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BackgroundAntipsychotics are increasingly used among women of childbearing age and during pregnancy.ObjectiveTo determine whether children exposed to antipsychotics in utero are at increased risk of attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), accounting for maternal diagnoses of bipolar, psychotic and other psychiatric disorders.DesignPopulation-based cohort study, including a sibling analysis.SettingNationwide data on all pregnant women and their live-born singletons in Denmark (1997-2017), Finland (1996-2016), Iceland (2004-2017), Norway (2004-2017), and Sweden (2006-2016).Participants4 324 086 children were eligible for inclusion to the study cohort.InterventionAntipsychotic exposure in utero, assessed by pregnancy trimester, type of antipsychotic, and varying patterns of use.Main outcome measuresNon-mutually exclusive diagnoses of ADHD and ASD. We used Cox proportional hazard models to calculate hazard ratios (HRs) controlling for maternal psychiatric disorders and other potential confounding factors.FindingsAmong 4 324 086 singleton births, 15 466 (0.4%) were exposed to antipsychotics in utero. During a median follow-up of 10 years, we identified 72 257 children with ADHD and 38 674 children with ASD. Unadjusted HRs were raised for both outcomes but shifted substantially towards the null after adjustment; 1.10 (95%CI 1.00 to 1.27) for ADHD and 1.12 (0.97 to 1.29) for ASD. Adjusted HRs remained consistent by trimester of exposure and type of antipsychotic. Comparing in utero exposure with pre-pregnancy use yielded HRs of 0.74 (0.62 to 0.87) for ADHD and 0.88 (0.70 to 1.10) for ASD. Sibling analyses yielded HRs of 1.14 (0.79 to 1.64) for ADHD and 1.34 (0.75 to 2.39) for ASD.DiscussionOur findings suggest little or no increased risk of child ADHD or ASD after in utero exposure to antipsychotics.Clinical implicationsResults regarding child neurodevelopment are reassuring for women who need antipsychotics during pregnancy.

BackgroundAdjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin’s place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.ObjectiveTo produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.MethodsA list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be ‘adopted or adapted’ from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008–2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.FindingsWe confirmed that no published guideline—of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.ConclusionAll 11 recommendations and 7 supporting good practice developed here were formulated de novo.Clinical implicationsThese recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

Background Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission. Methods This pre-post intervention quality improvement study compared changes in the management of psychiatric patients’ admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments’ costs. Fisher’s Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student’s t-test for continuous variables and Fishers’s Exact test for proportions. Results Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p Conclusion Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

IntroductionThere have been reports of increased prevalence in psychiatric conditions in non-veteran survivors of COVID-19. To date, however, no known study has examined the prevalence, risk and protective factors of psychiatric conditions among US military veterans who survived COVID-19.MethodsData were analysed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative, prospective cohort of 3078 US veterans. Prepandemic and 1-year peripandemic risk and protective factors associated with positive screens for peripandemic internalising (major depressive, generalised anxiety and/or posttraumatic stress disorders) and externalising psychiatric disorders (alcohol and/or drug use disorders) and suicidal ideation were examined using bivariate and multivariate logistic regression analyses.ResultsA total of 233 veterans (8.6%) reported having been infected with COVID-19. Relative to veterans who were not infected, veterans who were infected were more likely to screen positive for internalising disorders (20.5% vs 13.9%, p=0.005), externalising disorders (23.2% vs 14.8%, p=0.001) and current suicidal ideation (12.0% vs 7.6%, p=0.015) at peripandemic. Multivariable analyses revealed that greater prepandemic psychiatric symptom severity and COVID-related stressors were the strongest independent predictors of peripandemic internalising disorders, while prepandemic trauma burden was protective. Prepandemic suicidal ideation, greater loneliness and lower household income were the strongest independent predictors of peripandemic suicidal ideation, whereas prepandemic community integration was protective.ConclusionPsychiatric symptoms and suicidal ideation are prevalent in veterans who have survived COVID-19. Veterans with greater prepandemic psychiatric and substance use problems, COVID-related stressors and fewer psychosocial resources may be at increased risk of these outcomes.

Under the auspices of the Polish Psychiatric Association and the National Consultant in Psychiatry, on the basis of analysis of international guidelines, the expert group consisting of psychiatrists and an epidemiologist compiled recommendations for the treatment of adepressive episode and recurrent depressive disorder. The recommendations take into account the information that the patient should receive before starting the treatment, the selection criteria for the treatment method and the choice of the antidepressant, the method of assessing the efficacy of treatment, treatment monitoring, and the duration of treatment. Formulating the recommendations, the experts analyzed the source data for their applicability in Poland. The current recommendations of scientific societies and an analysis of the literature on the treatment of depressive episodes and recurrent depressive disorder broken down by the treatment of acute episodes and maintenance treatment, as well as the recommendations on the method of creating guidelines have been taken into account. Furthermore, the guidelines developed in collaboration with the Supreme Medical Council and the Polish Psychiatric Association, entitled: "Diagnostic work-up and treatment of depression in adults - guidelines for family physicians", and recommendations of theNationalConsultantin Adult Psychiatry have been taken into account. The recommendations were discussed among the experts and accepted by the General Board of the Polish Psychiatric Association. Subsequently, the recommendations were modified in line with the Board's commentsand endorsed by the Association for use in the management of patients with depression in Poland.

BackgroundThe use of health services is likely to vary among veterans with an accepted disability of post-traumatic stress disorder (PTSD), however, the extent of variation is not known. We aimed to determine the extent and type of health services used by veterans with an accepted disability of PTSD.MethodsThe cohort included veterans who served post 1975, were eligible for all Australian Government Department of Veterans’ Affairs funded health services, had PTSD as an accepted disability prior to July 2015 and were alive at the 30 June 2016. Veterans were assigned to groups based on their use of health services using K-means cluster analysis.ResultsThe cohort comprised five clusters involving 2286 veterans. The largest cluster (43%) were a younger, general practitioner (GP) managed cluster who saw their GP quarterly and the psychiatrist twice a year. The second GP cluster (30%) had higher levels of physical comorbidity. The psychiatrist managed cluster (14%) had a mean of 12 psychiatrist visits and one PTSD hospitalisation in the year. The remaining two clusters involved GP and allied healthcare, but no psychologist care. High levels of antidepressant use occurred in all clusters, ranging from 44% up to 69%. The psychiatrist managed cluster had 47% on antipsychotics and 58% on anxiolytics.ConclusionOur study highlights the heterogeneity in health service use. These results identify the significant health utilisation required for up to one-sixth of veterans with PTSD and the significant role of primary care physicians in supporting veterans with PTSD.

Background and objectives Coercion is frequent in psychiatry, with an overall downward trend. Knowledge on the application of seclusion and restraint in open wards remains limited. We aimed to describe the prevalence of coercion in an open inpatient setting and identify risk factors for it. Methods We conducted a retrospective analysis of the use of seclusion and restraint in 2017 in the adult psychiatry division of Geneva University Hospital. To identify risk factors for coercion, we estimated incidence rate ratios using multivariable Poisson regressions. Results Of 865 patients, 142 (16.4%) experienced at least one coercive measure (mostly seclusion). The incidence of coercion was higher in men, single patients, patients with psychotic or bipolar disorders, patients receiving disability benefits, patients with a higher number of previous psychiatric hospitalizations, and patients with higher global scores and higher scores on item 1 (overactive, aggressive or agitated behaviour) on Health of the Nation Outcome Scales (HoNOS) at admission. Age and referrals from the emergency department were not associated with a higher risk of coercion. Conclusion Risk factors for coercion were being male, being single, having psychotic or bipolar disorders, having previous psychiatric hospitalizations, having high HoNOS scores at admission, and being referred from outpatient centres or private physicians. Ratings on the first HoNOS item at admission might be sufficient for a pertinent aggression risk evaluation and thus for the prevention of coercion due to violence. This study is the first to analyse the risks of seclusion in open wards and calls for further research.

