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BACKGROUND: The fast-growing migrant population in Japan and globally poses challenges in mental healthcare, yet research addressing migrants mental health treatment engagement remains limited. OBJECTIVE: This study examined language proficiency, demographic and clinical characteristics as predictors of early treatment discontinuation among migrants. METHODS: Electronic health record data from 196 adult migrants, identified from 14 511 patients who received mental health outpatient treatment during 2016 and 2019 at three central hospitals in the Tokyo-Yokohama metropolitan region of Japan, were used. We conducted multivariable regression models to identify predictors of early discontinuation within 3 months. FINDINGS: The study cohort (65% women, age range: 18-90 years, from 29 countries or regions) included 23% non-Japanese speakers. Japanese and non-Japanese speakers had similar discontinuation rates (26% vs 22%). Multivariable models revealed younger age (OR=0.97; 95% CI: 0.95, 0.99; p=0.016) and those with a primary diagnosis other than a schizophrenia spectrum disorder (OR=3.99; 95% CI: 1.36, 11.77; p=0.012) or a neurotic, stress-related and somatoform disorder (OR=2.79; 95% CI: 1.14, 6.84; p=0.025) had higher odds of early discontinuation. These effects were more pronounced among the Japanese speakers with significant language-by-age and language-by-diagnoses interactions. CONCLUSION: Younger age and having a primary diagnosis other than a schizophrenia spectrum disorder or a neurotic, stress-related and somatoform disorder increased vulnerability for discontinuing mental health treatment early in Japanese-speaking migrants but not for migrants with limited Japanese proficiency. CLINICAL IMPLICATIONS: Understanding language needs within a context of mental health treatment should go beyond assumed or observed fluency. Unmet language needs might increase vulnerability for treatment disengagement among migrants. Targeted clinical efforts are crucial for enhancing early treatment engagement and informing health practices in Japan and countries with growing migrant populations.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) last published clinical guidelines for the management of major depressive disorder (MDD) in 2016. Owing to advances in the field, an update was needed to incorporate new evidence and provide new and revised recommendations for the assessment and management of MDD in adults. Methods: CANMAT convened a guidelines editorial group comprised of academic clinicians and patient partners. A systematic literature review was conducted, focusing on systematic reviews and meta-analyses published since the 2016 guidelines. Recommendations were organized by lines of treatment, which were informed by CANMAT-defined levels of evidence and supplemented by clinical support (consisting of expert consensus on safety, tolerability, and feasibility). Drafts were revised based on review by patient partners, expert peer review, and a defined expert consensus process. Results: The updated guidelines comprise eight primary topics, in a question-and-answer format, that map a patient care journey from assessment to selection of evidence-based treatments, prevention of recurrence, and strategies for inadequate response. The guidelines adopt a personalized care approach that emphasizes shared decision-making that reflects the values, preferences, and treatment history of the patient with MDD. Tables provide new and updated recommendations for psychological, pharmacological, lifestyle, complementary and alternative medicine, digital health, and neuromodulation treatments. Caveats and limitations of the evidence are highlighted. Conclusions: The CANMAT 2023 updated guidelines provide evidence-informed recommendations for the management of MDD, in a clinician-friendly format. These updated guidelines emphasize a collaborative, personalized, and systematic management approach that will help optimize outcomes for adults with MDD. [ABSTRACT FROM AUTHOR]

Background: To date, few randomized controlled trials of psilocybin with nondirective support exist for obsessive-compulsive disorder (OCD). Results and participant feedback from an interim analysis of an ongoing single-dose trial (NCT03356483) converged on the possibility of administering a higher fixed dose and/or more doses of psilocybin in future trials for presumably greater benefits. Objectives: This trial aims to evaluate the safety, feasibility, tolerability, and clinical effects of two doses of psilocybin paired with non-directive support in the treatment of OCD. This trial also seeks to examine whether two doses of psilocybin lead to greater OCD symptom reduction than a single dose, and to elucidate psychological mechanisms underlying the effects of psilocybin on OCD. Design: A randomized (1:1), waitlist-controlled design with blinded ratings will be used to examine the effects of two doses of oral psilocybin paired with non-directive support vs. waitlist control on OCD symptoms. An adaptive dose selection strategy will be implemented (i.e., first dose: 25 mg; second dose: 25 or 30 mg). Methods and analysis: This single-site trial will enroll 30 adult participants with treatment-refractory OCD. Aside from safety, feasibility, and tolerability metrics, primary outcomes include OCD symptoms assessed on the Yale-Brown Obsessive-Compulsive Scale - Second Edition (Y-BOCS-II). A blinded independent rater will assess primary outcomes at baseline and the primary endpoint at the end of the second dosing week. Participants will be followed up to 12 months post-second dosing. Participants randomized to waitlist will be rescreened after 7 weeks post-randomization, and begin their delayed treatment phase thereafter if still eligible. Ethics: Written informed consent will be obtained from participants. The institutional review board has approved this trial (protocol v. 1.7; HIC #2000032623). Discussion: This study seeks to advance our ability to treat refractory OCD, and catalyze future research seeking to optimize the process of psilocybin treatment for OCD through understanding relevant psychological mechanisms. [ABSTRACT FROM AUTHOR]

Onset of mental health disorder peaks during adolescence making continuity of care during this period of life crucial both to ensure a smooth treatment course and high quality of mental health services for adolescents. We aimed to examine which clinical and sociodemographic features predict transfer from child and adolescent mental health services to adult mental health services and if transfer is associated with prognosis. A Danish register study including all 16–17-year-olds with an outpatient contact in child and adolescent mental health services, who were discharged in the period of 1/1/06–10/05/15. Out of 27,170 Danish adolescents, 16% transferred to adult mental health services. Transfer was predicted by schizophrenia (OR 6.16; 95% CI 5.51–6.90) and personality disorders (OR 2.08; 95% CI 1.84–2.34), while hyperkinetic (OR 0.54; 95% CI 0.49–0.59) and pervasive developmental disorders (OR 0.42; 95% CI 0.31–0.58) decreased likelihood of transfer. Transfer was also substantially predicted by inpatient admission (OR 3.37; 95% CI 3.14–3.61) and psychiatric medication (OR 2.07; 95% CI 1.92–2.23). Transfer was associated with higher rates of inpatient admission to adult mental health services (IRR 5.83; 95% CI 4.37–7.77), more psychiatric emergency contacts (IRR 12.0; 95% CI 10.7–13.4), more convictions (IRR 1.40; 95% CI 1.23–1.59) and suicide attempts (IRR 5.70; 95% CI 4.72–6.90). Policy-makers and clinicians should push for improvements and open a discussion of how to ensure continuity of care for adolescents with psychiatric disorders. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic shed light on the burden of behavioral health conditions prevalent in the United States (U.S.). Consequently, there is a behavioral healthcare provider shortage, particularly in rural areas, to support this need. Recently, primary care providers (PCPs) have shifted to incorporate behavioral health to their practice. However, many PCPs lack knowledge and skills to successfully manage their patients' behavioral health conditions. In response to the need for effective behavioral healthcare across the U.S. Weitzman ECHO launched the Advanced Primary Care (APC ECHO) Adult Psychiatry Module to provide continuing education (CE) for rural PCPs. This study presents the results from the APC ECHO pilot to demonstrate how CE can support PCPs in addressing their patients' mental health needs. Evaluators used a one-group repeated measures study design to assess the APC ECHO Module and understand learner outcomes and individual practice changes. Participant characteristics and individual practice changes were summarized using descriptive statistics, with support from open-ended responses to illustrate findings. Repeated measures analyses of covariance were applied to compare the differences in pre- and post-module learner outcomes. A total of 18 providers participated in the study, with the majority encompassing medical providers (72.2%). There was a significant increase in knowledge (pre-module: 21.11 + 6.99; post-module: 25.08 + 5.66; p < .01), self-efficacy (pre-module: 6.89 + 3.05; post-module: 9.78 + 3.25; p < .01), and skills (pre-module: 7.67 + 4.03; post-module: 10.06 + 3.23; p < .05) gained over the duration of the ECHO module. Additionally, participants indicated they are applying best practices learned through the module to their patients experiencing psychiatric conditions (3.96 + 0.09). This study suggests that tailored CE for PCPs can promote an increase in knowledge, self-efficacy, and skills to apply best practices when treating patients with behavioral health conditions. This, in turn, allows patients to receive more comprehensive care and mitigates access barriers, especially for rural populations. [ABSTRACT FROM AUTHOR]

