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Objectives: To address the lack of individual-level socioeconomic information in electronic healthcare records, we linked the 2011 census of England and Wales to patient records from a large mental healthcare provider. This paper describes the linkage process and methods for mitigating bias due to non-matching., Setting: South London and Maudsley NHS Foundation Trust (SLaM), a mental healthcare provider in Southeast London., Design: Clinical records from SLaM were supplied to the Office of National Statistics for linkage to the census through a deterministic matching algorithm. We examined clinical (International Classification of Disease-10 diagnosis, history of hospitalisation, frequency of service contact) and socio-demographic (age, gender, ethnicity, deprivation) information recorded in Clinical Record Interactive Search (CRIS) as predictors of linkage success with the 2011 census. To assess and adjust for potential biases caused by non-matching, we evaluated inverse probability weighting for mortality associations., Participants: Individuals of all ages in contact with SLaM up until December 2019 (N=459 374)., Outcome Measures: Likelihood of mental health records' linkage to census., Results: 220 864 (50.4%) records from CRIS linked to the 2011 census. Young adults (prevalence ratio (PR) 0.80, 95% CI 0.80 to 0.81), individuals living in more deprived areas (PR 0.78, 95% CI 0.78 to 0.79) and minority ethnic groups (eg, Black African, PR 0.67, 0.66 to 0.68) were less likely to match to census. After implementing inverse probability weighting, we observed little change in the strength of association between clinical/demographic characteristics and mortality (eg, presence of any psychiatric disorder: unweighted PR 2.66, 95% CI 2.52 to 2.80; weighted PR 2.70, 95% CI 2.56 to 2.84)., Conclusions: Lower response rates to the 2011 census among people with psychiatric disorders may have contributed to lower match rates, a potential concern as the census informs service planning and allocation of resources. Due to its size and unique characteristics, the linked data set will enable novel investigations into the relationship between socioeconomic factors and psychiatric disorders., Competing Interests: Competing interests: MH is principal investigator of the RADAR-CNS, a precompetitive public–private collaboration on mobile health funded by the Innovative Medicine Initiative with cash and in-kind contributions paid to the university from Janssen, Lundbeck, UCB, MSD and Biogen. RS declares research support in the last 3 years from Janssen, GSK and Takeda., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To describe the process and outcomes of a data linkage between electronic secondary mental healthcare records from the South London and Maudsley (SLaM) NHS Foundation Trust with benefits records from the Department for Work and Pensions (DWP). We also describe the mental health and benefit profile of patients who were successfully linked., Design: A deterministic linkage of routine records from health and welfare government service providers within a secure environment., Setting and Participants: Adults aged≥18 years who were referred to or accessed treatment at SLaM services between January 2007 and June 2019, including those who were treated as part of Improving Access to Psychological Therapies (IAPT) services between January 2008 and June 2019 (n=448 404). Benefits data from the DWP from January 2005 to June 2020., Outcome Measures: The linkage rate and associated sociodemographic, diagnostic and treatment factors. Recorded primary psychiatric diagnosis based on International Classification of Diseases (ICD)-10 codes and type of benefit receipt., Results: A linkage rate of 92.3% was achieved. Women, younger patients and those from ethnic minority groups were less likely to be successfully linked. Patients who had subsequently died, had a recorded primary psychiatric diagnosis, had also engaged with IAPT and had a higher number of historical postcodes available were more likely to be linked. Overall, 83% of patients received benefits at some point between 2005 and 2020. Benefit receipt across the psychiatric diagnosis spectrum was high, over 80% across most ICD-10 codes., Conclusions: This data linkage is the first of its kind in the UK demonstrating the use of routinely collected mental health and benefits data. Benefit receipt was high among patients accessing SLaM services and varied by psychiatric diagnosis. Future areas of research are discussed, including exploring the effectiveness of interventions for helping people into work and the impact of benefit reforms., Competing Interests: Competing interests: MH is principal investigator of RADAR-CNS consortium—a public private partnership in collaboration with five pharmaceutical companies—Janssen, Biogen, UCB, MSD and Lundbeck, outside of the submitted work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Purpose: To compare sex-specific rates of hospital admission and repeat admission following self-harm between ethnic groups in London and test whether differences persist after adjustment for socio-economic deprivation., Methods: A population-based cohort of all individuals aged over 11 admitted to a general hospital for physical health treatment following self-harm between 2008 and 2018, using administrative Hospital Episode Statistics for all people living in Greater London., Results: There were 59,510 individuals admitted to the hospital following self-harm in the 10 year study period, ethnicity data were available for 94% of individuals. The highest rates of self-harm admission and readmission were found in the White Irish group. Rates of admission and readmission were lower in Black and Asian people compared to White people for both sexes at all ages and in all more specific Black and Asian ethnic groups compared to White British. These differences increased with adjustment for socio-economic deprivation. People of Mixed ethnicity had higher rates of readmission. Rates were highest in the 25-49 age group for Black and Mixed ethnicity men, but in under-25 s for all other groups. There were substantial differences in rates within the broader ethnic categories, especially for the Black and White groups., Conclusion: In contrast to earlier UK studies, self-harm rates were not higher in Black or South Asian women, with lower self-harm admission rates seen in almost all ethnic minority groups. Differences in rates by ethnicity were not explained by socio-economic deprivation. Aggregating ethnicity into broad categories masks important differences in self-harm rates between groups., (© 2021. The Author(s).)

Background: Across international contexts, people with serious mental illnesses (SMI) experience marked reductions in life expectancy at birth. The intersection of ethnicity and social deprivation on life expectancy in SMI is unclear. The aim of this study was to assess the impact of ethnicity and area-level deprivation on life expectancy at birth in SMI, defined as schizophrenia-spectrum disorders, bipolar disorders and depression, using data from London, UK., Methods: Abridged life tables to calculate life expectancy at birth, in a cohort with clinician-ascribed ICD-10 schizophrenia-spectrum disorders, bipolar disorders or depression, managed in secondary mental healthcare. Life expectancy in the study population with SMI was compared with life expectancy in the general population and with those residing in the most deprived areas in England., Results: Irrespective of ethnicity, people with SMI experienced marked reductions in life expectancy at birth compared with the general population; from 14.5 years loss in men with schizophrenia-spectrum and bipolar disorders, to 13.2 years in women. Similar reductions were noted for people with depression. Across all diagnoses, life expectancy at birth in people with SMI was lower than the general population residing in the most deprived areas in England., Conclusions: Irrespective of ethnicity, reductions in life expectancy at birth among people with SMI are worse than the general population residing in the most deprived areas in England. This trend in people with SMI is similar to groups who experience extreme social exclusion and marginalisation. Evidence-based interventions to tackle this mortality gap need to take this into account.