The traditional model of psychiatric assessment and diagnosis can be criticised as reductive. We developed an innovative model for psychiatric assessment of adult patients referred to our adult mental health team, the Systemic Assessment Clinic, incorporating the principles and techniques of systemic family therapy and dialogical practice into standard psychiatric assessment. We conducted a service evaluation, comparing prospective use of mental health services for patients assessed either in the Systemic Assessment Clinic or in standard assessment. Patients assessed in the Systemic Assessment Clinic had more favourable outcomes than those in standard assessment: they were significantly less likely to need multiple follow-up treatment appointments with a psychiatrist and to be re-referred to mental health services once discharged, indicating reduced healthcare costs. Satisfaction rates for participants attending the systemic assessment clinic were high. Our service evaluation gives preliminary evidence that the Systemic Assessment Clinic could be a potential new model for psychiatric assessment; further evaluation is warranted in a randomised controlled trial.

Objective:There is a paucity of literature on genetic diagnosis in psychiatric populations, particularly the vulnerable population of patients with concomitant neurodevelopmental disorder (NDD). In this cross-sectional study, we investigated the genetic diagnostic rate in 151 adult psychiatric patients from two centers in Ontario, Canada, including a large subset (73.5%) with concurrent NDD, and performed phenotypic analysis to determine the strongest predictors for the presence of a genetic diagnosis.Method:Patients 16 years of age or older and affected with a psychiatric disorder plus at least one of NDD, neurological disorder, congenital anomaly, dysmorphic features, or family history of NDD were recruited through the genetics clinics between 2012 and 2016. Patients underwent genetic assessment and testing according to clinical standards. Chi-squared test was used for phenotypic comparisons. Multivariate logistic regression analysis was performed to determine which phenotypic features were predictive of genetic diagnosis types.Results:Overall, 45.7% of patients in the total cohort were diagnosed with genetic disorders with the vast majority of diagnoses (89.9%) comprising single gene and chromosomal disorders. There were management and treatment implications for almost two-thirds (63.8%) of diagnosed patients. Presence of a single gene disorder or chromosomal diagnosis was predicted by differing combinations of neurological, NDD, and psychiatric phenotypes.Conclusion:The results of this study highlight the frequency and impact of genetic diagnosis in psychiatric populations, particularly those with concomitant NDD. Genetic assessment should be considered in psychiatric patients, particularly those with multiple brain phenotypes (psychiatric, neurodevelopmental, neurological).

OBJECTIVE: Early-onset schizophrenia (EOS) may have worse outcomes than adult-onset schizophrenia (AOS), but data are scarce. We compared outcomes of EOS vs. AOS.METHODS: Longitudinal, register-based study of patients diagnosed with schizophrenia in Denmark between 1996 and 2012, with follow-up until 12/2014. Co-primary outcomes were psychiatric inpatient days during the initial two years after schizophrenia diagnosis and mean number of annual inpatient days for the remaining follow-up.RESULTS: Altogether, 16,337 patients with schizophrenia were included (EOS = 1223, AOS = 15,114, mean follow-up = 9.5 ± 5.0 years). EOS were hospitalized longer during the first two years than AOS (180.9 ± 171.0 vs 163.4 ± 183.1 days, p < 0.005; IRR = 1.27, 95% CI = 1.19-1.35, p < 0.001), but duration and annual rates thereafter did not differ (EOS = 26.8 ± 57.1 days, AOS = 26.6 ± 56.2 days, p = 0.95; IRR = 1.07, 95% CI = 0.94-1.23, p = 0.30). Fewer EOS patients were never psychiatrically hospitalized (EOS = 17.2%, AOS = 20.1%, p < 0.001), but with no difference in re-admissions in patients diagnosed during hospitalization (EOS = 77.1% vs AOS = 78.1%, p = 0.56). More EOS patients were admitted involuntarily (41% vs. 36%, p < 0.02). AOS patients had more often comorbid substance use disorders during follow-up than EOS (EOS = 21.7%, AOS = 34.2%, p < 0.001). Substance use disorders and out-of-home placement were significantly associated with more inpatient days during both short- and long-term follow-up.CONCLUSION: Although EOS was associated with more inpatient days in the first two years after diagnosis, results do not seem to support a generally poorer long-term outcome of EOS compared to AOS. Longer initial hospitalization may be driven by different treatment patterns in child and adolescent vs. adult psychiatry. These data suggest that patient characteristics other than age of onset significantly affect outcomes.

IntroductionPsilocybin-assisted therapy may be a new treatment for major depressive disorder (MDD), with encouraging data from pilot trials. In this trial (short name: PsiDeR) we aimed to test the feasibility of a parallel-group, randomised, placebo-controlled design. The primary outcomes in this trial are measures of feasibility: recruitment rates, dropout rates and the variance of the primary outcome measure of depression.Methods and analysisWe are recruiting up to 60 participants at a single centre in London, UK who are unresponsive to, or intolerant of, at least two evidence-based treatments for MDD. Participants are randomised to receive a single dosing session of 25 mg psilocybin or a placebo. All participants receive a package of psychological therapy. The primary outcome measure for depression is the Montgomery Asberg Depression Rating Scale collected by blinded, independent raters. The primary endpoint is at 3 weeks, and the total follow-up is 6 weeks. With further informed consent, this study collects neuroimaging and omics data for mechanism and biomarker analyses and offers participants an open label extension consisting of a further, open label dose of 25 mg of psilocybin.Ethics and disseminationAll participants will be required to provide written informed consent. The trial has been authorised by the National Research Ethics Committee (20-LO/0206), Health Research Authority (252750) and Medicine’s and Healthcare Products Regulatory Agency (CTA 14523/0284/001-0001) in the UK. Dissemination of results will occur via a peer-reviewed publication and other relevant media.Trial registration numbersEUDRACT2018-003573-97; NCT04959253.

ObjectivesLittle is known about resident physicians being treated at physician health programmes around the world despite the fact that it is a highly demanding training period. This study aims to describe the profiles of resident physicians accessing a specialised mental health service in Spain over a 20-year period and to compare them to consultant-grade physicians.DesignRetrospective observational study.SettingMedical records of the Galatea Care Programme for Sick Physicians.Participants1846 physicians registered at the Barcelona Medical Council-Association and admitted to the programme from January 1998 to December 2018.Primary and secondary outcome measuresNumber of admissions, sociodemographic and clinical variables, including medical specialty, main diagnosis and need of hospitalisation.ResultsResidents accounted for 18.1% (n=335) of the sample and admissions increased over the years. Most residents (n=311; 94.5%) and consultant-grade physicians (n=1391; 92.8%) were self-referred. The most common specialty among residents was family medicine (n=107; 31.9%), followed by internal medicine (n=18; 5.4%), paediatrics (n=14; 4.2%), psychiatry (n=13; 3.9%) and anaesthesiology (n=13; 3.9%). Residents, regardless of year of training, mainly asked for help because of adjustment (n=131; 39.1%), affective (n=77; 23%), anxiety disorders (n=40; 18.8%) and addictions (n=19; 5.7%). There were no significant differences between groups in the main diagnosis and in the variables related to need of hospitalisation. The percentage of residents accessing the programme was higher than in the reference population registered at the Barcelona Medical Council-Association (18.1% vs 7.6%; z=7.2, pConclusionsResidents are more likely than consultant-grade physicians to seek help when suffering from mental disorders. Local primary prevention actions since the beginning of their training period and having access to a well-known highly reliable programme may partly explain these findings.

IntroductionPost-traumatic stress symptoms (PTSS), pain and disability frequently co-occur following traumatic injuries. Although the coexistence of these symptoms is common, the relation between these symptoms and the impact on longer-term outcome remains poorly understood. This systematic review aims to determine the role of PTSS on the development of chronic pain and/or pain-related disability following musculoskeletal trauma.Methods/analysisThis protocol is developed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocol. The review will include studies that recruited individuals aged ≥16 years sustaining any traumatic event that resulted in one or more musculoskeletal injuries and where a recognised measure for the presence of PTSS symptoms, pain and disability using either validated questionnaires or symptom checklists was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, ZETOC, Web of Science, PubMed and Google Scholar, as well as reference lists from key journals and grey literature, will be searched from inception to 31 November 2021. Two independent reviewers will search, screen studies, extract data and assess risk of bias. The relationship of PTSS, pain and pain-related disability by injury type and severity will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity between studies is high, data analyses will be presented descriptively. The overall quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation guidelines.Ethics and disseminationEthical approval will not be required for this systematic review since only data from existing studies will be used. This review is expected to provide a better understanding of the factors associated with PTSS, pain and pain-related disability following musculoskeletal trauma, and help with the development of targeted therapeutic interventions. Results of this review will be disseminated in peer-reviewed publications and via national and international conferences.PROSPERO registration numberCRD42021285243.