Predatory marriage is a form of financial abuse where individuals with impaired decision-making capacity are exploited for personal gain. The prevalence of predatory marriages is difficult to determine due to their covert nature, but legal challenges related to these marriages are increasing in Canada. Factors such as increased wealth among seniors and the rise in conditions that impair decision-making capacity, like dementia, contribute to the vulnerability of individuals to predatory marriages. The legal standard for the capacity to marry is historically low, but there have been calls for a more stringent standard to protect individuals from financial consequences. Psychiatrists may play a role in identifying and supporting individuals at risk of predatory marriage. [Extracted from the article]

ABSTRACTThe COVID-19 pandemic shed light on the burden of behavioral health conditions prevalent in the United States (U.S.). Consequently, there is a behavioral healthcare provider shortage, particularly in rural areas, to support this need. Recently, primary care providers (PCPs) have shifted to incorporate behavioral health to their practice. However, many PCPs lack knowledge and skills to successfully manage their patients’ behavioral health conditions. In response to the need for effective behavioral healthcare across the U.S. Weitzman ECHO launched the Advanced Primary Care (APC ECHO) Adult Psychiatry Module to provide continuing education (CE) for rural PCPs. This study presents the results from the APC ECHO pilot to demonstrate how CE can support PCPs in addressing their patients’ mental health needs. Evaluators used a one-group repeated measures study design to assess the APC ECHO Module and understand learner outcomes and individual practice changes. Participant characteristics and individual practice changes were summarized using descriptive statistics, with support from open-ended responses to illustrate findings. Repeated measures analyses of covariance were applied to compare the differences in pre- and post-module learner outcomes. A total of 18 providers participated in the study, with the majority encompassing medical providers (72.2%). There was a significant increase in knowledge (pre-module: 21.11 + 6.99; post-module: 25.08 + 5.66; p

Accessible Summary: What is Known on the Subject?: Mental health recovery has become a more prevalent approach to empowering people with schizophrenia (PWS), especially in western countries. However, despite the benefits, there is a lack of evidence regarding its practice in developing countries such as Southeast Asian Countries.The optimal treatment for PWS has not yet been identified, since most mental health care is provided in hospital‐based settings in Southeast Asia.Mental health treatment in Southeast Asia is highly influenced by cultural norms, values, and practices. What the Paper Adds to Existing Knowledge?: The findings highlight the importance of integrating cultural aspects into the treatment of people with schizophrenia.The sample of unique elements in Southeast Asian mental health recovery include using a close neighbour/cadre as social support and using religious activity to increase hope.Lack of government support, high level of employment, and stigma are the biggest barriers in the PWS recovery process. What is the Implication for Practice?: There is a research gap regarding the awareness and implementation of mental health recovery in psychiatric programs across the Southeast Asian region which likely impacts the effectiveness of the treatment.The review shows that little research has explored the concept of personal recovery in Southeast Asian Countries. Introduction: Recovery has become an important approach used by mental health services around the world. Many mental health systems have taken steps to move towards more recovery‐oriented practices and service delivery. Therefore, establishing recovery‐oriented services in developing countries like those in the Southeast Asian region requires a detailed understanding of the cultural norms, values, and current mental health practices. Aims: To investigate the mental health practices that promote recovery, its barrier in Southeast Asia, and to determine if they align with the CHIME recovery model. Method: Electronic databases MEDLINE, EMBASE, CINAHL, PsycINFO and SCOPUS, were searched [PROSPERO] (CRD42021227962). Peer‐reviewed English language articles from 2004 to January 2021 were included. Methodological quality was assessed using the CASP checklist, and thematic synthesis of included studies was conducted. Results: Thirty‐one studies met inclusion criteria. Several themes illustrated mental health recovery services and the current obstacles identified in South‐east Asian studies. Connection includes peer support and support groups, relationship status, and limited opportunities to become involved in the community. Hope is found in cultural concepts of hope, stimulating recovery through mental health programs, whilst lack of knowledge and education are the main barriers. Ethnicity is linked to a high level of stigma, but ethnicity also builds identity. Meaning and spirituality manifest in religious activities as the catalyst for recovery. Finally, the opposite of Empowerment is seen in the tendency of people with schizophrenia to remain in a passive position. Further barriers to empowerment are unemployment and a lack of social support. Discussion: In Southeast Asia, the elements of culture, religiosity, and communality are essential to mental health recovery. The obstacles to recovery are relate to human rights, social support, family involvement, and continuity of care. Implications for Practice: This review explores the concept of mental health recovery for people who are experiencing psychosis and living in Southeast Asian countries. The evidence may contribute to the further development of mental health programs in this region. [ABSTRACT FROM AUTHOR]

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.

QuestionThe context for the implementation of evidence-based psychological treatments (EBPTs) often differs from the context in which the treatment was developed, which necessitates adaptations. In this systematic review we build on, and add to, prior approaches by examining the method used to guide such adaptations. In particular, we sought to elucidate the extent to which an empirical process is used.Study selection and analysisWe focused on publications describing adaptations made to EBPTs for adults diagnosed with a mental illness. We searched PubMed, PsycINFO, Embase and Web of Science from database inception to July 2018. Two raters independently coded the articles for the method used to conduct the adaptation, the reason for and nature of the adaptation, and who made the adaptation.FindingsThe search produced 20 194 citations, which yielded 152 articles after screening. The most commonly used methods for planned adaptations were literature review (57.7%), clinical intuition (47.0%) and theory (38.9%). The use of data from stakeholder interviews ranked fourth (21.5%) and the use of other types of data (eg, pilot study, experiment, survey, interview) ranked last at fifth (12.1%). Few publications reporting ad hoc adaptations were identified (n=3).ConclusionsThis review highlights a need to (a) educate providers and researchers to carefully consider the methods used for the treatment adaptation process, and to use empirical methods where possible and where appropriate, (b) improve the quality of reporting of stakeholder interviews and (c) develop reporting standards that articulate optimal methods for conducting treatment adaptations.

Background Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials. Aims We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies. Method We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences. Conclusions Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.

Background: Psilocybin may help treat obsessive-compulsive disorder (OCD). To date, only one open-label study of psilocybin for OCD exists, necessitating further investigation with a randomized controlled design. The neural correlates of psilocybin's effects on OCD have also not been studied. Objectives: This first-of-its-kind trial aims to evaluate the feasibility, safety, and tolerability of psilocybin in the treatment of OCD, provide preliminary evidence on the effects of psilocybin on OCD symptoms, and elucidate neural mechanisms that may mediate psilocybin's effects on OCD. Design: We use a randomized (1:1), double-blind, placebo-controlled, noncrossover design to examine the clinical and neural effects of either a single dose of oral psilocybin (0.25 mg/kg) or active placebo-control agent (250 mg of niacin) on OCD symptoms. Methods and analysis: We are enrolling 30 adult participants at a single site in Connecticut, USA who have failed at least one trial of standard care treatment (medication/psychotherapy) for OCD. All participants will also receive unstructured, non-directive psychological support during visits. Aside from safety, primary outcomes include OCD symptoms over the past 24 h, assessed by the Acute Yale-Brown Obsessive-Compulsive Scale and Visual Analog Scale ratings. These are collected by blinded, independent raters at baseline and the primary endpoint of 48 h post-dosing. Total follow-up is 12 weeks post-dosing. Resting state neuroimaging data will be collected at baseline and primary endpoint. Participants randomized to placebo will be offered the chance to return for an open-label dose of 0.25 mg/kg. Ethics statement: All participants will be required to provide written informed consent. The trial (protocol v. 5.2) was approved by the institutional review board (HIC #2000020355) and registered with ClinicalTrials.gov (NCT03356483). Discussion: This study may represent an advance in our ability to treat refractory OCD, and pave the way for future studies of neurobiological mechanisms of OCD that may respond to psilocybin. [ABSTRACT FROM AUTHOR]