Objectives: The fit note replaced the sick note in the UK in 2010, with the aim of improving support for patients requiring sickness absence, yet there has been very little research into fit note use. This study aims to describe number of fit notes by condition, to improve our understanding of patterns of fit note use in primary care. Previous fit note research has relied on extracting diagnoses directly from fit notes, rather than extracting information from clinical records. In this paper, we extract information from clinical records to explore demographic factors and conditions associated with number of fit notes issued., Design: This is a longitudinal study of clinical data. We analysed individual-level anonymised data from general practitioner consultations, including demographic information and condition recorded at first fit note. The latter encompassed diagnoses, individual symptoms and psychosocial issues., Setting: A database called Lambeth DataNet, containing electronic clinical records on 326 415 adults (ages 16-60) from all 45 general practices within the London Borough of Lambeth from 1 January 2014 to 30 April 2017., Participants: Our analytical sample contained 40 698 people with a condition recorded at first fit note., Primary Outcome Measure: Predicted number of fit notes in the period January 2014-April 2017 RESULTS: Of all studied diagnostic groups, mental illness had the highest predicted number of fit notes (n=3.3; 95% CI: 3.1 to 3.4) after controlling for demographic factors and long-term conditions. The highest predicted number of fit notes for any condition subgroup was among patients presenting for drug and/or alcohol misuse (n=4.5; 95% CI: 4.1 to 4.8)., Conclusions: For the first time, we show drug and/or alcohol misuse at first fit note are associated with the highest number of fit notes. Research is needed to understand the trajectories of individuals at highest risk of long-term sickness absence, in particular, people presenting with drug and/or alcohol misuse., Competing Interests: Competing interests: Professor MH receives funding from Janssen as part of the RADAR-CNS consortium, which includes a project on depression. He is a principal investigator of RADAR-CNS, a precompetitive public private partnership cofunded by Innovative Medicines Initiative (European Commission) and European Federation of Pharmaceutical Industries and Associations (EFPIA). He has also been an independent expert witness in group litigations instructed by claimants against pharmaceutical companies for alleged harmful effects of their products. Authors have no other conflict of interest to declare., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Increased circulating pro-inflammatory markers have repeatedly been associated with major depressive disorder (MDD). However, it remains unclear whether inflammation represents a causal mechanism for MDD, or whether the association is influenced by confounding factors such as body mass index (BMI)., Methods: To better understand this complex relationship, we generated polygenic risk scores (PRS) for MDD and BMI in a population cohort and attempted to isolate the impact these potential risk factors have on adulthood inflammation. Peripheral blood samples were collected as part of the South East London Community Health study, where we generated individualized PRS for MDD and BMI and quantified inflammatory markers using multiplex ELISA-based technology. We performed linear regressions to investigate the effects of PRS for MDD and BMI on inflammatory marker levels., Results: Out of 35 inflammatory markers, we found a nominal effect of PRS for MDD on interleukin-10. We also found a significant positive effect of BMI on nine inflammatory markers, of which the two most strongly affected markers, interleukin-6 (IL-6) and C-reactive protein (CRP), were also nominally predicted by BMI PRS., Limitations: The study utilized a cross-sectional design with a moderately sized sample., Conclusions: Our findings suggest there may not be a shared genetic mechanism contributing to MDD and higher inflammatory marker levels. However, there may be shared genetic etiology between BMI and adulthood levels of CRP and IL-6. Therefore, polygenic risk scores for BMI may represent a useful indicator for heightened levels of inflammation in adulthood., (Copyright © 2020. Published by Elsevier B.V.)

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

London has unexpectedly low overall rates of self-harm in public health data and contains highly deprived areas with these paradoxically low rates. Qualitative data were collected via interviews and focus groups with 26 individuals living and working in one such area. Using the Stress Process Model, we explore why this ethnically diverse community, which is exposed to multiple, chronic stressors, might nonetheless appear to have low rates of self-harm. Participants described significant impacts of stressors on the mental health of people locally. These were partly buffered by social resources related to community solidarity and a culture of self-reliance. However, identifying oneself as mentally ill through being known to have self-harmed was seen as highly risky, diminishing a person's social status and exposing them to additional stressors from the community and services. Consequently, people tended to hide distress, respond with behaviors less linked to mental illness, and avoid mental health services.

Objectives: Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, 'maybe fit' use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the 'maybe fit' option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt., Methods: Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis., Results: In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. 'Maybe fit' recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use., Conclusions: For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support., Competing Interests: Competing interests: Professor MH receives funding from Janssen as part of the RADAR-CNS consortium which includes a project on depression. He is a principal investigator of RADAR-CNS, a pre-competitive public–private partnership co-funded by Innovative Medicines Initiative (European Commission) and European Federation of Pharmaceutical Industries and Associations. He has also been an independent expert witness in group litigations instructed by claimants against pharmaceutical companies for alleged harmful effects of their products. The authors have no other conflict of interest to declare., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To compare the proportions of emergency department (ED) attendances following self-harm that result in admission between hospitals, examine whether differences are explained by severity of harm and examine the impact on spatial variation in self-harm rates of using ED attendance data versus admissions data., Setting: A dataset of ED attendances and admissions with self-harm to four hospitals in South East London, 2009-2016 was created using linked electronic patient record data and administrative Hospital Episode Statistics., Design: Proportions admitted following ED attendance and length of stay were compared. Variation and spatial patterning of age and sex standardised, spatially smoothed, self-harm rates by small area using attendance and admission data were compared and the association with distance travelled to hospital tested., Results: There were 20 750 ED attendances with self-harm, 7614 (37%) resulted in admission. Proportion admitted varied substantially between hospitals with a risk ratio of 2.45 (95% CI 2.30 to 2.61) comparing most and least likely to admit. This was not altered by adjustment for patient demographics, deprivation and type of self-harm. Hospitals which admitted more had a higher proportion of admissions lasting less than 24 hours (54% of all admissions at highest admitting hospital vs 35% at lowest). A previously demonstrated pattern of lower rates of self-harm admission closer to the city centre was reduced when ED attendance rates were used to represent self-harm. This was not altered when distance travelled to hospital was adjusted for., Conclusions: Hospitals vary substantially in likelihood of admission after ED presentation with self-harm and this is likely due to the differences in hospital practices rather than in the patient population or severity of self-harm seen. Public health policy that directs resources based on self-harm admissions data could exacerbate existing health inequalities in inner-city areas where these data may underestimate rates relative to other areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Aims: We have previously reported an association between childhood abuse and psychotic experiences (PEs) in survey data from South East London. Childhood abuse is related to subsequent adulthood adversity, which could form one pathway to PEs. We aimed to investigate evidence of mediation of the association between childhood abuse and PEs by adverse life events., Methods: Data were analysed from the South East London Community Health Study (SELCoH, n = 1698). Estimates of the total effects on PEs of any physical or sexual abuse while growing up were partitioned into direct (i.e. unmediated) and indirect (total and specific) effects, mediated via violent and non-violent life events., Results: There was strong statistical evidence for direct (OR 1.58, 95% CI: 1.19-2.1) and indirect (OR 1.51, 95% CI: 1.32-1.72) effects of childhood abuse on PEs after adjustment for potential confounders, indicating partial mediation of this effect via violent and non-violent life events. An estimated 47% of the total effect of abuse on PEs was mediated via adulthood adverse life events, of which violent life events made up 33% and non-violent life events the remaining 14%., Conclusions: The association between childhood abuse and PEs is partly mediated through the experience of adverse life events in adulthood. There is some evidence that a larger proportion of this effect was mediated through violent life events than non-violent life events.

AimsAlthough violence is a vital public health problem, no prospective studies have tested for subsequent vulnerability to violence, as a victim or witness, in members of the general population with a range of psychiatric symptoms, or evaluated the importance of higher symptom burden on this vulnerability., Methods: We used successive waves of a household survey of Southeast London, taken 2 years apart, to test if association exists between psychiatric symptoms (symptoms of psychosis, common mental disorders, post-traumatic stress disorder and personality disorder) and later victimisation, in the form of either witnessing violence or being physically victimised, in weighted logistic regression models. Statistical adjustment was made for prior violence exposure, sociodemographic confounders, substance/alcohol use and violence perpetration. Sensitivity analyses were stratified by violence perpetration, sex and history of mental health service use., Results: After adjustments, psychiatric symptoms were prospectively associated with reporting any subsequent victimisation (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.25-2.83), a two times greater odds of reporting witnessed violence (OR 2.24, 95% CI 1.33-3.76) and reporting physical victimisation (OR 1.76, 95% CI 1.01-3.06). One more symptom endorsed was accompanied by 47% greater odds of subsequent victimisation (OR 1.47, 95% CI 1.16-1.86). In stratified analyses, statistical associations remained evident in non-perpetrators, and among those without a history of using mental health services, and were similar in magnitude in both men and women., Conclusions: Psychiatric symptoms increase liability to victimisation compared with those without psychiatric symptoms, independently of a prior history of violence exposure and irrespective of whether they themselves are perpetrators of violence. Clinicians should be mindful of the impact of psychiatric symptoms on vulnerability to victimisation, including among those with common psychiatric symptoms and among those who are not considered at risk of perpetrating violence.