Background70%–84% of individuals with antipsychotic treatment resistance show non-response from the first episode. Emerging cross-sectional evidence comparing cognitive profiles in treatment resistant schizophrenia to treatment-responsive schizophrenia has indicated that verbal memory and language functions may be more impaired in treatment resistance. We sought to confirm this finding by comparing cognitive performance between antipsychotic non-responders (NR) and responders (R) using a brief cognitive battery for schizophrenia, with a primary focus on verbal tasks compared against other measures of cognition.DesignCross-sectional.SettingThis cross-sectional study recruited antipsychotic treatment R and antipsychotic NR across four UK sites. Cognitive performance was assessed using the Brief Assessment of Cognition in Schizophrenia (BACS).ParticipantsOne hundred and six participants aged 18–65 years with a diagnosis of schizophrenia or schizophreniform disorder were recruited according to their treatment response, with 52 NR and 54 R cases.OutcomesComposite and subscale scores of cognitive performance on the BACS. Group (R vs NR) differences in cognitive scores were investigated using univariable and multivariable linear regressions adjusted for age, gender and illness duration.ResultsUnivariable regression models observed no significant differences between R and NR groups on any measure of the BACS, including verbal memory (ß=−1.99, 95% CI −6.63 to 2.66, p=0.398) and verbal fluency (ß=1.23, 95% CI −2.46 to 4.91, p=0.510). This pattern of findings was consistent in multivariable models.ConclusionsThe lack of group difference in cognition in our sample is likely due to a lack of clinical distinction between our groups. Future investigations should aim to use machine learning methods using longitudinal first episode samples to identify responder subtypes within schizophrenia, and how cognitive factors may interact within this.Trail registration numberREC: 15/LO/0038.

IntroductionDevelopment of fully internet-based programs could provide a new avenue to improve access to healthcare for problem gamblers. In this project, we aim to assess the efficacy of a web-based cognitive intervention targeting inhibitory control among problem gamblers, using a randomised controlled design. As impaired inhibitory control is involved in self-regulation difficulties in behavioural addictions, it represents a particularly relevant cognitive process to target for an online psychological intervention.Methods and analysisThis will be a single-blinded, randomised, comparative therapeutic web-based, controlled trial. Up to 200 non-treatment seeking adult problem gamblers with a Problem Gambling Severity Index-recent (PGSI-recent) score ≥5 will be included. The intervention will be a computerised cognitive training program targeting inhibitory skills. The comparator, an active control, will be a computerised neutral sensorial program. Both programs will be carried out under similar conditions: biweekly online training for 6 weeks and optional telephone support will be offered to patients for debriefing. The main objective of the study is to assess the clinical efficacy of the online cognitive training program at 6 weeks, measured with the PGSI-recent. The secondary objectives are to assess the efficacy on the gambling behaviour assessed by the account-based gambling data, on the self-reported gambling practice, and on the inhibition performance at the neuropsychological level at 6, 14 and 52 weeks. We will also assess the acceptability of this program and the preferred level of guidance. Data analysis will be in intention-to-treat.Ethics and disseminationThis randomized controlled trial will be executed in compliance with the Helsinki Declaration, and was approved by the local ethics boards (Comité de Protection des Personnes) in October 2017. The findings will be published in peer-reviewed journals.Trial registration numberNCT03673800.

Introduction Digital mental health tools have become popular alternatives to traditional psychotherapy. One emerging form of digital mental health is message-based care, the use of text messages or asynchronous voice or video messaging to provide psychotherapy. There has been no research into whether this is an effective method of psychotherapy as a stand-alone treatment or in combination with traditional psychotherapy. Methods and analysis This is a sequential, multiple assignment randomised trial to compare message-based care, videoconference-psychotherapy and a combination of the two treatments in 1000 depressed adults. Participants will be recruited through Talkspace, a digital mental health company, and randomised to receive 6 weeks of either message-based care only or videoconference-psychotherapy only. At 6 weeks, participants will be evaluated for their response to treatment. Those with a 50% or more response to treatment will continue with their assigned condition. Those who do not respond will be randomised to either monthly videoconference-psychotherapy or weekly videoconference-psychotherapy plus message-based care. Primary outcomes will be depression and social functioning. We will also explore moderators of treatment outcome. Ethics and dissemination The study received ethics approval from the University of Washington Institutional Review Board. Results of this study will be presented in peer-reviewed journals and at professional conferences. Trial registration number NCT04513080; Pre-results.

IntroductionThe atypical antipsychotic clozapine has shown superior efficacy compared with other antipsychotics and is the gold standard for treating otherwise treatment resistant schizophrenia. However, multiple studies have found that clozapine is underutilised in most parts of the world. A few reviews of literature addressing barriers to clozapine prescribing have been conducted. While there is some variation in the literature included in these reviews, a common feature of the studies included is that they primarily focus on clinical staff’s attitudes and perceived barriers for prescribing. Studies of patient perspectives are only sparsely included. A preliminary literature search revealed though, that additional literature on the subject exists, including literature on patient perspectives. It is therefore difficult to conclude if the formerly synthesised literature is representative of current evidence or if the topic has been adequately investigated to inform clinical practice. A scoping review is warranted in order to map and synthesise primary literature on patients’ and psychiatrists’ perspectives on clozapine treatment, and to identify gaps for future research.Methods and analysisThe electronic databases Cochrane Library, CINAHL, Web of Science, Psychinfo, MEDLINE and EMBASE will be searched for relevant publications, supplied with searches of Google scholar, The Networked Digital Library of Theses and Dissertations and OpenGrey. Citation tracking of selected studies will furthermore be undertaken. Two researchers will independently screen and extract data. Data will be collated to provide a descriptive summary of the literature, along with a qualitative content analysis of key findings. Identified gaps in research will be accompanied by recommendations for future investigations.Ethics and disseminationFindings will be disseminated through a peer-reviewed journal and conference presentations. The scoping review does not require ethics approval.

ObjectivesTo identify aspects of the organisation and delivery of acute inpatient services for people with dementia that are associated with shorter length of hospital stay.Design and settingRetrospective cohort study of patients admitted to 200 general hospitals in England and Wales.Participants10 106 people with dementia who took part in the third round of National Audit of Dementia.Main outcome measureLength of admission to hospital.ResultsThe median length of stay was 12 days (IQR=6–23 days). People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission (estimated effect −0.24, 95% CI: −0.29 to −0.18, pConclusionsThe way that services for inpatients with dementia are delivered can influence how long they spend in hospital. Initiating discharge planning within the first 24 hours of admission may help reduce the amount of time that people with dementia spend in hospital.

BackgroundThe occurrence of depression in patients with schizophrenia (PWS) increases the risk of relapse, frequency and duration of hospitalisation, and decreases social and occupational functioning.ObjectiveThis study aimed to assess prevalence of unrecognised comorbid depression and its determinants in PWS.MethodA cross-sectional study was conducted from 1 to 30 March 2019 at Amanuel mental specialized hospital among 300 PWS. The 9-item Calgary Depression Scale for Schizophrenia was used to assess comorbid depression. Logistic regression was used to determine the association between outcome and explanatory variables. Statistical significance was declared at p value ResultsThe prevalence of unrecognised comorbid depression was found to be 30.3%. Living alone (adjusted OR (AOR)=3.49, 95% CI=0.45 to 8.36), having poor (AOR=4.43, 95% CI=1.45 to 13.58) and moderate (AOR=4.45, 95% CI=1.30 to 15.22) social support, non-adherence to medication (AOR=3.82, 95% CI=1.70 to 8.55), presenting with current negative symptoms such as asocialia (AOR=4.33, 95% CI=1.98 to 9.45) and loss of personal motivation (AOR=3.46, 95% CI=1.53 to 7.84), and having suicidal behaviour (AOR=6.83, 95% CI=3.24 to 14.41) were the significant predictors of comorbid depression in PWS.ConclusionThis study revealed considerably a high prevalence of unrecognised comorbid depression among PWS. Therefore, clinicians consider timely screening and treating of comorbid depression in PWS.