Background: Therapeutic alliance represents a rarely studied object when it relates to nurses and care provided by a nursing team in acute care hospitalization.Objective: The objective was to study how factors might influence the therapeutic alliance built between nurses and aides and adult inpatients in an acute care unit of sectorial general psychiatry.Method: This is a prospective, observational and cross-sectional study using a therapeutic alliance measurement scale. Therapeutic alliance (TA) score was measured with a STAR-P scale in a sample of 240 patients.Results: The median score found is 33.4 (±7.8) out of a maximum theoretical score of 48. The global score of TA in patients aged 60 years old or more is significantly higher than the score of patients between 18 and 29 years old (p=0.021). The lack of external follow-up in the three months after hospital release is not associated with TA global score (p=0.73). If inpatients, no matter what their diseases or types of care are, under legal obligation or not, consider their TA is rather good after their hospital stay. Only sociodemographic factors like age, housing conditions (insecure or sustainable), having a job or not, living alone or with a partner affect TA and follow-up.Conclusion: Results evoke concepts of anomie and attachment, that seem to play an important role in the lack of follow-up after hospital stay, and indicate the mandatory global approach to care and an involvement of health professionals as well as social beings, where empathy must find its place. [ABSTRACT FROM AUTHOR]

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INTRODUCTION: Insomnia is a major public health concern. While cognitive behaviour therapy for insomnia (CBT-I) is acknowledged as the best available intervention, there are unanswered questions about its wider dissemination, socioeconomic benefits and its impact on health resource utilisation. The aim of this randomised controlled trial (RCT) is to investigate the effectiveness of a fully automated online version of CBT-I compared with online patient education about sleep (PE). Outcome measures comprise changes in symptoms of insomnia, time off work due to sick leave as well as medication and health resource utilisation. Also, we will examine (i) putative mediators of the effects of CBT-I on insomnia severity and (ii) selected potential psycho-bio-social moderators of the effects of the interventions. METHODS AND ANALYSIS: A parallel-group RCT will be conducted in a target sample of about 1500 adults recruited across Norway. Participants will complete an online screening and consent process. Those who meet eligibility criteria will be randomised to receive direct access to fully automated online CBT-I or to an online PE programme. The primary outcome is change in insomnia severity immediately postintervention; secondary outcomes are change in daytime functioning and other sleep measures postintervention and at 6-month and 24-month follow-up. Objective data from national registries will be obtained at two time points (1 year and 2 years post-treatment), allowing a mirror image study of preintervention and postintervention rates of sick leave, and of medication and healthcare utilisation by condition. ETHICS AND DISSEMINATION: The study protocol was approved by the Regional Committee for Medical and Health Research Ethics in South East Norway (2015/134). Findings from the RCT will be disseminated in peer-reviewed publications and conference presentations. Exploratory analyses of potential mediators and moderators will be reported separately. User-friendly outputs will be disseminated to patient advocacy and other relevant organisations. TRIAL REGISTRATION NUMBER: NCT02558647; Pre-results.

