness, psychiatric diagnosis, treatment and its consequences of stigma for the individual., Method: Narrative interviews were conducted by trained users of the local mental health services; 46 patients were recruited from community and day mental health services in North London., Results: Stigma was a pervasive concern to almost all participants. People with psychosis or drug dependence were most likely to report feelings and experiences of stigma and were most affected by them. Those with depression, anxiety and personality disorders were more affected by patronising attitudes and feelings of stigma even if they had not experienced any overt discrimination. However, experiences were not universally negative., Conclusions: Stigma may influence how a psychiatric diagnosis is accepted, whether treatment will be adhered to and how people with mental illness function in the world. However, perceptions of mental illness and diagnoses can be helpful and non-stigmatising for some patients.

Background: Little is known about the effects of the physical environment on individual health., Aims: The present study tested the hypothesis that the prevalence of depression is associated with independently rated measures of the built environment, after adjusting for individuals' socio-economic status and the internal characteristics of their dwellings., Method: Cross-sectional survey of 1887 individuals aged 16 years and over in two electoral wards in north London. Depression was ascertained using the Center for Epidemiologic Studies Depression scale (CES-D). The built environment was rated independently, using a validated measure., Results: After adjusting for socio-economic status, floor of residence and structural housing problems, statistically significant associations were found between the prevalence of depression and living in housing areas characterised by properties with predominantly deck access (odds ratio=1.28, 95% CI 1.03-1.58; P=0.02) and of recent (post-1969) construction (odds ratio=1.43, 95% CI 1.06-1.91; P=0.02)., Conclusions: The prevalence of depression was associated with independently rated features of the built environment, independent of individuals' socio-economic status and internal characteristics of dwellings.

Background: It is not known why the most common mental disorders (CMD), anxiety and depression, are more prevalent among women. This gradient has not been explained by differences in the number or type of social roles occupied by men and women. Given the dearth of longitudinal studies, these negative findings could reflect reverse causality, if men with CMD relinquish social roles more readily than women., Methods: Cohort study using data from the first seven (annual) waves of the British Household Panel Survey. The prevalence of CMD was assessed using the General Health Questionnaire (GHQ), 12 months after ascertaining occupancy of five social roles. Of 12379 participants aged 16-70, 9947 completed the GHQ on at least two consecutive occasions, resulting in 44139 paired observations. Random effects models adjusted for the correlation of repeated measures and for baseline GHQ score., Results: The odds ratio for the gender difference in the future prevalence of CMD (adjusted for baseline GHQ score) was 192 (95% CI 1.75-2.10). Neither the number or type of social roles occupied, nor socio-economic status explained the gender difference in these conditions (adjusted OR 182, 95% CI 1.66-1.99). While CMD at baseline was associated with a subsequent reduction in social role occupancy, this did not vary between men and women., Conclusions: Gender differences in CMD were not explained by differences in the number or type of social roles occupied by men and women, or by reverse causality. Future studies should consider characteristics of social roles, such as demand, control and reward.

Background: It has been hypothesised that the association between greater income inequality and increased mortality is mediated by poor psychosocial health., Aims: To test the hypothesis that individuals in regions of Britain with the highest income inequality have a higher prevalence of the common mental disorders, after adjusting for individual income., Method: Cross-sectional survey of 8191 adults aged 16-75 in private households in England, Wales and Scotland. The prevalence of common mental disorders was assessed using the General Health Questionnaire., Results: The association between income inequality and prevalence of the common mental disorders varied with individual income level. Among persons with the highest incomes, common mental disorders were more frequent in regions with greater income inequality (as indicated by high Gini coefficient) (adjusted OR 1.31,95% C1 1.05-1.65; P: = 0.02). The opposite was true for those with the lowest incomes., Conclusions: Income inequality was associated with worse mental health among the most affluent individuals.

Background: It is not known why the most common mental disorders, anxiety and depression, are more prevalent among women then men. The aim was to test the hypothesis that this gender difference could be explained by differences between men and women in social role occupancy, after adjusting for age and socio-economic status., Method: A cross-sectional survey of 8979 adults aged 16-74 years living in private households in England, Wales and Scotland was carried out. Prevalence of common mental disorders was assessed using the General Health Questionnaire., Results: The gender difference in the prevalence of the common mental disorders (unlike social role occupancy) did not vary with age to a statistically significant degree (unadjusted odds ratio 1.35, 95% CI 1.23-1.48) (P < 0.0001). Although those of either gender occupying the fewest, and women occupying the most social roles (after adjusting for age) had the highest prevalence of common mental disorders, neither number of social roles, occupancy of traditional 'female' caring and domestic roles, nor socio-economic status explained the gender difference in these conditions (adjusted OR 1.26, 95% CI 1.14-1.41) (P < 0.001)., Conclusions: The gender difference in the prevalence of the common mental disorders is not explained by differences between men and women in the number or type of social roles occupied.

Background: Factor analysis has been employed to identify latent variables that are unifying constructs and that parsimoniously describe correlations among a related group of variables. Confirmatory factor analysis is used to test hypothesized factor structures for a set of variables; it can also, as in this paper be used to model data from two or more groups simultaneously to determine whether they have the same factor structure., Method: Non-psychotic psychiatric morbidity, elicited by the Revised Clinical Interview Schedule (CIS-R), from four culturally diverse populations was compared. Confirmatory factor analysis was employed to compare the factor structures of CIS-R data sets from Santiago, Harare, Rotherhithe and Ealing. These structures were compared with hypothetical one and two factor (depression-anxiety) models., Results: The models fitted well with the different data sets. The depression-anxiety model was marginally superior to the one factor model as judged by various statistical measures of fit. The two factors in depression-anxiety model were, however, highly correlated., Conclusions: The findings suggest that symptoms of emotional distress seem to have the same factor structure across cultures.

In a prospective cohort study of consecutive primary care attenders in south London, the estimated prevalence of non-psychotic psychiatric disorder was 45.6%, using the Revised Clinical Interview Schedule (CIS-R). The estimated 12-month incidence rate was 15.7%. Extremely high stability was found in CIS-R scores over 12 months (r = 0.65) and 68.8% of cases at baseline were also cases 12 months later. A clear difference emerged in the types of risk factor which were associated with the incidence and maintenance of disorder in the study population: while socio-economic variables, especially low household income and not having a partner were associated with a worse outcome among prevalent cases at baseline, such variables were only weakly associated with the incidence of psychiatric disorder after adjusting for potential confounders. The latter, notably family psychiatric history and the severity of psychiatric symptoms at baseline were independently associated with the incidence of psychiatric disorder after adjusting for other risk factors, including measures of previous psychiatric disorder.