Objectives: Creation of linked mental health, social and education records for research to support evidence-based practice for regional mental health services., Setting: The Clinical Record Interactive Search (CRIS) system was used to extract personal identifiers who accessed psychiatric services between September 2007 and August 2013., Participants: A clinical cohort of 35 509 children and young people (aged 4-17 years)., Design: Multiple government and ethical committees approved the link of clinical mental health service data to Department for Education (DfE) data on education and social care services. Under robust governance protocols, fuzzy and deterministic approaches were used by the DfE to match personal identifiers (names, date of birth and postcode) from National Pupil Database (NPD) and CRIS data sources., Outcome Measures: Risk factors for non-matching to NPD were identified, and the potential impact of non-match biases on International Statistical Classification of Diseases, 10th Revision (ICD-10) classifications of mental disorder, and persistent school absence (<80% attendance) were examined. Probability weighting and adjustment methods were explored as methods to mitigate the impact of non-match biases., Results: Governance challenges included developing a research protocol for data linkage, which met the legislative requirements for both National Health Service and DfE. From CRIS, 29 278 (82.5%) were matched to NPD school attendance records. Presenting to services in late adolescence (adjusted OR (aOR) 0.67, 95% CI 0.59 to 0.75) or outside of school census timeframes (aOR 0.15, 95% CI 0.14 to 0.17) reduced likelihood of matching. After adjustments for linkage error, ICD-10 mental disorder remained significantly associated with persistent school absence (aOR 1.13, 95% CI 1.07 to 1.22)., Conclusions: The work described sets a precedent for education data being used for medical benefit in England. Linkage between health and education records offers a powerful tool for evaluating the impact of mental health on school function, but biases due to linkage error may produce misleading results. Collaborative research with data providers is needed to develop linkage methods that minimise potential biases in analyses of linked data., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Purpose: Urban areas are usually found to have higher rates of self-harm, with deprivation the strongest predictor at area-level. We use a disease mapping approach to examine how self-harm is patterned within an urban area and its associations with deprivation, urbanness and ethnicity., Methods: Data from clinical records on individuals admitted for self-harm for 725 small areas in South East London were included. Bayesian hierarchical models explored the spatio-temporal patterns of self-harm admission rates and potential associations with proximity to city centre, population density, percentage greenspace and non-white ethnic-minority populations. All models were adjusted for area-level deprivation, social fragmentation and hospital of admission., Results: There were 8327 first admissions for self-harm during the study period. Self-harm admission rates varied fourfold across the study area, with lower rates close to the city centre [adjusted standardised admission ratio, closest versus furthest quartile 0.71(95% CrI 0.54-0.96)]. Deprivation was associated with self-harm but partially masked rather than explained the spatial pattern, which strengthened after adjustment. After adjustment for deprivation, hospital of admission and social fragmentation, greenspace, population density and ethnicity were not associated with self-harm rates., Conclusion: Proximity to the city centre was associated with lower rates of self-harm, but the usual operationalisations of urbanness, population density and greenspace, were not. Deprivation did not explain the spatial patterning, nor did ethnicity. While nationally self-harm rates are higher in urban and deprived areas, this cannot be extrapolated to mean that within cities the inner-city is the highest risk area nor that risk will be principally patterned according to deprivation.

The prevalence of negative symptoms (NS) at first episode of early-onset psychosis (EOP), and their effect on psychosis prognosis is unclear. In a sample of 638 children with EOP (aged 10-17 y, 51% male), we assessed (1) the prevalence of NS at first presentation to mental health services and (2) whether NS predicted eventual development of multiple treatment failure (MTF) prior to the age of 18 (defined by initiation of a third trial of novel antipsychotic due to prior insufficient response, intolerable adverse-effects or non-adherence). Data were extracted from the electronic health records held by child inpatient and community-based services in South London, United Kingdom. Natural Language Processing tools were used to measure the presence of Marder Factor NS and antipsychotic use. The association between presenting with ≥2 NS and the development of MTF over a 5-year period was modeled using Cox regression. Out of the 638 children, 37.5% showed ≥2 NS at first presentation, and 124 (19.3%) developed MTF prior to the age of 18. The presence of NS at first episode was significantly associated with MTF (adjusted hazard ratio 1.62, 95% CI 1.07-2.46; P = .02) after controlling for a number of potential confounders including psychosis diagnostic classification, positive symptoms, comorbid depression, and family history of psychosis. Other factors associated with MTF included comorbid autism spectrum disorder, older age at first presentation, Black ethnicity, and family history of psychosis. In EOP, NS at first episode are prevalent and may help identify a subset of children at higher risk of responding poorly to antipsychotics.

Background: Discrimination is a well-established stressor that is substantially associated with poor health and a known contributor to health inequalities. However, the role of discrimination in health service use is less explored. This study will take an intersectional approach to investigate differences in health service use and examine the role of discrimination experiences., Methods: Data on health service use were assessed in a diverse inner London sample of 1052 participants in the South East London Community Health (SELCoH) Study. Latent class analysis (LCA) was used to define classes of intersectional social status using multiple indicators of socioeconomic status (SES), ethnicity and migration status. Adjusted associations between intersectional social status and discrimination experiences with health service use indicators are presented., Results: Using latent class analysis allowed us to identify an intersectional social status characterized by multiple disadvantage that was associated with decreased secondary physical health service use and a class characterized by both privilege and disadvantage that was associated with increased health service use for mental disorder after controlling for age, gender and health status. Anticipated discrimination was also associated with increased service use for mental disorder in adjusted models. There was no evidence to suggest that discrimination experiences were acting as a barrier to health service use., Conclusions: This study highlights the complex ways in which discrimination experiences may increase the need for health services whilst also highlighting differences in health service use at the intersection of ethnicity, migration status and SES. Findings from this study illustrate the importance of measuring multiple levels of discrimination and taking an intersectional approach for health service use research.

Aims: Inequalities in mental health are well documented using individual social statuses such as socioeconomic status (SES), ethnicity and migration status. However, few studies have taken an intersectional approach to investigate inequalities in mental health using latent class analysis (LCA). This study will examine the association between multiple indicator classes of social identity with common mental disorder (CMD)., Methods: Data on CMD symptoms were assessed in a diverse inner London sample of 1052 participants in the second wave of the South East London Community Health study. LCA was used to define classes of social identity using multiple indicators of SES, ethnicity and migration status. Adjusted associations between CMD and both individual indicators and multiple indicators of social identity are presented., Results: LCA identified six groups that were differentiated by varying levels of privilege and disadvantage based on multiple SES indicators. This intersectional approach highlighted nuanced differences in odds of CMD, with the economically inactive group with multiple levels of disadvantage most likely to have a CMD. Adding ethnicity and migration status further differentiated between groups. The migrant, economically inactive and White British, economically inactive classes both had increased odds of CMD., Conclusions: This is the first study to examine the intersections of SES, ethnicity and migration status with CMD using LCA. Results showed that both the migrant, economically inactive and the White British, economically inactive classes had a similarly high prevalence of CMD. Findings suggest that LCA is a useful methodology for investigating health inequalities by intersectional identities.

Background: Uncertainty remains as to whether the effects of debt on common mental disorder (CMD) are persistent over time and what impact it has on mental health service use (MHSU)., Aims: To determine the distribution of debt across sociodemographic and socioeconomic statuses; to examine whether debt influences CMD recovery over time; and to determine the effects of episodic and/or long-term debt and CMD on MHSU outcomes., Methods: Data were collected from phase 1 (N = 1698) and phase 2 (N = 1052) of the South East London Community Health (SELCoH) study, a population-based survey., Results: 37.2% of participants who reported debt at SELCoH 1 and 46.6% at SELCoH 2 experienced concurrent CMD. Those with concurrent exposure to debt and CMD at SELCoH 1 were at greater risk of CMD at SELCoH 2. Debt accumulation was strongly associated with CMD cross-sectionally; however, this somewhat dissipated over time. Reporting any debt at SELCoH 2 or debt at both time-points were strongly associated with MHSU in the past year in the fully adjusted model adjusting for prior mental health., Conclusions: More focus is needed on concurrent exposure to debt and CMD with regards to subsequent psychological impact and consequences for MHSU.

Background: Consent to research with decision-making capacity for research (DMC-R) is normally a requirement for study participation. Although the symptoms of schizophrenia and related psychoses are known to affect decision-making capacity for treatment (DMC-T), we know little about their effect on DMC-R.AimsWe aimed to determine if DMC-R differs from DMC-T in proportion and associated symptoms in an in-patient sample of people with schizophrenia and related psychoses., Method: Cross-sectional study of psychiatric in-patients admitted for assessment and/or treatment of schizophrenia and related psychoses. We measured DMC-R and DMC-T using 'expert judgement' clinical assessment guided by the MacArthur Competence Assessment Tool for Clinical Research, the MacArthur Competence Assessment Tool for Treatment and the legal framework of the Mental Capacity Act (2005), in addition to symptoms of psychosis., Results: There were 84 participants in the study. Half the participants had DMC-R (51%, 95% CI 40-62%) and a third had DMC-T (31%, 95% CI 21-43%) and this difference was statistically significant (P < 0.01). Thought disorder was most associated with lacking DMC-R (odds ratio 5.72, 95% CI 2.01-16.31, P = 0.001), whereas lack of insight was most associated with lacking DMC-T (odds ratio 26.34, 95% CI 3.60-192.66, P = 0.001). With the exception of improved education status and better DMC-R, there was no effect of sociodemographic variables on either DMC-R or DMC-T., Conclusions: We have shown that even when severely unwell, people with schizophrenia and related psychoses in in-patient settings commonly retain DMC-R despite lacking DMC-T. Furthermore, different symptoms have different effects on decision-making abilities for different decisions. We should not view in-patient psychiatric settings as a research 'no-go area' and, where appropriate, should recruit in these settings.Declaration of interestNone.