Objectives: Little is known about adults who self-report as autistic. This study aimed to profile the demographic characteristics, long-term health conditions and primary care experiences of adults who self-report as autistic (including those with and without a formal diagnosis)., Design/setting: A nationally representative cross-sectional survey of adults registered with National Health Service (NHS) General Practitioner (GP) surgeries in England., Participants: 623 157 survey respondents aged 16 and over, including 4481 who self-report as autistic., Outcomes: Weighted descriptive statistics, with 95% CIs. Logistic regression modelling adjusted for age, gender, ethnicity and area-level deprivation compared those who self-report as autistic with the rest of the population., Results: A total of 4481 of the 623 157 survey participants included in the analysis self-reported autism, yielding a weighted proportion estimate of 1.41% (95% CI 1.35% to 1.46%). Adults self-reporting as autistic were more likely to be younger, male or non-binary, to identify as a gender different from their sex at birth, have a non-heterosexual sexual identity, be of white or mixed or multiple ethnic groups, non-religious, without caring responsibilities, unemployed, live in more deprived areas and not smoke. All chronic conditions covered were more prevalent among adults self-reporting as autistic, including learning disability, mental health conditions, neurological conditions, dementia, blindness or partial sight and deafness or hearing loss. Adults self-reporting as autistic were also less likely to report a positive experience of making an appointment (adjusted OR (aOR) 0.90, 95% CI 0.82 to 0.98) and navigating GP practice websites (aOR 0.78, 95% CI 0.70 to 0.87) and more likely to report seeking advice from a friend or family member prior to making an appointment (aOR 1.25, 95% CI 1.14 to 1.38) and having a preferred GP (aOR 2.25, 95% CI 2.06 to 2.46). They were less likely to report that their needs were met (aOR 0.73, 95% CI 0.65 to 0.83)., Conclusions: Adults self-reporting as autistic have a distinctive sociodemographic profile and heightened rates of long-term conditions. They report challenges in both accessing primary care and having their needs met when they do. These findings should inform future care initiatives designed to meet the needs of this group., Competing Interests: Competing interests: SJT has previously received funding from The Wellcome Trust, and the National Health Service Small Business Research Initiative, as well as research support from the National Institute for Health and Care Research for autism-related research studies. SM receives salary support from UKPRP/MRC (Grant MR/V049879/1)., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Question: Mindfulness-based programmes (MBPs) and practices have demonstrated effects in mental health and well-being, yet questions regarding the target mechanisms that drive change across the population remain unresolved., Study Selection and Analysis: Five databases were searched for randomised controlled trials that evaluate the indirect effects (IEs) of an MBP or mindfulness practice in relation to mental health and well-being outcomes through psychological mechanisms., Findings: 27 eligible studies were identified, with only four exploring mechanisms in the context of specific mindfulness practices. Significant IEs were reported for mindfulness skills, decentering and attitudes of mindfulness (eg, self-compassion) across different outcomes, population samples, mental health strategies and active comparators. Evidence gap maps and requirements for testing and reporting IEs are provided to help guide future work., Conclusions: Mindfulness skills, decentering and attitudes of mindfulness may be key intervention targets for addressing the mental health of whole populations. However, future work needs to address significant knowledge gaps regarding the evidence for alternative mechanisms (eg, attention and awareness) in relation to unique outcomes (eg, well-being), mental health strategies (ie, promotion) and active comparators. High-quality trials, with powered multivariate mediation analyses that meet key requirements, will be needed to advance this area of work., Trial Registration Number: 10.17605/OSF.IO/NY2AH., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric condition prevalent in both children and adults. With growing awareness of the importance of the preconception period in health, it is essential to understand whether preconception parental mental health and related factors are related to onset of offspring ADHD. This protocol presents the methodology for undertaking a systematic review to investigate associations between parental mental health and/or psychotropic use during the preconception years and offspring ADHD., Methods and Analysis: Peer-reviewed literature will be identified by searching relevant electronic databases including Medline complete, Embase, PsycINFO and CINAHL; reference lists of eligible articles will be hand searched and grey literature considered. Eligible study designs include population-based and/or clinically based cohort or case-control studies. The primary exposure and outcome of interest is parental history of mental health conditions in the preconception period and offspring ADHD, respectively (ie, according to semistructured interviews/confirmed diagnosis by a relevant health professional or screening instruments). Critical appraisal will be undertaken. A descriptive synthesis will be presented including characteristics of the included studies, critical appraisal scores and a summary of main findings (eg, presented in tables, text and figures). A meta-analysis will be conducted, if possible, and statistical techniques will be employed if heterogeneity is detected., Ethics and Dissemination: Ethical permissions are not required for this systematic review since the study will only use published data. Findings from this systematic review will be published in a peer-reviewed scientific journal/presented at national and international conferences relevant to the field., Prospero Registration Number: CRD42023460379., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Question: For parents of children and young people (CYP) with diagnosed mental health difficulties, what are the levels of parents' well-being and psychological need?, Study Selection and Analysis: Medline, PsycINFO, EMBASE, AMED, CINAHL, Web of Science and Cochrane Library of Registered Trials were searched from inception to June 2023., Inclusion Criteria: parents of CYP aged 5-18 years with formal mental health diagnosis. Data were extracted from validated measures of well-being or psychological needs with established cut-off points or from a controlled study., Findings: 32 of the 73 310 records screened were included. Pooled means showed clinical range scores for one measure of depression, and all included measures of anxiety, parenting stress and general stress. Meta-analyses showed greater depression (g=0.24, 95% CI 0.11 to 0.38) and parenting stress (g=0.34, 95% CI 0.20 to 0.49) in parents of CYP with mental health difficulties versus those without. Mothers reported greater depression (g=0.42, 95% CI 0.18 to 0.66) and anxiety (g=0.73, 95% CI 0.27 to 1.18) than fathers. Narrative synthesis found no clear patterns in relation to CYP condition. Rates of parents with clinically relevant levels of distress varied. Typically, anxiety, parenting stress and general stress scored above clinical threshold. Quality appraisal revealed few studies with a clearly defined control group, or attempts to control for important variables such as parent gender., Conclusions: The somewhat mixed results suggest clinical anxiety, parenting and general stress may be common, with sometimes high depression. Assessment and support for parents of CYP with mental health problems is required. Further controlled studies, with consideration of pre-existing parental mental health difficulties are required., Prospero Registration Number: CRD42022344453., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: In military populations, the potential for under-reporting of Post-traumatic Stress Disorder (PTSD) symptoms and challenges in recognising early changes can make it difficult to detect an emerging disorder. However, early identification of PTSD symptoms would improve opportunities for intervention, and potentially reduce the likelihood of chronic mental health problems., Method: This study explored if changes in levels of inflammation, measured by C reactive protein (CRP) and interleukin 6 (IL-6), were associated with the onset of psychological symptoms associated with PTSD. It also examined if changes in inflammation over time contributed to psychological risk and resilience, which was defined by psychological reactivity to deployment-related combat exposures. Participants were special forces personnel who completed psychological self-report questionnaires and had measures of CRP and IL-6 taken pre and post deployment. Regression analysis was used to examine how psychological symptoms predicted change in inflammation, and Analysis of Variance (ANOVA) were used to examine differences between identified subgroups., Results: Results identify this population as having high levels of combat and trauma exposures, with low-level psychological symptoms. The results also identified a decrease in CRP and an increase in IL-6 over time. A significant difference in inflammation was identified between subgroups (p<0.05). An association between inflammatory markers and subthreshold symptoms related to anger (p<0.01) and sleep (p<0.05) was also identified., Conclusion: These preliminary findings suggest inflammatory markers may help to identify adaptive responses post deployment. In addition, low-level increases in inflammatory markers may be associated with subthreshold PTSD symptoms. These findings offer potential insights for prevention, early identification and treatment in military and veteran populations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Mental disorders are endemic. However, the mental health treatment gap remains high, especially in low-resource settings. Task-shifting is a universally recommended strategy to mitigate the care gap. The Friendship Bench (FB), a task-shifting, low-intensity psychotherapy programme founded in Zimbabwe, is effective in managing anxiety and depression. The FB programme offers clients the choice of joining add-on mental health support groups known as Circle Kubatana Tose (CKT). These groups offer an opportunity for continued psychoeducation, social support and economic strengthening. However, the evidence base for the effectiveness of add-on support groups is sparse. We hypothesise that participation in CKT is associated with increased adherence to treatment regimens, social support and well-being. This mixed-methods prospective cohort study seeks to evaluate the intermediate effects (6-month follow-up) of CKT groups, including process outcome evaluation., Methods and Analysis: We will recruit participants (N=178) receiving mental healthcare from the FB in Harare primary care clinics. Follow-up assessments will occur at enrolment, 6 weeks, 3 months and 6 months, assessing changes in common mental disorders (depression and anxiety), social support, positive psychological indices (hope and resilience), health-related quality of life, working alliance, economic outcomes (net income) and implementation outcome (feasibility, acceptability/satisfaction and uptake of services). Quantitative data will be analysed using descriptive analysis, bivariate statistics, Cox proportional hazard models and generalised mixed models (maximum likelihood estimation). Qualitative data will be analysed using thematic analysis., Dissemination and Ethics: Ethical approval was granted by the Medical Research Council of Zimbabwe (MRCZ/A/2427). The findings will inform the potential utility of add-on support groups in the management of anxiety and depression using task-shifting. Dissemination study outcomes will be disseminated in academic journals, social media, conferences and policy briefs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Online-based interventions provide a low-threshold way to reach and support families. The mentalisation-based Lighthouse Parenting Programme is an established intervention aimed at preventing psychopathological development in children. The objective of this study is to examine the feasibility of an online adaptation of the Lighthouse Parenting Programme (LPP-Online), evaluating (a) recruitment capability, compliance, acceptability and satisfaction with the intervention; (b) the psychometric properties of and the acceptability regarding the adjunct psychological evaluation; and (c) the employed materials and resources. The study will also obtain a preliminary evaluation of participants' responses to the intervention., Method and Analysis: In this monocentric, one-arm, non-randomised feasibility trial, n=30 psychologically distressed parents with children aged 0 to 14 years will participate in the LPP-Online for a duration of 8 weeks. The intervention consists of online group sessions and individual sessions, 38 smartphone-based ecological momentary interventions (EMI), and psychoeducational materials (website, booklet). At baseline (T0) and the end of the intervention (T1), parents complete self-report questionnaires as well as 7-day ecological momentary assessments (EMA) via smartphone. During the intervention, additional EMA are completed before and after the daily EMI. An interview regarding parents' subjective experience with the intervention will be conducted at T1. The feasibility of the intervention, the psychological evaluation and the resources will be examined using descriptive and qualitative analyses. The preliminary evaluation of the parents' response to the intervention will be conducted by analysing pre-post changes in questionnaire measures and the 7-day EMA as well as data of additional EMA completed before and after the daily EMI., Ethics and Dissemination: Ethical approval of the study has been obtained from the local ethics board (Faculty of Behavioural and Cultural Studies, University of Heidelberg). Consent to participate will be obtained before starting the assessments. Results will be disseminated as publications in peer-reviewed scientific journals and at international conferences., Registration Details: German Clinical Trials Register (DRKS00027423), OSF (https://doi.org/10.17605/OSF.IO/942YW)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The fast-growing migrant population in Japan and globally poses challenges in mental healthcare, yet research addressing migrants' mental health treatment engagement remains limited., Objective: This study examined language proficiency, demographic and clinical characteristics as predictors of early treatment discontinuation among migrants., Methods: Electronic health record data from 196 adult migrants, identified from 14 511 patients who received mental health outpatient treatment during 2016 and 2019 at three central hospitals in the Tokyo-Yokohama metropolitan region of Japan, were used. We conducted multivariable regression models to identify predictors of early discontinuation within 3 months., Findings: The study cohort (65% women, age range: 18-90 years, from 29 countries or regions) included 23% non-Japanese speakers. Japanese and non-Japanese speakers had similar discontinuation rates (26% vs 22%). Multivariable models revealed younger age (OR=0.97; 95% CI: 0.95, 0.99; p=0.016) and those with a primary diagnosis other than a schizophrenia spectrum disorder (OR=3.99; 95% CI: 1.36, 11.77; p=0.012) or a neurotic, stress-related and somatoform disorder (OR=2.79; 95% CI: 1.14, 6.84; p=0.025) had higher odds of early discontinuation. These effects were more pronounced among the Japanese speakers with significant language-by-age and language-by-diagnoses interactions., Conclusion: Younger age and having a primary diagnosis other than a schizophrenia spectrum disorder or a neurotic, stress-related and somatoform disorder increased vulnerability for discontinuing mental health treatment early in Japanese-speaking migrants but not for migrants with limited Japanese proficiency., Clinical Implications: Understanding language needs within a context of mental health treatment should go beyond assumed or observed fluency. Unmet language needs might increase vulnerability for treatment disengagement among migrants. Targeted clinical efforts are crucial for enhancing early treatment engagement and informing health practices in Japan and countries with growing migrant populations., Competing Interests: Competing interests: Tsoh, Takubo, Fukui, Uchino, Katagiri, and Nemoto belong to the Department of Psychiatry and Implementation Science, Toho University Faculty of Medicine, which is funded by Nippon Life Insurance Company. All authors declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