ObjectivePositive psychotherapy (PPT) aims at increasing positive affect, meaning and engagement. We aimed to synthesise the available evidence on PPT efficacy.DesignWe conducted a preregistered systematic literature search and meta-analysis of randomised controlled trials examining the efficacy of PPT for increasing positive (eg, satisfaction with life) or decreasing negative psychological outcomes (eg, depression).Data sourcesMedline, PsycINFO and Web of Science from 2006 (ie, inception of PPT) to February 2020 as well as related systematic reviews and meta-analyses.ResultsWe included 20 randomised controlled trial with a total of 1360 participants. Moderate effect sizes were found for increasing positive outcomes (g=−0.72, 95% CI: −1.31 to −0.14, k=10, numbers needed to treat (NNT)=2.55) and reducing negative outcomes (g=0.48, 95% CI: 0.18 to 0.78, k=8, NNT=3.76) when PPT was compared with waitlist control conditions at post-treatment assessment. When compared with active control conditions, PPT yielded large effect sizes for increasing positive outcomes (g=−0.92, 95% CI: −1.74 to −0.11, k=6, NNT=2.05) and reducing depression (g=0.94, 95% CI: 0.18 to 1.70, k=6, NNT=2.03) at post-treatment assessment. No significant differences in efficacy were found when compared with established treatments such as cognitive–behavioural therapy. Evidence was found to support an association between trial quality and effect sizes. For positive outcomes, higher trial quality was related to larger effect size. Whereas higher trial quality was associated with smaller effect size for depression. Follow-up assessments remained too scarce for most planned analyses.ConclusionsOur findings support the short-term efficacy of PPT. However, results are to be regarded with due caution in the light of low number of trials. More high-quality trials that assess efficacy at follow-ups are needed to draw firmer conclusions on the long-term efficacy of PPT.PROSPERO registration numberCRD42020173567.

IntroductionA considerable literature implicates prenatal stress as a critical determinant of poor psychological functioning in childhood and beyond. However, knowledge about whether the timing of prenatal stress differentially influences the development of child outcomes, including psychopathology, is virtually unknown. The primary aim of our study is to examine how the timing of prenatal stress differentially affects early childhood regulatory functioning as a marker of psychopathology. Our second aim is to examine the mediating effects of maternal physiological and psychological factors during pregnancy. Our third aim is to examine the moderating effects of postnatal factors on child regulatory functioning. Our project is the first longitudinal, prospective, multimethod study addressing these questions.Methods and analysisOur ongoing study recruits pregnant women, oversampled for intimate partner violence (a common event-based stressor allowing examination of timing effects), with data collection starting at pregnancy week 15 and concluding 4 years post partum. We aim to have n=335 mother–child dyads. We conduct a granular assessment of pregnancy stress (measured weekly by maternal report) in order to reveal sensitive periods during fetal life when stress particularly derails later functioning. Pattern-based statistical analyses will be used to identify subgroups of women who differ in the timing of their stress during pregnancy and then test whether these patterns of stress differentially predict early childhood self-regulatory outcomes.Ethics and disseminationDue to the high-risk nature of our sample, care is taken to ensure protection of their well-being, including a safety plan for suicidal ideation and a safety mechanism (exit button in the online weekly survey) to protect participant data privacy. This study was approved by Michigan State University Institutional Review Board. Dissemination will be handled by data sharing through National Institute of Child Health and Human Development Data and Specimen Hub (DASH), as well as through publishing the findings in journals spanning behavioural neuroendocrinology to clinical and developmental psychology.

BackgroundThe effects of COVID-19 on the shift to remote consultations remain to be properly investigated.ObjectiveTo quantify the extent, nature and clinical impact of the use of telepsychiatry during the COVID-19 pandemic and compare it with the data in the same period of the 2 years before the outbreak.MethodsWe used deidentified electronic health records routinely collected from two UK mental health Foundation Trusts (Oxford Health (OHFT) and Southern Health (SHFT)) between January and September in 2018, 2019 and 2020. We considered three outcomes: (1) service activity, (2) in-person versus remote modalities of consultation and (3) clinical outcomes using Health of the Nation Outcome Scales (HoNOS) data. HoNOS data were collected from two cohorts of patients (cohort 1: patients with ≥1 HoNOS assessment each year in 2018, 2019 and 2020; cohort 2: patients with ≥1 HoNOS assessment each year in 2019 and 2020), and analysed in clusters using superclasses (namely, psychotic, non-psychotic and organic), which are used to assess overall healthcare complexity in the National Health Service. All statistical analyses were done in Python.FindingsMental health service activity in 2020 increased in all scheduled community appointments (by 15.4% and 5.6% in OHFT and SHFT, respectively). Remote consultations registered a 3.5-fold to 6-fold increase from February to June 2020 (from 4685 to a peak of 26 245 appointments in OHFT and from 7117 to 24 987 appointments in SHFT), with post-lockdown monthly averages of 23 030 and 22 977 remote appointments/month in OHFT and SHFT, respectively. Video consultations comprised up to one-third of total telepsychiatric services per month from April to September 2020. For patients with dementia, non-attendance rates at in-person appointments were higher than remote appointments (17.2% vs 3.9%). The overall HoNOS cluster value increased only in the organic superclass (clusters 18–21, n=174; pConclusions and clinical implicationsThe rapid shift to remote service delivery has not reached some groups of patients who may require more tailored management with telepsychiatry.

ObjectivesTo evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD).Design and settingA pilot randomised controlled trial conducted in the US Pacific Northwest.ParticipantsVeterans with PTSD due to any cause.InterventionsTwenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13).Primary and secondary outcome measuresFeasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up.ResultsOf 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group.ConclusionsThis pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes.Trial registration numberNCT03997344.

ObjectivesA collaborative service initiative involving community pharmacists and a specialist mental health pharmacist was developed to provide pharmacist reviews for care home residents with intellectual disabilities (IDs). This study aimed to characterise the medicines and lifestyle risk outcomes of the service and determine how these align with national priority issues in ID.DesignDescriptive statistical analysis of routinely collected service delivery data.SettingResidential care homes in the Wirral, England for people with ID.Participants160 residents.InterventionsPharmacist review of residents’ medicines and lifestyle risk factors between November 2019 and May 2020.Primary and secondary outcome measuresNumbers of medicines prescribed, the nature of pharmacists’ interventions/recommendations and general practitioner (GP)/psychiatrist acceptance.ResultsThe 160 residents were prescribed 1207 medicines, 74% were prescribed ≥5 medicines and 507 interventions/recommendations were made, averaging 3.3 per resident. The highest proportion (30.4%) were lifestyle risk related, while changing and stopping medicines accounted for 17.9% and 12.8%, respectively. Of the recommendations discussed with GPs/psychiatrists, 86% were accepted. Medicines with anticholinergic properties were prescribed for 115 (72%) residents, of whom 43 (37%) had a high anticholinergic burden score. Pharmacists recommended anticholinergic discontinuation or dose reduction for 28 (24%) residents. The pharmacists made interventions/recommendations about constipation management for 10% of residents and about respiratory medicines for 17 (81%) of the 21 residents with respiratory diagnoses.ConclusionsThe findings indicate considerable polypharmacy among the residents and a high level of pharmacists’ interventions/recommendations about medicines and lifestyle risk, most of which were accepted by GPs/psychiatrists. This included anticholinergic burden reduction and improving respiratory disease and constipation management, which are national priority issues. Wider adoption of collaborative pharmacist review models could have similar benefits for residential populations with ID and potentially reduce pressure on other health services.