Background: The association between cigarette smoking and psychosis remains unexplained, but could relate to causal effects in both directions, confounding by socioeconomic factors, such as ethnicity, or use of other substances, including cannabis. Few studies have evaluated the association between cigarettes and psychotic experiences (PEs) in diverse, inner-city populations, or relationships with number of cigarettes consumed., Methods: We assessed associations and dose-response relationships between cigarette smoking and PEs in a cross-sectional survey of household residents (n = 1680) in South East London, using logistic regression to adjust for cannabis use, other illicit substances, and socioeconomic factors, including ethnicity., Results: We found association between any PEs and daily cigarette smoking, which remained following adjustment for age, gender, ethnicity, cannabis and use of illicit stimulant drugs (fully adjusted odds ratio 1.47, 95% confidence interval 1.01-2.15). Fully adjusted estimates for the association, and with number of PEs, increased with number of cigarettes smoked daily, implying a dose-response effect (p = 0.001 and <0.001, respectively). Odds of reporting any PEs in ex-smokers were similar to never-smokers., Conclusions: In this diverse epidemiological sample, association between smoking and PEs was not explained by confounders such as cannabis or illicit drugs. Daily cigarette consumption showed a dose-response relationship with the odds of reporting PEs, and of reporting a greater number of PEs. There was no difference in odds of reporting PEs between ex-smokers and never-smokers, raising the possibility that the increase in PEs associated with smoking may be reversible.

Competing Interests: Competing interests: None declared.

Background: It has been observed that mental disorders, such as psychosis, are more common for people in some ethnic groups in areas where their ethnic group is less common. We set out to test whether this ethnic density effect reflects minority status in general, by looking at three situations where individual characteristics differ from what is usual in a locality., Method: Using data from the South East London Community Health study (n = 1698) we investigated associations between minority status (defined by: ethnicity, household status and occupational social class) and risk of psychotic experiences, common mental disorders and parasuicide. We used a multilevel logistic model to examine cross-level interactions between minority status at individual and neighbourhood levels., Results: Being Black in an area where this was less common (10%) was associated with higher odds of psychotic experiences [odds ratio (OR) 1.34 95% confidence interval (CI) 1.07-1.67], and attempted suicide (OR 1.84 95% CI 1.19-2.85). Living alone where this was less usual (10% less) was associated with increased odds of psychotic experiences (OR 2.18 95% CI 0.91-5.26), while being in a disadvantaged social class where this was less usual (10% less) was associated with increased odds of attempted suicide (OR 1.33 95% CI 1.03-1.71). We found no evidence for an association with common mental disorders., Conclusions: The relationship between minority status and mental distress was most apparent when defined in terms of broad ethnic group but was also observed for individual household status and occupational social class.

Purpose: Few studies have examined discrimination and mental health in the UK, particularly by migrant status and in urban contexts with greater demographic diversity. This study aims to (1) describe the prevalence of discrimination experiences across multiple life domains; (2) to describe associations between discrimination experiences and common mental disorder (CMD); (3) to determine whether or not the relationship between discrimination and CMD varies by migrant status and ethnicity., Methods: Data on major, anticipated and everyday discrimination and CMD symptoms were collected from an ethnically diverse prospective sample of 1052 participants followed up from 2008 to 2013 in the South East London Community Health study, a population-based household survey., Results: With few exceptions, discrimination was most prevalent among those in the Black Caribbean group. However, those in the White Other ethnic group had similar or greater reporting major and anticipated discrimination to Black or mixed ethnic minority groups. The effects of discrimination on CMD were most pronounced for individuals who had recently migrated to the UK, an ethnically heterogeneous group, and for Black and Mixed ethnic minority groups in partially adjusted models. Prior CMD accounted for differences between the Mixed and White British ethnic groups, but the strength of the association for the most recent migrant group and the Black ethnic groups remained two or more times greater than the reference groups., Conclusions: The strength of the relationship suggests a need for more consideration of migration status along with ethnicity in examining the impact of discrimination on mental disorder in community and clinical samples.

Importance: Psychotic experiences in early life are associated with neuropsychological impairment and the risk for later psychiatric disorders. Psychotic experiences are also prevalent in adults, but neuropsychological investigations spanning adulthood are limited, and confounding factors have not been examined rigorously., Objective: To characterize neuropsychological functioning in adults with psychotic experiences while adjusting for important sociodemographic characteristics and familial factors and investigating the effect of age., Design, Setting, and Participants: The South East London Community Health (SELCoH) study is a population-based household survey of physical and mental health in individuals 16 years or older conducted from June 1, 2008, to December 31, 2010, in 2 London boroughs. The study included 1698 participants from 1075 households. Data were analyzed from May 6, 2014, to April 22, 2015., Exposures: Psychotic experiences measured using the Psychosis Screening Questionnaire., Main Outcomes and Measures: Neuropsychological functioning measured using tests assessing verbal knowledge (Wechsler Test of Adult Reading), working memory (Spatial Delayed Response Task), memory (Visual Object Learning Task), and processing speed (digit symbol coding task). A composite IQ score of general cognitive ability was calculated., Results: A total of 1677 participants with a mean (SD) age of 40 (17) years were included in the analysis. Compared with the group without psychotic experiences, the 171 (9.7%) adults with psychotic experiences did not show a statistically significant impairment on mean (SD) measures of IQ (95.25 [16.58] vs 100.45 [14.77]; Cohen d, -0.22; P = .06) or processing speed (40.63 [13.06] vs 42.17 [13.79]; Cohen d, -0.03; P = .73) but were impaired on measures of verbal knowledge (31.36 [15.78] vs 38.83 [12.64]; Cohen d, -0.37; P = .003), working memory (20.97 [4.12] vs 22.51 [3.26]; Cohen d, -0.34; P = .005), and memory (43.80 [8.45] vs 46.53 [7.06]; Cohen d, -0.28; P = .01). Only participants 50 years and older with psychotic experiences showed medium to large impairments in neuropsychological functioning (mean [SD]) on measures of IQ (81.22 [15.97] vs 91.28 [14.31]; Cohen d, -0.70), verbal knowledge (28.31 [13.83] vs 38.51 [11.50]; Cohen d, -0.88), working memory (19.11 [4.77] vs 21.99 [3.42]; Cohen d, -0.82), and memory (39.17 [8.23] vs 44.09 [6.51]; Cohen d, -0.45) after adjusting for socioeconomic status, cannabis use, and common mental disorders. Medium impairments (mean [SD]) on measures of working memory (21.27 [3.64] vs 22.62 [2.97]; Cohen d, -0.45) and memory (44.32 [5.84] vs 46.91 [5.74]; Cohen d, -0.45) were seen in those aged 35 to 49 years and on a measure of verbal knowledge (30.81 [14.17] vs 37.60 [10.48]; Cohen d, -0.62) in those aged 16 to 24 years. First-degree relatives of adults with psychotic experiences showed a small impairment on a measure of verbal knowledge (34.71 [12.10] vs 38.63 [10.97]; Cohen d, -0.36; P = .02), and unrelated cohabitants showed no neuropsychological impairment., Conclusions and Relevance: The profile of cognitive impairment in adults with psychotic experiences differed from that seen in adults with psychotic disorders, suggesting important differences between subclinical and clinical psychosis.