Introduction: Harmful gambling negatively impacts individuals, families and communities. Growing international evidence indicates that the Armed Forces (AF) community may be at a comparatively higher risk of experiencing harm from gambling than the general population. The current study sought to identify general predictors of harmful gambling and gambling engagement among UK AF serving personnel (AFSP)., Methods: We conducted a cross-sectional, exploratory survey to identify associations between demographic factors, mental health, gambling engagement and gambling type in a sample (N=608) of AFSP., Results: Most of the sample reported past-year gambling, with 23% having experienced harm. Male gender, younger age and lower educational attainment all predicted harmful gambling, as did mental health variables of prior generalised anxiety and post-traumatic stress symptomatology. Strategy-based gambling and online sports betting were also predictive of experiencing harm from gambling., Conclusions: The risk of harm from gambling is associated with demographic, mental health and gambling engagement variables among AFSP. Better understanding of these predictors is important for the development of individualised treatment approaches for harmful gambling., Competing Interests: Competing interests: SD and JL are shareholders in Soteria Global Services, a risk management business for high-performance environments., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract 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

This document is a corrigendum published in the journal Frontiers in Psychiatry. It corrects an error in the author list of a previously published article titled "Safety, feasibility, tolerability, and clinical effects of repeated psilocybin dosing combined with non-directive support in the treatment of obsessive-compulsive disorder: protocol for a randomized, waitlist-controlled trial with blinded ratings." The corrected author list is provided, and the authors apologize for the error. The corrigendum does not affect the scientific conclusions of the original article. [Extracted from the article]

This document, published in the Canadian Journal of Psychiatry, explores the tensions between judicial transparency and respect for privacy at Ontario's Consent and Capacity Board (CCB). The CCB is responsible for hearing appeals of involuntary detention and findings of incapacity for psychiatric patients. The study reviewed Reasons for Decision documents published on the Canadian Legal Information Institute website in 2015 and 2019, and found that these documents contain numerous details about the patient's identity, including sociodemographic information, mental and physical health status, and treatment. The authors express concern about the level of detail published and propose new guidelines to better protect the privacy of this potentially vulnerable population. [Extracted from the article]

Abstract Background Little information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD). Methods Data included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted. Results Psychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support. Conclusion Quebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

Introduction Attention-Deficit/Hyperactivity Disorder (ADHD) was classically considered a childhood-onset neurodevelopmental condition. Over the past 40 years, it became evident that it can persist during adulthood. Objectives The purpose of the authors is to describe the characteristics of ADHD in adults and the specific comorbidities, proposing an approach to these patients. Methods A brief non-systematized review is presented, using the literature available on PubMed and Google Scholar. Results Only 40-50% of children and adolescents with ADHD will have symptoms that persist into adulthood (estimated adult prevalence of 2.8% across 20 countries; 25% in prisons). A more subtle presentation in adults and the difficulty to access past medical history, lead to diagnosis and treatment rates of lower than 20% (versus 50% in children). Well-characterized core symptoms in children evolve into a predominance of inattention symptoms. They became adults with marked disorganization, difficulties in completing tasks and managing time. Emotional dysregulation is a very prevalent symptom in this population. The comorbidities rate increase over time (reaching 75% of patients). Conclusions Adults (or even older subjects) with cognitive and/or behavioural complaints should be submitted to systematic screening for ADHD. Non-treated ADHD symptoms in adulthood are associated with severe impairment, therefore adjustments in the health care system to support the transition from child to adult services are needed. Disclosure No significant relationships.

\n Capacity to consent to treatment of substance use disorders at Ontario's Consent and Capacity Board: A review of past reported decisionsAn Ontario review of legal cases which have considered patients' ability to consent to substance use treatments Plain Language Summary In general, prescribers must consider whether informed consent was provided prior to starting a treatment. A patient is presumed to be capable to consent to a proposed treatment but could be incapable with respect to any medical treatment. While incapacity is often considered for psychiatric treatments, it could be relevant to substance use treatment like methadone or suboxone, which are also called “Opioid Agonist Therapies” or OAT. OAT is lifesaving and prevents relapse and overdose when a person has an opioid use disorder. If a patient is found incapable of consenting to a treatment, a Substitute Decisions Maker would become the decision maker. In such cases, the patient has the ability to contest or disagree with the finding, and this results in a tribunal hearing at the Consent and Capacity Board in Ontario (CCB). In certain circumstances, the CCB publishes what are known as its Reasons for Decision (RDs), which explain the tribunal's reasoning in coming to a decision in favour of the physician or the person found incapable. This information is publicly searchable. Our methods involved a search of all available CCB RDs in Ontario for search terms related to substance use treatment, such as "methadone”. We found that between June 1, 2003 (the date on reporting of RDs began) and June 27, 2023, only 71 RDs involved substance use search terms, out of a total of 10,463 reported RDs. Only one case involved the CCB upholding a finding of incapacity with respect to methadone treatment. These results imply that there are few cases in which the CCB has considered incapacity with respect to substance use treatment, although it is possible that these cases are reported at a lower frequency than other cases. [ABSTRACT FROM AUTHOR]

Objective: Although euthanasia in the context of adult psychiatry is legalized in Belgium, it poses major ethical and clinical challenges for the health care professionals and volunteers involved. This study aimed to address these members' concrete experiences and support needs. Methods: A qualitative semi-structured interview study was conducted with 16 physicians and 14 other health care professionals and volunteers, with at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions. Findings: Concrete experiences concerned the following 8 domains: (1) the impact of euthanasia on the clinical trajectory and (2) on the therapeutic relationship, (3) internal and (4) external collaborative partnerships, (5) patients' social inner circle (non-)involvement, (6) the use of recently published guidelines and, (7) the first criminal trials on this topic, and (8) the act of euthanasia. The following 8 main support needs emerged; (1) protocols addressing specific sub-populations and pathologies, (2) protocols specifically drawn up for non-medics, (3) guidance on how to adequately implement the two-track approach, (4) (after)care for patients, (5) (after)care for the health care team, (6) guidance on the patient's social inner circle involvement, (7) enhanced education measures, and (8) enhanced financial measures, including incentives for holistic, palliative care approaches. Conclusion: The health care professionals and volunteers reported many positive and negative experiences in dealing with euthanasia requests in adult psychiatry. They reported several support needs across the extensive euthanasia trajectory, pertaining to concrete management of thorny issues that guidelines do not (yet) touch on. Important implications of our study relate to tackling these existing issues, and to paying sufficient attention to the impact of a euthanasia trajectory on all actors, including the patients and their social inner circle, involved. [ABSTRACT FROM AUTHOR]

ObjectiveAlthough euthanasia in the context of adult psychiatry is legalized in Belgium, it poses major ethical and clinical challenges for the health care professionals and volunteers involved. This study aimed to address these members' concrete experiences and support needs.MethodsA qualitative semi-structured interview study was conducted with 16 physicians and 14 other health care professionals and volunteers, with at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions.FindingsConcrete experiences concerned the following 8 domains: (1) the impact of euthanasia on the clinical trajectory and (2) on the therapeutic relationship, (3) internal and (4) external collaborative partnerships, (5) patients' social inner circle (non-)involvement, (6) the use of recently published guidelines and, (7) the first criminal trials on this topic, and (8) the act of euthanasia. The following 8 main support needs emerged; (1) protocols addressing specific sub-populations and pathologies, (2) protocols specifically drawn up for non-medics, (3) guidance on how to adequately implement the two-track approach, (4) (after)care for patients, (5) (after)care for the health care team, (6) guidance on the patient's social inner circle involvement, (7) enhanced education measures, and (8) enhanced financial measures, including incentives for holistic, palliative care approaches.ConclusionThe health care professionals and volunteers reported many positive and negative experiences in dealing with euthanasia requests in adult psychiatry. They reported several support needs across the extensive euthanasia trajectory, pertaining to concrete management of thorny issues that guidelines do not (yet) touch on. Important implications of our study relate to tackling these existing issues, and to paying sufficient attention to the impact of a euthanasia trajectory on all actors, including the patients and their social inner circle, involved.