IntroductionWhile there is considerable and growing research in the individual fields of obsessive–compulsive disorder (OCD) and chronic pain, focused research into their potential association remains limited. By exploring this potential association, better theoretical understanding of and better therapeutic approaches to chronic pain management could be developed. The study’s aim is to explore the prevalence and impact of obsessions–compulsions on the experience and rehabilitation of chronic pain among individuals attending different branches of a New Zealand pain service.Methods and analysisThis is a cohort study using well-validated questionnaires and semistructured interviews. Participants will be recruited through community pain services from a private rehabilitation-focused company with branches across New Zealand. Participants will complete an OCD screening measure (Obsessive–Compulsive Inventory-Revised (OCI-R)). These results will be used to compare results from the specialist pain services benchmarking electronic Persistent Pain Outcomes Collaboration measure sets, at both participant intake and completion of each Pain Service Programme. Prevalence rates of OCD caseness from the OCI-R will be estimated with 95% CI. Generalised linear regression models will be used to explore differences in pain baseline and outcome factors between those with high and low obsessive–compulsive symptoms. Semistructured interviews, assessed through interpretative phenomenological analysis (IPA), will be used to provide information on lived experiences of individuals with comorbid chronic pain and OCD. This will be supported through the administration of an Obsessive Beliefs Questionnaire 44.Ethics and disseminationEthical approval has been obtained from the Health and Disability Ethics Committee (HDEC20/CEN/82). Study results will be disseminated at professional conferences and in peer-reviewed journals. A lay summary of findings will be provided to requesting participants or through attendance at a local hui (gathering).Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12621000758808).

IntroductionPregnancy and new parenthood is an exciting time, but also a stressful life event that can predispose to mental health challenges. Perinatal anxiety is one such challenge, and is an important contributor to parental distress and other negative outcomes. Sleep and biological rhythms are often disrupted in the perinatal period. These disruptions have been associated with postpartum depression, and in some cases with perinatal anxiety. However, the literature concerning the association with perinatal anxiety is inconsistent and may be methodologically limited. To our knowledge, there has been no comprehensive review published characterising the relationships between sleep, biological rhythms, and perinatal anxiety and related disorders to date. In this systematic review, we will summarise the current state of the literature concerning these relationships, allowing us to highlight gaps and potentially inform clinical understanding of perinatal anxiety, sleep and biological rhythms.Methods and analysisPrimary research articles will be eligible for inclusion if they assess perinatal anxiety or related disorders using validated criteria (self-report or diagnostic), assess sleep and biological rhythms in the perinatal period, include >4 participants and meet other inclusion/exclusion criteria. We will conduct comprehensive searches of MEDLINE, PsycINFO, Embase and CINAHL, with coverage spanning from database conception to search date (August 1, 2021). Key search concepts include (1) the perinatal period, (2) sleep/biological rhythms and (3) anxiety. Risk of bias will be evaluated using the Cochrane Risk of Bias Tool. Data will be narratively synthesised, with quantitative synthesis included if possible. When relevant, strength of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation criteria, and potential publication bias will be assessed.Ethics and disseminationResearch ethics approval is not required. Study results will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results will be disseminated to relevant stakeholders as conference presentation(s) and submitted for publication in a peer-reviewed journal.PROSPERO registration number200166.

IntroductionWork is integral to the occupations of human beings and accounts for up to a third of time spent in an average adult life. Occupational therapists play a role in vocational rehabilitation of mental health service users (MHSUs) with the aim of optimising their work participation. It is advisable that occupational therapists providing vocational rehabilitation to MHSUs with chronic mental illness in mental healthcare settings are guided by a practice framework developed for that particular context. This scoping review aims to summarise existing evidence on vocational rehabilitation for MHSUs in low-income to upper-middle-income countries. The findings will inform subsequent phases of research undertaken to formulate a vocational rehabilitation practice framework for MHSUs in Namibia.Methods and analysisThe scoping review will employ the five stage methodological framework proposed by Arksey and O’Malley. This will be used in conjunction with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISM-ScR) and Joanna Briggs scoping review guidelines. MESH terms, Boolean operators and truncation strategies will be employed for a comprehensive article search in electronic scholarly databases. These databases will include PsycINFO, EBSCOhost, HINARI, Google scholar, Medline, CINAHL, PubMed, Cochrane Library, Scopus, Science Direct and Wiley Online Library. Mendeley and Rayyan, both open source platforms, will be used for title, abstract and full-text screening, as well as data extraction. Data will be sifted and sorted by key categories and themes using a data charting form.Ethics and disseminationThe scoping review findings will be published in a peer-reviewed journal and presented at local and international conferences. Ethical clearance for this study will not be required as secondary data will be utilised and there are no patients involved.

ObjectivesLittle research has looked at how people who do not use mental health services experience psychosis. Thus, the present study aimed to explore the experiences and views of people with psychosis who have neither sought nor received support from mental health services for at least 5 years.DesignA narrative interview study. Thematic analysis was used to analyse the data.SettingEngland.ParticipantsTwenty-eight participants with self-defined psychotic experiences were asked to provide a free narrative about their experiences.ResultsFive themes were identified: (1) Perceiving psychosis as positive; (2) Making sense of psychotic experiences as a more active psychological process to find explanations and meaning; (3) Finding sources of strength, mainly in relationships and the environment, but outside of services; (4) Negative past experiences of mental health services, leading to disengagement and (5) Positive past experiences with individual clinicians, as an appreciation of individuals despite negative views of services as a whole.ConclusionsPerceiving psychosis as something positive, a process of making sense of psychotic experiences and the ability to find external sources of strength all underpin—in addition to negative experiences with services—a choice to live with psychosis outside of services. Future research may explore to what extent these perceptions, psychological processes and abilities can be facilitated and strengthened, in order to support those people with psychosis who do not seek treatment and possibly also some of those who are in treatment.

ObjectivesThis two-group randomised controlled trial evaluates the feasibility of an Acceptance and Commitment Therapy (ACT)-based internet intervention for diabetes distress in people with diabetes type 1 or type 2. Participants were assigned to a guided self-help intervention (EG) or waitlist control group (CG).SettingRecruitment took place following an open recruitment strategy including different diabetes centres, self-help groups and social media platforms.ParticipantsEligibility criteria comprised being 18 years of age or older, self-reported diagnosis of type 1 or type 2 diabetes, internet access, sufficient German language skills and written informed consent.InterventionACTonDiabetes is an internet-based and mobile-based intervention and comprises an introduction and seven modules (one module per week, processing time about 45–60 min). Intervention contents are based on ACT.Primary and secondary outcome measuresParticipants were assessed before and 8 weeks after randomisation. Primary outcome was feasibility (trial recruitment, acceptability). Potential group differences in diabetes distress and other outcomes at follow-up were analysed using linear regression models with baseline values as predictors. All analyses were based on an intention-to-treat principle, potential negative effects were analysed on per-protocol basis.ResultsFrom October 2017 to April 2018, N=42 people with diabetes consented and were randomised (EG n=21, CG n=21). Forty-three per cent of the EG completed all treatment modules within 8 weeks. Across modules, formative user feedback revealed that contents could be optimised regarding comprehensibility (34%), individualisation (20%) and text amount (21%). Overall, 57% of participants dropped out prior to full treatment completion. There were reductions of diabetes distress in the EG (d=0.65, p=0.042).ConclusionsModifications of the intervention content according to the user feedback will be performed to further improve acceptability. Mechanisms to foster intervention adherence should be considered for lowering the attrition rate. ACTonDiabetes is feasible for the implementation in a confirmatory trial.Trial registration numberWHO International Clinical Trials Registry Platform via the German Clinical Trials Register (DRKS) (DRKS00013193).

ObjectivesThe COVID-19 pandemic has presented unprecedented healthcare challenges. Journalists covering the pandemic at close quarters are working in ways akin to first responders, but nothing to date is known of the psychological distress this is potentially causing them. This study aims to determine whether journalists reporting on the COVID-19 crisis have been affected emotionally, and if so to assess the severity of their distress. It also investigates potential demographic and work-related predictors and whether news organisations had provided counselling to their journalists.ParticipantsA total of 111 journalists working for two international news organisations were approached of which 73 (66%) participated in the study.Primary and secondary outcome measuresSymptoms of anxiety (Generalised Anxiety Disorder Scale-7 (GAD-7)), depression (Patient Health Questionnaire (PHQ-9)), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 (PCL-5)), overall psychological distress (12-item General Health Questionnaire (GHQ-12)), and treatment.ResultsThe percentages of journalists exceeding threshold scores for clinically significant anxiety, depression, PTSD and psychological distress were: GAD-7, 26%; PHQ-9, 20.5%; PCL-5, 9.6%; GHQ-12, 82.2%. Journalists assigned to cover the pandemic (n=54 (74%)) were significantly more anxious (pConclusionsJournalists covering the COVID-19 pandemic are experiencing levels of anxiety and depression similar to those seen in first responders. Psychological therapy provided in a timely manner can significantly alleviate emotional distress.