Background: Self-harm is a significant public health concern in the UK. This is reflected in the recent addition to the English Public Health Outcomes Framework of rates of attendance at Emergency Departments (EDs) following self-harm. However there is currently no source of data to measure this outcome. Routinely available data for inpatient admissions following self-harm miss the majority of cases presenting to services. We aimed to investigate (i) if a dataset of ED presentations could be produced using a combination of routinely collected clinical and administrative data and (ii) to validate this dataset against another one produced using methods similar to those used in previous studies., Methods: Using the Clinical Record Interactive Search system, the electronic health records (EHRs) used in four EDs were linked to Hospital Episode Statistics to create a dataset of attendances following self-harm. This dataset was compared with an audit dataset of ED attendances created by manual searching of ED records. The proportion of total cases detected by each dataset was compared., Results: There were 1932 attendances detected by the EHR dataset and 1906 by the audit. The EHR and audit datasets detected 77% and 76 of all attendances respectively and both detected 82% of individual patients. There were no differences in terms of age, sex, ethnicity or marital status between those detected and those missed using the EHR method. Both datasets revealed more than double the number of self-harm incidents than could be identified from inpatient admission records., Conclusions: It was possible to use routinely collected EHR data to create a dataset of attendances at EDs following self-harm. The dataset detected the same proportion of attendances and individuals as the audit dataset, proved more comprehensive than the use of inpatient admission records, and did not show a systematic bias in those cases it missed.

Clozapine can cause severe adverse effects yet it is associated with reduced mortality risk. We test the hypothesis this association is due to increased clinical monitoring and investigate risk of premature mortality from natural causes. We identified 14 754 individuals (879 deaths) with serious mental illness (SMI) including schizophrenia, schizoaffective and bipolar disorders aged ≥ 15 years in a large specialist mental healthcare case register linked to national mortality tracing. In this cohort study we modeled the effect of clozapine on mortality over a 5-year period (2007-2011) using Cox regression. Individuals prescribed clozapine had more severe psychopathology and poorer functional status. Many of the exposures associated with clozapine use were themselves risk factors for increased mortality. However, we identified a strong association between being prescribed clozapine and lower mortality which persisted after controlling for a broad range of potential confounders including clinical monitoring and markers of disease severity (adjusted hazard ratio 0.4; 95% CI 0.2-0.7; p = .001). This association remained after restricting the sample to those with a diagnosis of schizophrenia or those taking antipsychotics and after using propensity scores to reduce the impact of confounding by indication. Among individuals with SMI, those prescribed clozapine had a reduced risk of mortality due to both natural and unnatural causes. We found no evidence to indicate that lower mortality associated with clozapine in SMI was due to increased clinical monitoring or confounding factors. This is the first study to report an association between clozapine and reduced risk of mortality from natural causes., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Introduction: This study aimed to validate the SCOFF, an eating disorders (ED) screening questionnaire, in a multiethnic general population sample of adults., Method: A two-stage design was employed using the South East London Community Health Study phases I and II data. A total of 1,669 participants were screened using the SCOFF in SELCoHI, and 145 were administrated an ED clinical interview in SELCoHII. We explored the diagnostic validity of the questionnaire restricting to the 145 individuals with the clinical questionnaire., Results: Sensitivity and specificity of the SCOFF were 53.7 and 93.5%, respectively., Conclusion: The SCOFF showed good levels of specificity but low sensitivity, resulting in a high percentage of false negatives. Given the low sensitivity found in our sample the SCOFF is likely to be a suboptimal measure for the identification of ED in the community., (© 2014 The Authors International Journal of Eating Disorders Published by Wiley Periodicals, Inc.)

Objectives: This study aimed to investigate the associations between migration status and health-related outcomes and to examine whether and how the effect of migration status changes when it is disaggregated by length of residence, first language, reason for migration and combined with ethnicity., Design: A total of 1698 adults were interviewed from 1076 randomly selected households in two South London boroughs. We described the socio-demographic and socio-economic differences between migrants and non-migrants and compared the prevalence of health-related outcomes by migration status, length of residence, first language, reason for migration and migration status within ethnic groups. Unadjusted models and models adjusted for socio-demographic and socio-economic indicators are presented., Results: Migrants were disadvantaged in terms of socio-economic status but few differences were found between migrant and non-migrants regarding health or health service use indicators; migration status was associated with decreased hazardous alcohol use, functional limitations due to poor mental health and not being registered with a general practitioner. Important differences emerged when migration status was disaggregated by length of residence in the UK, first language, reason for migration and intersected with ethnicity. The association between migration status and functional limitations due to poor mental health was only seen in White migrants, migrants whose first language was not English and migrants who had moved to the UK for work or a better life or for asylum or political reasons. There was no association between migration status and self-rated health overall, but Black African migrants had decreased odds for reporting poor health compared to their non-migrant counterparts [odds ratio = 0.15 (0.05-0.48), p < 0.01]., Conclusions: Disaggregating migration status by length of residence, first language and reason for migration as well as intersecting it with ethnicity leads to better understanding of the effect migration status has on health and health service use.

Purpose: Psychological therapy services are sometimes characterised as being small and inequitable, with an over-representation of white middle class women. The 'Improving Access to Psychological Therapies (IAPT)' initiative is a programme in England that attempts to make evidence-based therapies accessible to more people more equitably. The aim of this study is to assess whether an IAPT service is delivering an equitable service a London borough. Patients using services at the Southwark IAPT service (n = 4,781) were compared with a sub-group of participants in the South East London Community Health study (SELCOH) with diagnosable mental health problems and who were also resident in Southwark (n = 196)., Methods: We compared Southwark IAPT patients and SELCOH participants on equity criteria of age, gender, ethnicity, occupational status and benefits status. To investigate if referral pathways influenced equity, patients referred by their general practitioner (GP pathway) (n = 3,738) or who self-referred (self-referral pathway) (n = 482) were compared with SELCOH participants., Results: Southwark IAPT patients significantly differed from SELCOH participants on all our equity criteria and similar differences were found with GP pathway patients. However, self-referrals did not differ from the SELCOH group on age, gender, ethnicity and benefit status., Conclusions: When compared to a community sample with diagnosable mental disorders, health disparities were found with the overall Southwark IAPT service and with GP pathway patients. Although unemployed people did access IAPT, fewer disparities were found with the self-referral pathway patients, suggesting that the IAPT self-referral pathway may be important in reducing inequitable access to services.

Purpose: Disordered eating has been shown to be more prevalent than full eating disorders diagnoses. However, research on its prevalence, socio-demographic, psychological correlates, and patterns of service use in multi-ethnic samples is still limited. This paper explores these associations in a South London-based (UK) sample., Methods: The South East London Community Health (SELCoH) study is a general population survey (N = 1,698) of individuals aged 16+. Disordered eating was defined as ≥2 positive answers at the SCOFF questionnaire. Crude and adjusted logistic and multinomial logistic regression models were fit to investigate associations between socio-demographic characteristics, disordered eating, psychiatric comorbidity, and service use., Results: A total of 164 (10 %) participants reported disordered eating and the majority were from ethnic minorities. In adjusted models, Asian ethnicity was associated with purging, loss of control eating and preoccupation with food. Individuals with disordered eating had higher odds of screening positive for post-traumatic stress disorder and personality disorders and of having anxiety/mood disorders, suicidal ideation/attempts, hazardous levels of drinking, and used drugs in the previous year. Only 36 % of individuals with disordered eating had sought professional help in the previous 12 months mostly through their general practitioner (27.4 %), followed by psychotherapists (12.8 %) and mental health specialists (5.5 %)., Conclusion: This study found a high prevalence of disordered eating, especially amongst ethnic minorities, and associations with a number of psychiatric conditions. Overall few participants accessed specialist services. These findings suggest that both disordered eating manifestations amongst ethnic minorities and access to care need better investigation.