Psychomotricity was born at Sainte-Anne's hospital and has evolved in many ways since then. In Dr Jean-Luc Marcel's department, psychomotricity finds a special place in the care of the patients, within a multidisciplinary team, constantly mobilizing for a humanist psychiatry, as close as possible to the patient. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to evaluate psychological impact of COVID-19 outbreak on postgraduate trainees in Pakistan by quantifying the symptoms of depression, anxiety and acute stress disorder and by analysing potential risk factors associated with these symptoms.Methods: Following Institutional Review Board approval, a cross-sectional study was conducted among 10,178 postgraduate trainees following COVID-19 outbreak through e-log system of College of Physicians and Surgeons of Pakistan. The nine-item Patient Health Questionnaire, seven-item Generalised Anxiety Disorder scale and Stanford Acute Stress Reaction Questionnaire were used to collect data. Statistical analyses were conducted using SPSS.26. Descriptive statistics, Mann-Whitney U test, the χ2 test and logistic regression analysis were performed. The significance level was set at α=0.05.Results: The prevalence of depressive symptoms, generalised anxiety disorder and acute stress disorder were 26.4%, 22.6% and 4.4%, respectively. Female postgraduate trainees, senior trainees and front-line workers reported experiencing more anxiety, depression and acute stress symptoms (p value<0.001). Logistic regression showed that being a front-line and senior staff member and female was associated with higher risk of experiencing symptoms of depression, anxiety and acute stress.Conclusions: Our study findings raise concerns about the psychological well-being of postgraduate trainees during the acute COVID-19 outbreak in Pakistan. It is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during crisis situation such as COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Anorexia nervosa (AN) is a severe psychiatric disorder associated with frequent relapses and variability in treatment responses. Previous literature suggested that such variability is influenced by premorbid vulnerabilities such as abnormalities of the reward system. Several factors may indicate these vulnerabilities, such as neurocognitive markers (tendency to favour delayed reward, poor cognitive flexibility, abnormal decision process), genetic and epigenetic markers, biological and hormonal markers, and physiological markers.The present study will aim to identify markers that can predict body mass index (BMI) stability 6 months after discharge. The secondary aim of this study will be focused on characterising the biological, genetic, epigenetic and neurocognitive markers of remission in AN., Methods and Analysis: One hundred and twenty-five (n=125) female adult inpatients diagnosed with AN will be recruited and evaluated at three different times: at the beginning of hospitalisation, when discharged and 6 months later. Depending on the BMI at the third visit, patients will be split into two groups: stable remission (BMI≥18.5 kg/m²) or unstable remission (BMI<18.5 kg/m²). One hundred (n=100) volunteers will be included as healthy controls.Each visit will consist in self-reported inventories (measuring depression, anxiety, suicidal thoughts and feelings, eating disorders symptoms, exercise addiction and the presence of comorbidities), neurocognitive tasks (Delay Discounting Task, Trail-Making Test, Brixton Test and Slip-of-action Task), the collection of blood samples, the repeated collection of blood samples around a standard meal and MRI scans at rest and while resolving a delay discounting task.Analyses will mainly consist in comparing patients stabilised 6 months later and patients who relapsed during these 6 months., Ethics and Dissemination: Investigators will ask all participants to give written informed consent prior to participation, and all data will be recorded anonymously. The study will be conducted according to ethics recommendations from the Helsinki declaration (World Medical Association, 2013). It was registered on clinicaltrials.gov on 25 August 2020 as 'Remission Factors in Anorexia Nervosa (REMANO)', with the identifier NCT04560517 (for more details, see https://clinicaltrials.gov/ct2/show/record/NCT04560517). The present article is based on the latest protocol version from 29 November 2019. The sponsor, Institut National de la Santé Et de la Recherche Médicale (INSERM, https://www.inserm.fr/), is an academic institution responsible for the monitoring of the study, with an audit planned on a yearly basis.The results will be published after final analysis in the form of scientific articles in peer-reviewed journals and may be presented at national and international conferences., Trial Registration Number: clinicaltrials.govNCT04560517., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Individuals with psychiatric disorders have an increased risk of developing dementia. Most cross-sectional studies suffer from selection bias, underdiagnosis and poor population representation, while there is only limited evidence from longitudinal studies on the role of anxiety, bipolar and psychotic disorders. Electronic health records (EHRs) permit large cohorts to be followed across the lifespan and include a wide range of diagnostic information., Objective: To assess the association between four groups of psychiatric disorders (schizophrenia, bipolar disorder/mania, depression and anxiety) with dementia in two large population-based samples with EHR., Methods: Using EHR on nearly 1 million adult individuals in Wales, and from 228 937 UK Biobank participants, we studied the relationships between schizophrenia, mania/bipolar disorder, depression, anxiety and subsequent risk of dementia., Findings: In Secure Anonymised Information Linkage, there was a steep increase in the incidence of a first diagnosis of psychiatric disorder in the years prior to the diagnosis of dementia, reaching a peak in the year prior to dementia diagnosis for all psychiatric diagnoses. Psychiatric disorders, except anxiety, were highly significantly associated with a subsequent diagnosis of dementia: HRs=2.87, 2.80, 1.63 for schizophrenia, mania/bipolar disorder and depression, respectively. A similar pattern was found in the UK Biobank (HRs=4.46, 3.65, 2.39, respectively) and anxiety was also associated with dementia (HR=1.34). Increased risk of dementia was observed for all ages at onset of psychiatric diagnoses when these were divided into 10-year bins., Conclusions: Psychiatric disorders are associated with an increased risk of subsequent dementia, with a greater risk of more severe disorders., Clinical Implications: A late onset of psychiatric disorders should alert clinicians of possible incipient dementia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Neuropsychiatric symptoms (NPS) are common non-motor symptoms among patients with Parkinson's disease (PD) and significantly impact their overall quality of life detrimentally. Several studies have reported the clinical effect of acupuncture therapy in treating NPS in PD. Therefore, the objective of this systematic review is to evaluate the potential inclusion of acupuncture therapy as an integral component of complementary treatment for PD with NPS., Methods and Analysis: From their inception until 1 December 2023, we will search eight databases, including PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, China Science Periodical Database, Chinese Citation Database and China Biology Medicine disc for randomised controlled trials examining the effectiveness of acupuncture for PD with NPS. Literature screening and data extraction will be carried out independently by the authors. RevMan V.5.3 software will be used for meta-analysis, while the Cochrane risk-of-bias tool will assess the potential for bias., Ethics and Dissemination: This systematic review protocol does not require ethical approval because it does not include private information or data of participants. This article will be published in a peer-reviewed journal., Prospero Registration Number: CRD42022324494., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Medical education poses serious stressors on medical students, as they report overall higher rates of psychiatric comorbidities compared with students enrolled in other university-level courses. The high rates of poor well-being reported should be considered a concern, as students represent the future workforce of healthcare professionals. Although there has been an increased interest towards well-being and burn-out in medical students, there is still much to be elucidated. Indeed, there is an overall lack of understanding of which attitudes medical students have towards well-being and welfare, something that could be used to develop targeted practice to improve medics' quality of life and reduce overall burn-out.This review will aim at evaluating and reporting the current research available on medical students' attitudes towards well-being and welfare. We will take into account which countries have published data on the topic, and we will analyse papers written during the COVID-19 period separately, giving this particular time frame a separate outlook., Methods and Analysis: This systematic review protocol has been developed following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. A systematic search including "medical students" AND "wellbeing" AND "perceptions" was carried out