IntroductionMajor depressive disorder (MDD) affects more than 264 million people worldwide and is associated with an impaired quality of life as well as a higher risk of mortality. Current routine treatments demonstrate limited effectiveness. Light therapy (LT) on its own or in combination with antidepressant treatments could be an effective treatment, but the use of conventional LT devices use is restrictive. Portable LT devices allow patients to continue with their day-to-day activities and therefore encourage better treatment compliance. They have not been evaluated in MDD.Methods and analysisThe study is a single-centre, double-blind, randomised controlled trial assessing the efficacy of LT delivered via a portable device in addition to usual care (medical care and drug treatment) for inpatients and outpatients with unipolar non-seasonal MDD. Over the course of 8 weeks, patients use the device daily for 30 min at medium intensity as soon as possible after waking up and preferably between 07:00 and 09:00. All patients continue their usual care with their referring physician. N=50 patients with MDD are included. The primary outcome measure is depressive symptom severity assessed using the Montgomery-Åsberg Depression Rating Scale between baseline and the eighth week. Secondary outcome measures are sleep quality assessed using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale and anxiety level assessed on the Hamilton Anxiety Rating Scale, between baseline and week 8. Further parameters relating to cognitive function are measured at baseline and after the intervention. An ancillary study aims to evaluate the impact of MDD on the retina and to follow its progression. Main limitations include risk of discontinuation or non-adherence and bias in patient selection.Ethics and disseminationThe study protocol was approved by Ile de France X’s Ethics Committee (protocol number 34–2018). Findings will be published in peer-reviewed journals.Trial registration numberNCT03685942.

IntroductionMost individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.DesignCluster randomised controlled trial.Setting and participants552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.InterventionsClusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.MeasurementsPrimary outcome: heroin abstinence measured by heroin-free urines (weeks 9–12). Secondary outcomes: heroin abstinence 12 weeks after discontinuation of CM (weeks 21–24); attendance; self-reported drug use, physical and mental health.ResultsCM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9–12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21–24 weeks. No differences between groups in self-reported heroin use.ConclusionsA pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.Trial registration numberISRCTN 01591254.

IntroductionThe heterogeneity in people with borderline personality disorder (BPD) and the range of specialised psychotherapies means that people with certain BPD characteristics might benefit more or less from different types of psychotherapy. Identifying moderating characteristics of individuals is a key to refine and tailor standard treatments so they match the specificities of the individual participant. The objective of this is to improve the quality of care and the individual outcomes. We will do so by performing three systematic reviews with meta-analyses of individual participant data (IPD). The aim of these reviews is to investigate potential predictors and moderating patient characteristics on treatment outcomes for patients with BPD.Methods and analysisWe performed comprehensive searches in 22 databases and trial registries up to October 6th 2020. These will be updated with a top-up search up until June 2021. Our primary meta-analytic method will be the one-stage random-effects approach. To identify predictors, we will use the one-stage model that accounts for interaction between covariates and treatment allocation. Heterogeneity in case-mix will be assessed with a membership model based on a multinomial logistic regression where study membership is the outcome. A random-effects meta-analysis is chosen to account for expected levels of heterogeneity.Ethics and disseminationThe statistical analyses will be conducted on anonymised data that have already been approved by the respective ethical committees that originally assessed the included trials. The three IPD reviews will be published in high-impact factor journals and their results will be presented at international conferences and national seminars.PROSPERO registration numberCRD42021210688.

IntroductionThe primary aim of the National Institute of Health Research-funded global health research group, Warwick-India-Canada (WIC), is to reduce the burden of psychotic disorders in India. India has a large pool of undetected and untreated patients with psychosis and a treatment gap exceeding 75%. Evidence-based packages of care have been piloted, but delivery of treatments still remains a challenge. Even when patients access treatment, there is minimal to no continuity of care. The overarching ambition of WIC programme is to improve patient outcomes through (1) developing culturally tailored clinical interventions, (2) early identification and timely treatment of individuals with mental illness and (3) improving access to care by exploiting the potential of digital technologies.Methods and analysisThis multicentre, multicomponent research programme, comprising five work packages and two cross-cutting themes, is being conducted at two sites in India: Schizophrenia Research Foundation, Chennai (South India) and All India Institute of Medical Sciences, New Delhi (North India). WIC will (1) develop and evaluate evidence-informed interventions for early and first-episode psychosis; (2) determine pathways of care for early psychosis; (3) investigate the efficacy and cost-effectiveness of community care models, including digital and mobile technologies; (4) develop strategies to reduce the burden of mental illnesses among youth; (5) assess the economic burden of psychosis on patients and their carers; and (6) determine the feasibility of an early intervention in psychosis programme in India.Ethics and disseminationThis study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (reference: REGO-2018-2208), Coventry, UK and research ethics committees of all participating organisations. Research findings will be disseminated through peer-reviewed scientific publications, presentations at learnt societies and visual media.

ObjectivesTo investigate changes in daily mental health (MH) service use and mortality in response to the introduction and the lifting of the COVID-19 ‘lockdown’ policy in Spring 2020.DesignA regression discontinuity in time (RDiT) analysis of daily service-level activity.Setting and participantsMental healthcare data were extracted from 10 UK providers.Outcome measuresDaily (weekly for one site) deaths from all causes, referrals and discharges, inpatient care (admissions, discharges, caseloads) and community services (face-to-face (f2f)/non-f2f contacts, caseloads): Adult, older adult and child/adolescent mental health; early intervention in psychosis; home treatment teams and liaison/Accident and Emergency (A&E). Data were extracted from 1 Jan 2019 to 31 May 2020 for all sites, supplemented to 31 July 2020 for four sites. Changes around the commencement and lifting of COVID-19 ‘lockdown’ policy (23 March and 10 May, respectively) were estimated using a RDiT design with a difference-in-difference approach generating incidence rate ratios (IRRs), meta-analysed across sites.ResultsPooled estimates for the lockdown transition showed increased daily deaths (IRR 2.31, 95% CI 1.86 to 2.87), reduced referrals (IRR 0.62, 95% CI 0.55 to 0.70) and reduced inpatient admissions (IRR 0.75, 95% CI 0.67 to 0.83) and caseloads (IRR 0.85, 95% CI 0.79 to 0.91) compared with the pre lockdown period. All community services saw shifts from f2f to non-f2f contacts, but varied in caseload changes. Lift of lockdown was associated with reduced deaths (IRR 0.42, 95% CI 0.27 to 0.66), increased referrals (IRR 1.36, 95% CI 1.15 to 1.60) and increased inpatient admissions (IRR 1.21, 95% CI 1.04 to 1.42) and caseloads (IRR 1.06, 95% CI 1.00 to 1.12) compared with the lockdown period. Site-wide activity, inpatient care and community services did not return to pre lockdown levels after lift of lockdown, while number of deaths did. Between-site heterogeneity most often indicated variation in size rather than direction of effect.ConclusionsMH service delivery underwent sizeable changes during the first national lockdown, with as-yet unknown and unevaluated consequences.

ObjectiveTo develop a psychometrically reliable instrument to assess psychological distress during the COVID-19 pandemic across Arab countries.DesignThe new instrument was developed through the review of relevant literature. We adapted multiple items from the following tools: The Fear of COVID-19 Scale, Social Phobia Inventory, Health Anxiety Inventory, Swine Influenza Anxiety Scale and the Arabic Scale of Death Anxiety to design our new assessment tool which is called COVID-19 Psychological Distress Scale (CPDS). For psychometric analyses and validation, we conducted a cross-sectional study that solicited data through a web-based survey using the newly developed CPDS.Setting and participantsThis validation study was conducted in four Arab countries, including Algeria, Kuwait, Saudi Arabia and Yemen. A total of 1337 participants from these countries have voluntarily responded to our survey questionnaire that included the newly developed scale.ResultsThe final version of the CPDS comprised 12 items. Participants from Algeria (n=447), Kuwait (n=437), Saudi Arabia (n=160) and Yemen (n=293) have completed the 12-item CPDS. Exploratory factor analysis (used on the Algerian sample) suggested a two-factor structure of the CPDS. The two-factor structure was then supported by the confirmatory factor analysis with an independent sample. Additionally, Rasch analyses showed that all the items fit well in their embedded construct; only one item showed somewhat substantial differential item functioning across gender and country.ConclusionThe 12-item CPDS was found to be measurement invariant across country and gender. The CPDS, with its promising psychometric properties, might help healthcare professionals to identify people with COVID-19-induced psychological distress.