Background: a large and increasing number of older people in the UK are living in care homes. Dementia is a frequent reason underlying admission and determining care needs, but prevalence data are becoming increasingly outdated and reliant on brief screening instruments., Objective: to describe the prevalence and severity of dementia, depression, behavioural problems and relevant medication use in a representative sample of residential and nursing care home residents., Design/setting: a survey conducted in 15 randomly selected South East London care homes. Consensus clinical dementia diagnoses were made from multi-source information, and the Clinical Dementia Rating (CDR) Scale applied. Depression was ascertained using the Cornell Depression in Dementia Scale and psychological/behavioural problems using the Neuropsychiatric Inventory (NPI)., Participants: three hundred and one residents with a mean (SD) age of 83.5 (9.8) and 65.8% female were included., Results: dementia (CDR 1-3) prevalence was 75.1% overall, 55.8% in residential homes, 91.0% in residential elderly mentally infirm care and 77.0% in nursing homes. Depression prevalences were 26.5, 22.0 and 29.6%, respectively, and mean (95% CI) NPI severity scores 3.99 (3.47-4.50), 6.34 (5.29-7.39) and 6.10 (5.50-6.70) with 87.3% of the sample exhibiting at least one NPI symptom. Antidepressants were prescribed in 25.6, 25.0 and 41.3%, respectively, and antipsychotics in 7.0, 34.1 and 19.1%., Conclusion: dementia is substantially more common in care homes than recorded diagnoses would suggest, but studies using brief screening instruments may overestimate prevalence. High prevalences of depressive and/or behavioural symptoms and psychotropic use suggest significant unmet need., (© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: Fear of crime and perceived neighbourhood disorder have been linked to common mental illness (CMI). However, few UK studies have also considered the experience of crime at the individual and neighbourhood level. This study aims to identify individual and local area factors associated with increased perceived neighbourhood disorder and test associations between CMI and individuals' perceptions of disorder in their neighbourhoods, personal experiences of crime and neighbourhood crime rates., Methods: A cross-sectional survey was conducted of 1,698 adults living in 1,075 households in Lambeth and Southwark, London. CMI was assessed using the Revised Clinical Interview Schedule. Data were analysed using multilevel logistic regression with neighbourhood defined as lower super output area., Results: Individuals who reported neighbourhood disorder were more likely to suffer CMI (OR 2.12) as were those with individual experience of crime. These effects remained significant when individual characteristics were controlled for. While 14 % of the variance in perceived neighbourhood disorder occurred at the neighbourhood level, there was no significant variance at this level for CMI., Conclusions: Perceived neighbourhood disorder is more common in income-deprived areas and individuals who are unemployed. Worry about one's local area and individual experience of crime are strongly and independently associated with CMI, but neighbourhood crime rates do not appear to impact on mental health.

Objective: To assess the feasibility and acceptability of routine web-based screening in general hospital settings, and describe the level of common mental disorder., Method: A service development platform to integrate mental and physical healthcare was implemented in six specialties (rheumatology, limb reconstruction, hepatitis C, psoriasis, adult congenital heart disease (ACHD), chronic pain) across three general hospitals in London, UK. Under service conditions, patients completed a web-based questionnaire comprising mental and physical patient-reported outcome measures, whilst waiting for their appointment. Feasibility was quantified as the proportion of patients who completed the questionnaire. Acceptability was quantified as the proportion of patients declining screening, and the proportion requiring assistance completing the questionnaire. The prevalence of probable depression and anxiety was expressed as the percentage of cases determined by the Patient Health Questionnaire-9 and Generalised Anxiety Disorder Questionnaire-7., Results: The proportion of patients screened varied widely across specialties (40.1-98.2%). The decline rate was low (0.6-9.7%) and the minority required assistance (11.7-40.4%). The prevalence of probable depression ranged from 60.9% in chronic pain to 6.6% in ACHD. The prevalence of probable anxiety ranged from 25.1% in rheumatology to 11.4% in ACHD., Conclusion: Web-based screening is acceptable to patients and can be effectively embedded in routine practice. General hospital patients are at increased risk of common mental disorder, and routine screening may help identify need, inform care and monitor outcomes., (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: General population surveys have seldom examined violence as a multidimensional concept and in relation to an array of mental disorders., Methods: Data from the South East London Community Health Study was used to examine the prevalence, overlap and distribution of proximal witnessed, victimised and perpetrated violence and their association with current mental disorders. We further investigated the cumulative effect of lifetime exposure to violence on current mental disorders. Unadjusted and adjusted (for confounders and violence) models were examined., Results: In the last twelve months, 7.4% reported witnessing violence, 6.3% victimisation and 3.2% perpetration of violence. There was a significant overlap across violence types, with some shared correlates across the groups such as being younger and male. Witnessing violence in the past year was associated with current common mental disorders (CMD) and post-traumatic stress disorder (PTSD) symptoms. Proximal perpetration was associated with current CMD, PTSD symptoms and past 12 months drug use; whereas proximal victimisation was associated with lifetime and past 12 months drug use. Lifetime exposure to two or more types of violence was associated with increased risk for all mental health outcomes, suggesting a cumulative effect., Conclusion: Exposure to violence needs to be examined in a multi-faceted manner: i) as discrete distal and proximal events, which may have distinct patterns of association with mental health and ii) as a concept with different but overlapping dimensions, thus also accounting for possible cumulative effects.

Background: The Mental Adjustment to Cancer Scale is an assessment tool commonly used to measure coping in cancer patients, which characterises adaptive coping under the label of 'fighting spirit'., Aim: This study explores adaptation in patients with advanced cancer, by examining the factor structure of the Mental Adjustment to Cancer Scale. Further aims were to examine associations between types of coping and psychological outcomes measured at the same time (time 1) and 4 weeks after referral to palliative care services (time 2)., Design: A cross-sectional study with a follow-up assessment 4 weeks later. Factor analysis examined the structure of the Mental Adjustment to Cancer Scale at time 1., Setting/participants: A total of 275 patients with advanced cancer receiving palliative care, of whom 193 took part at follow-up., Results: This study provided evidence for the internal consistency and validity of a new scale of 'acceptance and positivity' for use in advanced cancer patients. Patients with a desire for hastened death had lower acceptance and positivity, and patients with higher global quality of life reported a higher level. Social support was positively associated with acceptance and positivity. Higher scores on the acceptance and positivity scale were associated with reduced odds of a desire for hastened death at time 2., Conclusion: Adaptation to advanced cancer differs from adaptation to early stage cancer, comprising a general acceptance of the illness and trying to make the most of the time that is left. Individuals with low social support were less likely to evidence appropriate adaptation to their illness.

Objectives: To assess the stage at cancer diagnosis and survival after cancer diagnosis among people served by secondary mental health services, compared with other local people., Setting: Using the anonymised linkage between a regional monopoly secondary mental health service provider in southeast London of four London boroughs, Croydon, Lambeth, Lewisham and Southwark, and a population-based cancer register, a historical cohort study was constructed., Participants: A total of 28 477 cancer cases aged 15+ years with stage of cancer recorded at diagnosis were identified. Among these, 2206 participants had been previously assessed or treated in secondary mental healthcare before their cancer diagnosis and 125 for severe mental illness (schizophrenia, schizoaffective or bipolar disorders)., Primary and Secondary Outcome Measures: Stage when cancer was diagnosed and all-cause mortality after cancer diagnosis among cancer cases registered in the geographical area of southeast London., Results: Comparisons between people with and without specific psychiatric diagnosis in the same residence area for risks of advanced stage of cancer at diagnosis and general survival after cancer diagnosed were analysed using logistic and Cox models. No associations were found between specific mental disorder diagnoses and beyond local spread of cancer at presentation. However, people with severe mental disorders, depression, dementia and substance use disorders had significantly worse survival after cancer diagnosis, independent of cancer stage at diagnosis and other potential confounders., Conclusions: Previous findings of associations between mental disorders and cancer mortality are more likely to be accounted for by differences in survival after cancer diagnosis rather than by delayed diagnosis.

Purpose: This study aimed to estimate the prevalence of symptoms of post-traumatic stress disorder (PTSD) and its association with traumatic events in a representative sample of an inner city population in the UK., Methods: A representative community sample of 1,698 adults, aged 16 years and over, from two south London boroughs were interviewed face to face with structured survey questionnaires., Results: The prevalence of current symptoms of PTSD was 5.5 %. Women were more likely to screen positive (6.4 %) than men (3.6 %), and symptoms of PTSD were high in the unemployed (12.5 %), in those not working because of health reasons (18.2 %) and in the lowest household income group (14.8 %). Most (78.2 %) of the study population had lifetime trauma and more than a third (39.7 %) reported childhood trauma. There was an independent association between childhood as well as lifetime trauma and current symptoms of PTSD and a gradient association between an increase in cumulative traumatic events and the likelihood of reporting symptoms of current PTSD (OR 1.8, 95 % CI (1.6-2.1)). Although we observed the highest prevalence of current symptoms of PTSD in those migrated for asylum or political reason (13.6 %), compared to the non-migrants, the prevalence of exposure to most traumatic life events was higher in the non-migrant group., Conclusion: The present study demonstrates the high prevalence of exposure to trauma in a South East London community and the cumulative effect on current symptoms of PTSD. As PTSD is a condition which is associated with disability and co-morbidity, the association of current PTSD with common adversities in the community should be noted.