on MEDLINE, Embase and Scopus databases. The Mixed Method Appraisal Tool will be used to assess the quality of the available studies and risk of bias. Studies will be screened using predetermined inclusion and exclusion criteria. Data will be summarised narratively and in tabular forms. A narrative subgroup analysis of the COVID-19 period will be carried out, and a country-wise approach will be used to describe which areas have published relevant studies., Ethics and Dissemination: This will be the first systematic review looking at the reported attitudes that medical students have towards well-being and welfare. This will provide an account of the available data on the topic, and a starting point to understand where further research is needed in the future., Prospero Registration Number: CRD42023471022., Competing Interests: Competing interests: NSK received funding from the British Heart Foundation for 4-year MRes/PhD DTP., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: New National Institute for Health and Care Excellence (NICE) guidance endorses the prescription of statins in larger population groups for the prevention of cardiovascular and cerebrovascular morbidity and mortality, especially in people with severe mental illness. However, the evidence base for their safety and risk/benefit balance in depression is not established., Objectives: This study aims to assess the real-world mortality and adverse events of statins in depressive disorders., Methods: Population-based, nationwide (England), between-subject, cohort study. We used electronic health records (QResearch database) of people aged 18-100 years with first-episode depression, registered with English primary care practices over January 1998-August 2020 for 12(+) months, divided into statin users versus non-users.Primary safety outcomes included all-cause mortality and any adverse event measured at 2, 6 and 12 months. Multivariable logistic regression was employed to control for several potential confounders and calculate adjusted ORs (aORs) with 99% CIs., Findings: From over 1 050 105 patients with depression (42.64% males, mean age 43.23±18.32 years), 21 384 (2.04%) died, while 707 111 (67.34%) experienced at least one adverse event during the 12-month follow-up. Statin use was associated with lower mortality over 12 months (range aOR 2-12months 0.66-0.67, range 99% CI 0.60 to 0.73) and with lower adverse events over 6 months (range aOR 2-6months 0.90-0.96, range 99% CI 0.91 to 0.99), but not at 1 year (aOR 12months 0.99, 99% CI 0.96 to 1.03). No association with any other individual outcome measure (ie, any other neuropsychiatric symptoms) was identified., Conclusions: We found no evidence that statin use among people with depression increases mortality or other adverse events., Clinical Implications: Our findings support the safety of updated NICE guidelines for prescribing statins in people with depressive disorders., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare the following: RDG is supported by the Wellcome Trust (award 102176/Z/13/Z, grant 216452/Z/19/Z, title 'The effects of anti-inflammatory drugs on emotional and reward processing'). FDC is supported by the National Institute for Health Research (NIHR) Research Professorship to AC (grant RP-2017-08-ST2-006) and by the NIHR Oxford Health Biomedical Research Centre (grant BRC-1215-20005). EGO is supported by the NIHR Research Professorship to AC (grant RP-2017-08-ST2-006). PC is supported by the Medical Research Council (MRC) (grant MR/S003037/1, title 'Clinical Psychopharmacology of Depression'). CJH is supported by the NIHR Oxford Health Biomedical Research Centre. SF is supported by the NIHR Oxford Health Biomedical Research Centre. AC is supported by the NIHR Oxford Cognitive Health Clinical Research Facility, by an NIHR Research Professorship (grant RP-2017-08-ST2-006), by the NIHR Oxford and Thames Valley Applied Research Collaboration, by the NIHR Oxford Health Biomedical Research Centre (grant BRC-1215-20005) and by Wellcome Trust (GALENOS Project). CJH has received consultancy fees from P1vital, Lundbeck, Servier, UCB, Zogenix, J&J and Syndesi outside of the current work. AC has received research and consultancy fees from INCiPiT (Italian Network for Paediatric Trials), CARIPLO, Lundbeck and Angelini Pharma outside of the current work. The other authors declare that they have no conflict of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Dementia is a growing public health concern, and providing long-term care for individuals affected by this condition is challenging for their family caregivers. While researchers have explored various intervention options to provide psychological support for dementia caregivers, mentalising imagery therapy (MIT) has gained significant recognition as an effective programme. Despite its significance and effectiveness, there is a lack of comprehensive scoping reviews of MIT in dementia caregiving. Thus, conducting such a review can provide valuable insights into the status and outcomes of MIT, identify gaps in existing research and provide recommendations for a more effective clinical practice., Methods and Analysis: This study proposes a scoping review conducted according to the Joanna Briggs Institute, Arksey and O'Malley's methodological framework, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension. PubMed, Web of Science, Embase, Scopus, CINAHL and PsycINFO databases will be searched while grey literature will be retrieved via Google Scholar. Covidence will be used to manage the literature selection process and remove duplicate publications. Two researchers will independently screen the literature according to the inclusion criteria, with any discrepancies resolved through discussions with a third researcher. Data will be presented in a structured tabular format, with a narrative synthesis providing an overview of the findings on the identified research gaps and the effectiveness of MIT in the field of dementia caregiving., Ethics and Dissemination: In a scoping review, no ethical approval is necessary. The results will be published in a peer-reviewed journal., Trial Registration Number: The scoping review protocol has been registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/FHRG8)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Although short-term benefits follow parenteral ketamine for treatment-resistant major depressive disorder (TR-MDD), there are challenges that prevent routine use of ketamine by clinicians. These include acute dissociative effects of parenteral ketamine, high relapse rates following ketamine dosing and the uncertain role of psychotherapy. This randomised controlled trial (RCT) seeks to establish the feasibility of evaluating repeated oral doses of ketamine and behavioural activation therapy (BAT), compared with ketamine treatment alone, for TR-MDD. We also aim to compare relapse rates between treatment arms to determine the effect size of adding BAT to oral ketamine., Methods and Analysis: This is a prospectively registered, two-centre, single-blind RCT. We aim to recruit 60 participants with TR-MDD aged between 18 and 65 years. Participants will be randomised to 8 weeks of oral ketamine and BAT, or 8 weeks of oral ketamine alone. Feasibility will be assessed by tracking attendance for ketamine and BAT, acceptability of treatment measures and retention to the study follow-up protocol. The primary efficacy outcome measure is the Montgomery-Asberg Depression Rating Scale (MADRS) measured weekly during treatment and fortnightly during 12 weeks of follow-up. Other outcome measures will assess the tolerability of ketamine and BAT, cognition and activity (using actigraphy). Participants will be categorised as non-responders, responders, remitters and relapsed during follow-up. MADRS scores will be analysed using a linear mixed model. For a definitive follow-up RCT study to be recommended, the recruitment expectations will be met and efficacy outcomes consistent with a >20% reduction in relapse rates favouring the BAT and ketamine arm will be achieved., Ethics and Dissemination: Ethics approval was granted by the New Zealand Central Health and Disability Ethics Committee (reference: 2023 FULL18176). Study findings will be reported to participants, stakeholder groups, conferences and peer-reviewed publications., Trial Registration Number: UTN: U1111-1294-9310, ACTRN12623000817640p., Competing Interests: Competing interests: KD and RP use software for research at no cost from Scientific Brain Training Pro. RP has received support for travel to educational meetings from Servier and Lundbeck. PG has a research contract with Douglas Pharmaceuticals to develop novel oral ketamine formulations. He has also attended advisory boards for Janssen Pharmaceuticals., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Therapeutic latency, lack of efficacy and adverse drug reactions are the major concerns in current antidepressant therapies. To overcome these treatment hurdles, add-on therapy to conventional antidepressant medications may lead to better therapeutic outcomes. The present randomised controlled trial has been planned to evaluate the efficacy and safety of add-on dextromethorphan to selective serotonin reuptake inhibitors (SSRIs) in major depressive disorder (MDD)., Methods and Analysis: A randomised, double-blind, add-on, placebo-controlled, group sequential design clinical trial will be conducted on patients with MDD who will be randomly assigned to the control and