ObjectivesWork performance has been known to be influenced by both psychological stress (mind) and physical conditions (body). The aim of this study was to investigate the association between work performance and ‘body trusting’, which is a dimension of interoceptive awareness representing mind–body interactions.MethodsA cross-sectional study was conducted among a sample of workers in an industrial manufacturing company in Japan. Participants were assessed with a self-reported questionnaire including evaluations of work performance, body trusting, psychological distress, pain persistence, workplace and home stressors, and workaholism. Participants’ sociodemographic, health and lifestyle characteristics were collected from their annual health check data. The association between work performance and body trusting was examined using multivariable regression analyses in the overall sample and in a subsample of people with pain.ResultsA total of 349 workers participated in the study. A significant association between work performance and body trusting was observed, with higher body trusting representing higher work performance. The association was significant after controlling for psychological distress, workplace and home stress, workaholism and participants’ characteristics (pConclusionsWorkers with higher body trusting showed higher work performance, even after controlling for various influencing factors. Body trusting may be an important target to promote work performance and to prevent loss of performance induced by health problems.

ObjectivesOur objectives were threefold: (1) describe a collaborative, theoretically driven approach to co-designing complex interventions; (2) demonstrate the implementation of this approach to share learning with others; and (3) develop a toolkit to enhance therapeutic engagement on acute mental health wards.Design and participantsWe describe a theory-driven approach to co-designing an intervention by adapting and integrating Experience-based Co-design (EBCD) with the Behaviour Change Wheel (BCW). Our case study was informed by the results of a systematic integrative review and guided by this integrated approach. We undertook 80 hours of non-participant observations, and semistructured interviews with 14 service users (7 of which were filmed), 2 carers and 12 clinicians from the same acute ward. The facilitated intervention co-design process involved two feedback workshops, one joint co-design workshop and seven small co-design team meetings. Data analysis comprised the identification of touchpoints and use of the BCW and behaviour change technique taxonomy to inform intervention development.SettingThis study was conducted over 12 months at an acute mental health organisation in England.ResultsThe co-designed Let’s Talk toolkit addressed four joint service user/clinician priorities for change: (1) improve communication with withdrawn people; (2) nurses to help service users help themselves; (3) nurses to feel confident when engaging with service users; (4) improving team relations and ward culture. Intervention functions included training, education, enablement, coercion and persuasion; 14 behaviour change techniques supported these functions. We detail how we implemented our integrated co-design-behaviour change approach with service users, carers and clinicians to develop a toolkit to improve nurse–patient therapeutic engagement.ConclusionsOur theory-driven approach enhanced both EBCD and the BCW. It introduces a robust theoretical approach to guide intervention development within the co-design process and sets out how to meaningfully involve service users and other stakeholders when designing and implementing complex interventions.

Background Health services have advocated a stratified medicine approach in mental health, but little is known about whether service users would accept this approach. Aims To explore service users’ views of the acceptability of stratified medicine for treatment-resistant schizophrenia compared to the traditional “trial-and-error” approach. Methods A mixed methods observational study that explored questionnaire responses on acceptability and whether these responses were affected by demographic or clinical variables. We also investigated whether treatment responsiveness or experience of invasive tests (brain scans and blood tests) affected participants’ responses. Questionnaire generated qualitative data were analyzed thematically. Participants (N108) were aged 18–65, had a diagnosis of schizophrenia, and were adherent to antipsychotic medication. Results Acceptability of a stratified approach was high, even after participants had experienced invasive tests. Most rated it as safer (62% vs 43%; P < .01 [CI: −1.69 to 2.08]), less risky (77% vs 44%; P < .01 [CI: −1.75 to 1.10]), and less painful (90% vs 73%; P < 0.01 [CI: −0.84 to 0.5]) and this was not affected by treatment responsiveness or test experience. Although not statistically significant, treatment nonresponders were more willing to undergo invasive tests. Qualitatively, all participants raised concerns about the risks, discomfort, and potential side effects associated with the invasive tests. Conclusions Service users were positive about a stratified approach for choosing treatments but were wary of devolving clinical decisions to purely data-driven algorithms. These results reinforce the value of service user perspectives in the development and evaluation of novel treatment approaches.

IntroductionBoth trauma exposure and post-traumatic stress disorder (PTSD) are associated with increased risk of cardiovascular disease (CVD), the leading cause of death in the USA. Endothelial dysfunction, a modifiable, early marker of CVD risk, may represent a physiological mechanism underlying this association. This mechanism-focused cohort study aims to investigate the relationship between PTSD (both in terms of diagnosis and underlying symptom dimensions) and endothelial dysfunction in a diverse, community-based sample of adult men and women.Methods and analysisUsing a cohort design, 160 trauma-exposed participants without a history of CVD are designated to the PTSD group (n=80) or trauma-exposed matched control group (n=80) after a baseline diagnostic interview assessment. Participants in the PTSD group have a current (past month) diagnosis of PTSD, whereas those in the control group have a history of trauma but no current or past psychiatric diagnoses. Endothelial dysfunction is assessed via flow-mediated vasodilation of the brachial artery and circulating levels of endothelial cell-derived microparticles. Two higher order symptom dimensions of PTSD—fear and dysphoria—are measured objectively with a fear conditioning paradigm and attention allocation task, respectively. Autonomic imbalance, inflammation, and oxidative stress are additionally assessed and will be examined as potential pathway variables linking PTSD and its dimensions with endothelial dysfunction. Participants are invited to return for a 2-year follow-up visit to reassess PTSD and its dimensions and endothelial dysfunction in order to investigate longitudinal associations.Ethics and disseminationThis study is conducted in compliance with the Helsinki Declaration and University of California, Los Angeles Institutional Review Board. The results of this study will be disseminated via articles in peer-reviewed journals and presentations at academic conferences and to community partners.Trial registration numberNCT03778307; pre-results.

IntroductionGoal planning is widely recognised as an integral part of mental health service delivery and an important element in supporting recovery. Goal planning identifies priorities for treatment through discussion and negotiation between service users and health practitioners. Goal planning enhances motivation, directs effort, and focuses the development of strategies and treatment options to improve recovery outcomes and promote service users’ ownership of the recovery process. While goal planning is a common practice in mental health settings, evidence regarding its impact on treatment outcomes is lacking. This paper outlines a protocol for a systematic review that aims to explore the types of goals planned, experiences of service users and practitioners, and the effectiveness of goal planning as a mental health intervention.Methods and analysisA systematic search will be conducted during March 2021 by searching Medline, CINAHL, Embase, Scopus and PsycINFO electronic databases to answer the following questions: (1) What types of goals are being developed within mental healthcare?; (2) What is the evidence for the effectiveness of goal planning on health and well-being for mental health service users?; (3) What are the experiences of mental health service users and their treating healthcare practitioners in relation to goal planning?; and (4) What are the barriers and facilitators to effective goal planning in mental health settings? Two independent researchers will screen the articles, selecting literature that meets criteria. All literature, regardless of study design that involves adult participants, with a mental illness and reporting on goal planning will be considered for inclusion. Data will be extracted from all eligible articles regardless of study design and summarised in a table. Appropriate quality assessment and data synthesis methods will be determined based on included study designs.Ethics and disseminationNo ethics approval is required. The results will be disseminated through peer-reviewed publications and conference presentations.PROSPERO registration numberCRD42020220595.