Background: Hepatitis C virus (HCV) affects 170 million worldwide. Currently, around 30% of patients receiving interferon-alpha (IFN-α) treatment for HCV experience clinically significant depression. Effective and timely detection of depression is crucial to ensuring appropriate treatment and support. However, little is known about how clinical nurse specialists identify patients at risk of developing interferon-alpha-induced depression, and monitor those receiving antiviral treatment for the occurrence of depression., Objective: This study aimed to gain an in-depth understanding of staff experience of, and attitudes towards, the identification and monitoring of interferon-alpha-induced-depression and the decision-making process concerning the use of liaison psychiatry and other clinical services., Design: A qualitative interview study was conducted among clinical staff involved in the care of patients with hepatitis C, using the perspective of naturalistic decision making., Settings: Outpatient liver clinics in three large teaching hospitals in South London, the United Kingdom., Participants: All clinical nurse specialists from the three outpatient liver clinics were included. All were involved directly in the care of patients receiving interferon-alpha treatment and had at least one year experience (mean 6.4 years, range 1-11 years) in this field., Methods: Semi-structured face-to-face interviews were conducted between 2010 and 2011. Data collection and analysis were carried out iteratively to ensure the reliability of the analysis using the constant comparison method., Results: Staff used verbal and non-verbal cues when assessing risks of patients developing depression before and during IFN-α treatment. Major sources of uncertainty were patient engagement and familiarity, referrals to psychiatrists, language barriers, and distinguishing between psychological and physical symptoms. Good rapport with patients and good communication among multidisciplinary professional groups were key strategies identified to reduce uncertainty., Conclusion: Current methods of identifying vulnerable patients rely on the availability of clinical experts and good communication within a multidisciplinary team. Detection and management of depression in this population is complex, however, various strategies are employed by nurses to overcome difficulties when making decisions regarding patient welfare. Current clinical practices should be taken into account when developing new tools and methods., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Mental disorders are widely recognized to be associated with increased risk of all-cause mortality. However, the extent to which highest-risk groups for mortality overlap with those viewed with highest concern by mental health services is less clear. The aim of the study was to investigate clinical risk assessment ratings for suicide, violence and self-neglect in relation to all-cause mortality among people receiving secondary mental healthcare., Method: A total of 9234 subjects over the age of 15 years were identified from the South London and Maudsley Biomedical Research Centre Case Register who had received a second tier structured risk assessment in the course of their clinical care. A cohort analysis was carried out. Total scores for three risk assessment clusters (suicide, violence and self-neglect) were calculated and Cox regression models used to assess survival from first assessment., Results: A total of 234 deaths had occurred over an average 9.4-month follow-up period. Mortality was relatively high for the cohort overall in relation to national norms [standardized mortality ratio 3.23, 95% confidence interval (CI) 2.83-3.67] but not in relation to other mental health service users with similar diagnoses. Only the score for the self-neglect cluster predicted mortality [hazard ratio (HR) per unit increase 1.14, 95% CI 1.04-1.24] with null findings for assessed risk of suicide or violence (HRs per unit increase 1.00 and 1.06 respectively)., Conclusions: Level of clinician-appraised risk of self-neglect, but not of suicide or violence, predicted all-cause mortality among people receiving specific assessment of risk in a secondary mental health service.

Background: in community studies the prevalence of depression is higher in women than men; however, in palliative care settings this relationship is usually less strong, absent or reversed., Aim: to identify reasons for excess depression among men receiving palliative care., Design: cross-sectional study., Setting/participants: we interviewed 300 patients recruited from a large hospice in South East London. Depression was measured using the Primary Care Evaluation of Mental Disorder., Results: the higher prevalence of depression among men was not explained by a higher prevalence of particular types of cancer nor confounding by other covariates. Possible effect modifiers were examined. Depending on others for help with basic tasks (eating, dressing, washing or using the toilet) was a risk factor for depression in men only, with 37.8% of dependent men being depressed compared to 2.4% of similarly affected women (OR = 24.3, 3.1-193.2, p = 0.003). We observed a dose-response effect between the level of dependency and depression in men (p for trend = 0.01)., Conclusion: depending on others for help with basic tasks appears to contribute to the burden of depression among men with terminal illness. This gender-specific association may explain why the usual gender differences in depression prevalence are not observed in palliative care.

Background: Reliance on national figures may be underestimating the extent of mental ill health in urban communities. This study demonstrates the necessity for local information on common mental disorder (CMD) and substance use by comparing data from the South East London Community Health (SELCoH) study with those from a national study, the 2007 English Adult Psychiatric Morbidity Study (APMS)., Methodology/principal Findings: Data were used from two cross-sectional surveys, 1698 men and women residing in south London and 7403 men and women in England. The main outcome, CMD, was indicated by a score of 12 or above on the Revised Clinical Interview Schedule. Secondary outcomes included hazardous alcohol use and illicit drug use. SELCoH sample prevalence estimates of CMD were nearly twice that of the APMS England sample estimates. There was a four-fold greater proportion of depressive episode in the SELCoH sample than the APMS sample. The prevalence of hazardous alcohol use was higher in the national sample. Illicit drug use in the past year was higher in the SELCoH sample, with cannabis and cocaine the illicit drugs reported most frequently in both samples. In comparisons of the SELCoH sample with the APMS England sample and the APMS sample from the Greater London area in combined datasets, these differences remained after adjusting for socio-demographic and socioeconomic indicators for all outcomes., Conclusions/significance: Local information for estimating the prevalence of CMD and substance use is essential for surveillance and service planning. There were similarities in the demographic and socioeconomic factors related to CMD and substance use across samples.

Background: Responses to public health need require information on the distribution of mental and physical ill health by demographic and socioeconomic factors at the local community level., Methods: The South East London Community Health (SELCoH) study is a community psychiatric and physical morbidity survey. Trained interviewers conducted face-to-face computer assisted interviews with 1698 adults aged 16 years and over, from 1076 randomly selected private households in two south London boroughs. We compared the prevalence of common mental disorders, hazardous alcohol use, long standing illness and general physical health by demographic and socioeconomic indicators. Unadjusted and models adjusted for demographic and socioeconomic indicators are presented for all logistic regression models., Results: Of those in the sample, 24.2% reported common mental disorder and 44.9% reported having a long standing illness, with 15.7% reporting hazardous alcohol consumption and 19.2% rating their health as fair or poor. The pattern of indicators identifying health inequalities for common mental disorder, poor general health and having a long term illness is similar; individuals who are socioeconomically disadvantaged have poorer health and physical health worsens as age increases for all groups. The prevalence of poor health outcomes by ethnic group suggests that there are important differences between groups, particularly for common mental disorder and poor general health. Higher socioeconomic status was protective for common mental disorder, fair or poor health and long standing illness, but those with higher socioeconomic status reported higher levels of hazardous alcohol use. The proportion of participants who met the criteria for common mental disorder with co-occurring functional limitations was similar or greater to those with poor physical health., Conclusions: Health service providers and policy makers should prioritise high risk, socially defined groups in combating inequalities in individual and co-occurring poor mental and physical problems. In population terms, poor mental health has a similar or greater burden on functional impairment than long term conditions and perceived health.

Objective: Despite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth., Method: People who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007-09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007-09, using a life table method., Results: A total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007-09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost)., Conclusion: The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.

Context: The long-term risk of suicide after a first episode of psychosis is unknown because previous studies often have been based on prevalence cohorts, been biased to more severely ill hospitalized patients, extrapolated from a short follow-up time, and have made a distinction between schizophrenia and other psychoses., Objective: To determine the epidemiology of suicide in a clinically representative cohort of patients experiencing their first episode of psychosis., Design: Retrospective inception cohort., Setting: Geographic catchment areas in London, England (between January 1, 1965, and December 31, 2004; n = 2056); Nottingham, England (between September 1, 1997, and August 31, 1999; n = 203); and Dumfries and Galloway, Scotland (between January 1, 1979, and December 31, 1998; n = 464)., Participants: All 2723 patients who presented for the first time to secondary care services with psychosis in the 3 defined catchment areas were traced after a mean follow-up period of 11.5 years., Main Outcome Measure: Deaths by suicide and open verdicts according to the International Classification of Diseases (seventh through tenth editions)., Results: The case fatality from suicide was considerably lower than expected from previous studies (1.9% [53/2723]); the proportionate mortality was 11.9% (53/444). Although the rate of suicide was highest in the first year after presentation, risk persisted late into follow-up, with a median time to suicide of 5.6 years. Suicide occurred approximately 12 times more than expected from the general population of England and Wales (standardized mortality ratio, 11.65; 95% confidence interval, 8.73-15.24), and 49 of the 53 suicides were excess deaths. Even a decade after first presentation-a time when there may be less intense clinical monitoring of risk-suicide risk remained almost 4 times higher than in the general population (standardized mortality ratio, 3.92; 95% confidence interval, 2.22-6.89)., Conclusions: The highest risk of suicide after a psychotic episode occurs soon after presentation, yet physicians should still be vigilant in assessing risk a decade or longer after first contact. The widely held view that 10% to 15% die of suicide is misleading because it refers to proportionate mortality, not lifetime risk. Nevertheless, there is a substantial increase in risk of suicide compared with the general population.