BackgroundInflammatory bowel disease (IBD) has a significant impact on quality of life for many people.ObjectiveTo assess the prevalence of common mental health conditions in IBD and the combined impact of IBD and mental health conditions on healthcare use and time off work.MethodsA UK population-based primary care database (Royal College of General Practitioners Research and Surveillance Centre) was used to identify adults with IBD (n=19 011) (Crohn’s disease (CD) or ulcerative colitis (UC)), and matched controls (n=76 044). Prevalences of anxiety, depressive episodes and depressive disorder recorded in primary care were assessed between 2016 and 2018. Outcomes comprised of rates of primary care visits, emergency secondary care visits, certificates for time off work, antidepressant and anxiolytic prescriptions.FindingsMental health conditions were more common in people with CD than controls: anxiety episodes (3.5% vs 3.0%; p=0.02), depressive episodes (5.7% vs 4.1%; pConclusionDepression and anxiety are more common in people with IBD than matched controls. Healthcare utilisation and prescribing of psychotropic medications are also higher in people with IBD. Mental health conditions in people with IBD are associated with additional healthcare use and time off work.Clinical implicationsEvidence-based mental health support programmes, including psychological treatments, are needed for people with IBD.

IntroductionStructural MRI is the most frequently used method to investigate brain volume alterations in neuropsychiatric disease. Previous meta-analyses have typically focused on a single diagnosis, thereby precluding transdiagnostic comparisons.Methods and analysisWe will include all structural MRI studies of adults that report brain volumes for participants from at least two of the following diagnostic groups: healthy controls, schizophrenia, schizoaffective disorder, delusional disorder, psychotic depression, clinical high risk for psychosis, schizotypal personality disorder, psychosis unspecified, bipolar disorder, autism spectrum disorder, major depressive disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, emotionally unstable personality disorder, 22q11 deletion syndrome, generalised anxiety disorder, social anxiety disorder, panic disorder, mixed anxiety and depression. Network meta-analysis will be used to synthesise eligible studies. The primary analysis will examine standardised mean difference in average volume, a secondary analysis will examine differences in variability of volumes.DiscussionThis network meta-analysis will provide a transdiagnostic integration of structural neuroimaging studies, providing researchers with a valuable summary of a large literature.PROSPERO registration numberCRD42020221143.

ObjectivesTo assess the magnitude of internalised stigma and associated factors among patients with bipolar disorder attending the outpatient department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.DesignInstitution-based cross-sectional study design.SettingAmanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.ParticipantsWe recruited about 418 participants using systematic sampling technique for an interview during the study period.MeasurementData were collected by face-to-face interviews. Internalized Stigma of Mental Illness scale was used to measure internalised stigma. The Rosenberg Self-Esteem Scale and the Oslo-3 Social Support were instruments used to assess the associated factors. Bivariate and multivariate logistic regressions were performed to identify factors associated with the outcome variable. ORs with 95% CI were computed to determine the level of significance.ResultsThe magnitude of internalised stigma was 24.9% (95% CI: 21.2% to 28.9%). In the multivariate analysis, unemployed (adjusted OR (AOR)=2.3, 95% CI: 1.0 to 5.0), unable to read and write (AOR=3.3, 95% CI: 1.05 to 10.7), poor social support (AOR=5.3, 95% CI: 1.9 to 15.0), ≥4 previous hospitalisations due to bipolar disorder (AOR=2.6, 95% CI: 1.1 to 6.1) and low self-esteem (AOR=2.4, 95% CI: 1.1 to 5.1) had a significant association with internalised stigma.ConclusionsOne in four patients with bipolar disorder reported high internalised stigma. Unemployment, low educational status, low self-esteem, poor social support and being hospitalised more than three times before were significantly associated with internalised stigma. Thus, a stigma-reduction programme focusing on self-esteem improvement and psychological health of patients to increase their stigma resistance to counteracting effects of internalised stigma is essential.

ObjectivesMental health problems significantly increased worldwide during the coronavirus (COVID-19) pandemic. At the early stage of the outbreak, the government of Bangladesh imposed lockdown and quarantine approaches to prevent the spread of the virus, which impacted people’s daily life and health. The COVID-19 pandemic has also affected people’s economic status, healthcare facilities and other lifestyle factors in Bangladesh. We aimed to assess the impact of the COVID-19 pandemic on mental health among the Bangladeshi population.MethodsWe conducted an online cross-sectional survey among 672 Bangladeshi people aged between 15 and 65 years all over the country from 15 April to 10 May 2020. After obtaining electronic consent, we conducted a survey assessing people’s sociodemographic profiles and psychometric measures. We used The University of California, Los Angeles (UCLA) Loneliness Scale-8, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-Item Scale and Pittsburgh Sleep Quality Index to assess loneliness, depression, anxiety and sleep disturbance, respectively.ResultsThe prevalence of loneliness, depression, anxiety and sleep disturbance was estimated at 71% (mild: 32%, moderate: 29%, severe: 10%), 38% (mild: 24%, moderate: 11%, severe: 3%), 64% (mild: 30%, moderate: 17%, severe: 17%) and 73% (mild: 50%, moderate: 18%, severe: 5%), respectively. In Bangladesh, the key factors associated with poor mental health during COVID-19 were female sex, unemployment, being a student, obesity and living without a family. The present study also identified statistically significant interrelationships among the measured mental health issues.ConclusionsA large portion of respondents reported mental health problems during the COVID-19 pandemic in Bangladesh. The present study suggests longitudinal assessments of mental health among Bangladeshi people to determine the gravity of this issue during and after the pandemic. Appropriate supportive programmes and interventional approaches would address mental health problems in Bangladesh during the COVID-19 pandemic.

BackgroundEquitable access to research studies needs to be increased for all patients. There is debate about which is the best approach to use to discuss participation in research in real-world clinical settings.ObjectiveWe aimed to determine the feasibility of asking all clinical staff within one hospital Trust (an organisation that provides secondary health services within the English and Welsh National Health Service) to use a newly created form on the Trust’s electronic patient records system, as a means of asking patients to consent to discuss participation in research (the opt-in approach). We also aimed to collect feedback from patients and clinicians about their views of the opt-in approach.MethodsFour pilot sites were selected in the Trust: two memory clinics, an adult mental health team and an acute adult ward. Data were collected in three phases: (1) for 6 months, pilot site staff were asked to complete a consent to discuss participation in research form with patients; (2) staff feedback on the form was collected through an online survey; and (3) patient feedback was collected through focus groups.FindingsOf 1779 patients attending services during the pilot period, 197 (11%) had a form completed by staff and 143 (8%) opted-in to finding out about research. Staff cited limited time, low priority and poor user experience of the electronic patient records system as reasons for low uptake of the form. Patients generally approved of the approach but offered suggestions for improvement.ConclusionsThere were mixed results for adopting an opt-in approach; uptake was very low, limiting its value as an effective strategy for improving access to research.Clinical implicationsAlternative strategies to the opt-in approach, such as transparent opt out approaches, warrant consideration to maximise access to research within routine clinical care.

The awareness and understanding of autoimmune encephalitis are blossoming in neurology, and patients are being diagnosed and successfully treated with immunotherapy. The diverse symptomatology associated with autoimmune encephalitis means that patients may present initially to mental health services, which are, as yet, less well equipped to identify and investigate such phenomena. Older adult mental health services are used to managing complexity, but the range of pathologies presenting with unusual symptoms that may mimic autoimmune encephalitis is wide and there is no clear guidance as to when and how to investigate for possible autoimmune encephalitis. This paper examines the evidence supporting investigation and management strategies for patients with possible autoimmune encephalitis presenting to older adult psychiatrists.

Objective: To determine the frequency and quality of physical examinations within 24 h of admission to an acute adult psychiatry unit, and whether a brief intervention involving feedback to clinicians could lead to improvement. Method: Retrospective review of the electronic medical records followed by four brief feedback sessions and email correspondence, followed by a further review of the medical records 1 month later. Results: The proportion of patients receiving a physical examination increased from 36/71 (50.7%) in the initial audit to 41/64 (64.1%) in the re-audit. The mean score of the quality of physical examinations improved from 7.5 to 9.3 (out of 15). The greatest improvement on re-audit occurred in the documentation of additional cardiac sounds (33.9% increase), additional breath sounds (17.7% increase), breath sounds (17.1% increase), cardiac sounds (14.2% increase) and bowel sounds (12.5% increase). Conclusion: This audit supports the use of brief peer-led feedback to improve the rates and quality of physical examinations.