Background: Higher mortality has been found for people with serious mental illness (SMI, including schizophrenia, schizoaffective disorders, and bipolar affective disorder) at all age groups. Our aim was to characterize vulnerable groups for excess mortality among people with SMI, substance use disorders, depressive episode, and recurrent depressive disorder., Methods: A case register was developed at the South London and Maudsley National Health Services Foundation Trust (NHS SLAM), accessing full electronic clinical records on over 150,000 mental health service users as a well-defined cohort since 2006. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information since 2008. Deaths were identified by regular national tracing returns after 2006. Standardized mortality ratios (SMRs) were calculated for the period 2007 to 2009 using SLAM records for this period and the expected number of deaths from age-specific mortality statistics for the England and Wales population in 2008. Data were stratified by gender, ethnicity, and specific mental disorders., Results: A total of 31,719 cases, aged 15 years old or more, active between 2007-2009 and with mental disorders of interest prior to 2009 were detected in the SLAM case register. SMRs were 2.15 (95% CI: 1.95-2.36) for all SMI with genders combined, 1.89 (1.64-2.17) for women and 2.47 (2.17-2.80) for men. In addition, highest mortality risk was found for substance use disorders (SMR = 4.17; 95% CI: 3.75-4.64). Age- and gender-standardised mortality ratios by ethnic group revealed huge fluctuations, and SMRs for all disorders diminished in strength with age. The main limitation was the setting of secondary mental health care provider in SLAM., Conclusions: Substantially higher mortality persists in people with serious mental illness, substance use disorders and depressive disorders. Furthermore, mortality risk differs substantially with age, diagnosis, gender and ethnicity. Further research into specific risk groups is required.

Background: Obesity is an increasing public health problem. A small number of studies have examined the relationship between obesity and sickness absence, with mixed results, particularly regarding short-term sickness absence., Aims: To determine if obesity is associated with short- and long-term sickness absence and to investigate the mechanisms that may underlie any association., Methods: Cross-sectional (n = 1489) and prospective (n = 625) analyses were conducted on staff from London Underground Ltd. All participants underwent regular clinical examinations that involved their height and weight being measured, obesity-related medical problems being diagnosed and psychiatric disorders being identified. The number of days taken for short- (<10 days in an episode) and long-term sickness absence were recorded by managers on an electronic database., Results: There was a positive linear association between employees' body mass index (BMI) and the number of days' work missed due to sickness absence on both cross-sectional and prospective analyses (P < 0.001). Obesity was a risk factor for both short- and long-term sickness absence. Obese individuals typically took an extra 4 days sick leave every year. The majority of the increased risk for long-term sickness absence appeared to be mediated via co-morbid chronic medical conditions. The excess short-term sickness absence was not explained by obesity-related medical problems, psychiatric disorders or workplace factors., Conclusions: Obese employees take significantly more short- and long-term sickness absence than workers of a healthy weight. There is growing evidence to support employers becoming more involved in tackling obesity.

Background: An individual's right to self-determination in treatment decisions is a central principle of modern medical ethics and law, and is upheld except under conditions of mental incapacity. When doctors, particularly psychiatrists, override the treatment wishes of individuals, they risk conflicting with this principle. Few data are available on the views of people regaining capacity who had their treatment wishes overridden., Aims: To investigate individuals' views on treatment decisions after they had regained capacity., Method: One hundred and fifteen people who lacked capacity to make treatment decisions were recruited from a sample of consecutively admitted patients to a large psychiatric hospital. After 1 month of treatment we asked the individuals for their views on the surrogate treatment decisions they received., Results: Eighty-three per cent (95% CI 66-93) of people who regained capacity gave retrospective approval. Approval was no different between those admitted informally or involuntarily using Mental Health Act powers (chi(2) = 1.52, P = 0.47). Individuals were more likely to give retrospective approval if they regained capacity (chi(2) = 14.2, P = 0.001)., Conclusions: Most people who regain capacity following psychiatric treatment indicate retrospective approval. This is the case even if initial treatment wishes are overridden. These findings moderate concerns both about surrogate decision-making by psychiatrists and advance decision-making by people with mental illness.

Longitudinal research helps to clarify changing needs and the timing of treatments and referral but is hampered by poor recruitment and retention of participants. We explored, using semi-structured interviews in a cross-sectional design, the views and preferences of patients with advanced cancer on taking part in planned longitudinal questionnaire-based research studies. Patients with advanced lung and colorectal cancer were recruited from outpatient clinics in a London hospital. Semi-structured interviews were undertaken to explore their views about taking part in a specific future questionnaire study and their preferences regarding format. In all, 20 of 47 patients initially identified were recruited. Their preferences for the planned questionnaire study were for face-to-face interviews undertaken at home from late morning onwards with recontact at a mean of 6 weeks. Fluctuating symptom control needs could result in unexpected admission to or discharge from hospital. Developing flexible and responsive recruitment procedures is vital to retain patient participation as more than one contact might be required to successfully conclude an interview.

Background: Sociologists, anthropologists, and psychologists agree that grief is a universal phenomenon. Reactions to it are, however, socially constructed and patterned., Objective: To compare the outcomes of bereavement among family or close friends of deceased first-generation black Caribbean and white native-born patients living in the United Kingdom., Design: Comparative cross-sectional questionnaire survey in three inner London health authorities administered 10 months after the patient's death., Participants: Family and close friends of 50 deceased first-generation black Caribbean and 50 native-born white patients with advanced disease., Main Outcome Measures: 28-item General Health Questionnaire (GHQ-28), Core Bereavement Items scale, a 17-item measure of grief., Results: The intensity of grief, measured using the Core Bereavement Items was similar between the two groups. Seventy-two respondents had visited their family doctor subsequent to bereavement, and of these, black Caribbean respondents reported more psychological problems. Depression and anxiety measured by the GHQ-28 were significantly higher among black Caribbean respondents (28.00 vs. 21.2) (t-test = -2.28, p = 0.025). Multiple regression analysis revealed this difference was best accounted for by bereavement concerns such as legal and housing problems., Conclusions: This study has observed higher psychological morbidity among the bereaved Caribbean individuals. Family doctors are a source of support for three-quarters of respondents, and they may need to focus on the needs of black and minority ethnic minorities.

Objective: To assess whether the fatigue commonly reported by patients following surgery is partly a result of somatization and/or cognitive-behavioral factors., Methods: One hundred eighty-three patients completed questionnaires before surgery and then 2 days, 3 weeks and 6 months afterward. Multiple regressions were used to assess which of the following factors were important in predicting self-reported postoperative fatigue, controlling for preoperative fatigue and for various demographic and surgical variables: negative mood, history of mood disorder, preoperative expectations of fatigue, preoperative worry or optimism about surgery, preoperative beliefs about the benefits of activity or rest, self-reported postoperative activity, self-reported cardiovascular deconditioning, and availability of social support., Results: Controlling for demographic and surgical variables and preoperative fatigue, postoperative fatigue showed significant associations with negative mood at each stage of follow-up (p < .001) and was significantly predicted by history of mood disorder at 2 days postoperatively (p = .02). Higher fatigue expectations were self-fulfilling at 3 weeks after surgery (p = .02), whereas preoperative belief in physical activity as being beneficial to recovery predicted reduced fatigue at 6 months (p < .001). Finally, self-reported breathlessness after exercise, an indicator of cardiovascular deconditioning, was also significantly associated with greater fatigue at 6 months (p = .02)., Conclusion: The results indicate that psychological processes may well be relevant in the etiology of postoperative fatigue. In particular, the results relating to mood and expectations suggest that somatization may be particularly important in the first few weeks following surgery, whereas cognitive-behavioral factors and cardiovascular deconditioning may be more important in determining later-stage recovery.