the test group in a 1:1 ratio. Patients in the test group will get dextromethorphan 30 mg once daily, whereas patients in the control group will receive a placebo once daily as an add-on to ongoing SSRI treatment for 8 weeks. All patients will be evaluated for the primary outcome (change in the Montgomery-Åsberg Depression Rating Scale score) and secondary outcomes (treatment response rate, remission rate, Clinical Global Impression, serum brain-derived neurotrophic factor, serum dextromethorphan and treatment-emergent adverse events) over the period of 8 weeks. Intention-to-treat analysis will be done for all parameters using suitable statistical tools., Ethics and Dissemination: This study was approved by the Institutional Ethics Committee of All India Institute of Medical Sciences, Bhubaneswar, India, and the study conformed to the provisions of the Declaration of Helsinki and ICMR's ethical guidelines for biomedical research on human subjects (2017). Written informed consent will be obtained from the participants before recruitment. The results of this study will be published in peer-reviewed publications., Trial Registration Number: NCT05181527., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Anxiety and depression pose a significant global health challenge, especially affecting adults in low-income and middle-income countries. In many low-income and middle-income countries, including those in sub-Saharan Africa, social determinants such as access to affordable health services, conflict, food insecurity, and poverty may be associated with the prevalence of anxiety and depression, further contributing to health disparities. To mitigate the burden of anxiety and depression in sub-Saharan Africa, it is essential to develop country-level tailored mental health policies and strategies. For example, Ghana is working towards improving mental health via its 12 year Mental Health policy launched in 2021. However, the prevalence of anxiety and depression among adults in Ghana, along with associated social determinants remains largely unknown, posing challenges for mental health planning, resource allocation and developing targeted interventions. This systematic review seeks to (1) examine the prevalence of anxiety and depression among adults in Ghana and (2) explore social determinants potentially associated with anxiety and depression., Methods and Analysis: Electronic databases (eg, African Index Medicus, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched with all screening steps conducted by two independent reviewers. Secondary search strategies, including grey literature searches, will be used. Studies reporting on the prevalence of anxiety, depression and/or a combined symptom measure (ie, psychological distress) among adults in Ghana, using validated instruments will be included. If data allows, random-effects-meta-analyses will be performed to estimate pooled prevalence rates of anxiety and depression. Potential clinical and methodological moderators will be examined using subgroup analyses and meta-regression. A narrative synthesis will explore social determinants potentially associated with anxiety and depression among adults in Ghana., Ethics and Dissemination: Ethical approval is not required as no primary data will be collected. Results will be disseminated via a peer-reviewed publication and presentations at academic conferences. Plain language summaries will be provided to relevant non-governmental organisations working in Ghana., Prospero Registration Number: CRD42023463078., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Electroencephalographic neurofeedback (NFB), as a non-invasive form of brainwave training, has been shown to be effective in the treatment of various mental health disorders. However, only few results regarding manualised and standardised NFB trainings exist. This makes comparison as well as replication of studies difficult. Therefore, we developed a standard manual for NFB training in patients with mental health disorders attending a psychosomatic outpatient clinic. The current study aims at investigating the conduction of a standardised manual for NFB training in patients with mental health disorders. If successful, the study provides new opportunities to investigate NFB in a more controlled and comparable manner in clinical practice., Methods and Analysis: 30 patients diagnosed with a mental health disorder will be included. After the educational interview, patients will undergo baseline diagnostics (T0). The subsequent intervention consists of 10 sessions of NFB training aiming at increasing sensorimotor rhythm and alpha-frequency amplitudes and decreasing theta-frequency and high beta-frequency amplitudes to induce relaxation and decrease subjective stress. All patients will undergo a post-treatment diagnostic assessment (T1) and a follow-up assessment 8 weeks following the closing session (T2). Changes in amplitude bands (primary outcome) will be recorded with electroencephalography during pre-assessments, post-assessments and follow-up assessments and during NFB sessions. Physiological (respiratory rate, blood volume pulse, muscle tension) and psychometric parameters (distress, perceived stress, relaxation ability, depressive and anxiety symptoms, insomnia, self-efficacy and quality of life) will be assessed at T0, T1 and T2. Moreover, satisfaction, acceptance and usability will be assessed at T1 after NFB training. Further, qualitative interviews about the experiences with the intervention will be conducted with NFB practitioners 6 months after the study starts. Quantitative data will be analysed using repeated measures analysis of variance as well as mediation analyses on mixed linear models. Qualitative data will be analysed using Mayring's content analysis., Ethics and Dissemination: The study was approved by the ethics committee of the Medical Faculty of the University of Duisburg-Essen (23-11140-BO) and patient enrolment began in April 2023. Before participation, written informed consent by each participant will be required. Results will be published in peer-reviewed journals and conference presentations., Trial Registration Number: Prospectively registered on 28 March 2023 in the German clinical trials register, DRKS00031497., Competing Interests: Competing interests: Author AK is employed by NeuroFit GmbH. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest, (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mental health disorders (MHDs) are associated with physical health disparities, but underlying excess risk and health burden have not yet been comprehensively assessed., Objective: To assess the burden of comorbid physical health conditions (PHCs) across serious MHDs in Europe., Methods: We estimated the relative prevalence risk of PHCs associated with alcohol use disorders (AUD), bipolar disorder (BD), depressive disorders (DD) and schizophrenia (SZ) across working-age populations of 32 European countries in 2019 based on a targeted literature review. Excess physical health burden was modelled using population-attributable fractions and country-level prevalence data., Findings: We screened 10 960 studies, of which 41 were deemed eligible, with a total sample size of over 18 million persons. Relative prevalence of PHCs was reported in 54%, 20%, 15%, 5% and 7% of studies, respectively, for SZ, DD, BD, AUD or mixed. Significant relative risk estimates ranged from 1.44 to 3.66 for BD, from 1.43 to 2.21 for DD, from 0.81 to 1.97 for SZ and 3.31 for AUD. Excess physical health burden ranged between 27% and 67% of the total, corresponding to 84 million (AUD), 67 million (BD), 66 million (DD) and 5 million (SZ) PHC diagnoses in Europe. A 1% reduction in excess risk assuming causal inference could result in two million fewer PHCs across investigated MHDs., Conclusions: This is the first comprehensive study of the physical health burden of serious MHDs in Europe. The methods allow for updates, refinement and extension to other MHDs or geographical areas., Clinical Implications: The results indicate potential population health benefits achievable through more integrated mental and physical healthcare and prevention approaches., Competing Interests: Competing interests: CA has been a consultant to or has received honoraria or grants from Acadia, Angelini, Biogen, Boehringer, Gedeon Richter, Janssen Cilag, Lundbeck, Medscape, Menarini, Minerva, Otsuka, Pfizer, Roche, Sage, Servier, Shire, Schering-Plough, Sumitomo Dainippon Pharma, Sunovion and Takeda. GMK has received honoraria as a speaker or consultant for Angelini, Gilgamesh, H Lundbeck, Onsero, Pangea, Sage and Sanos. GMG is Chief Medical Officer at Compass Pathways, holds shares and share options at Compass Pathways, and has served as consultant, advisor or CME speaker in the last 3 years for Beckley Psytech, Boehringer Ingelheim, Clerkenwell Health, Compass Pathways, Evapharma, Janssen, Lundbeck, Medscape, Novartis, Ocean Neuroscience, P1Vital, Servier and Takeda. JS has received honoraria as academic advisor from the European Brain Council., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

Adults with neurodevelopmental disorders frequently present to, but fit uneasily into, adult mental health services. We offer definitions of important terms related to neurodevelopmental disorders through unifying research data, medical and other viewpoints. This may improve understanding, clinical practice and development of neurodevelopmental disorder pathways within adult mental health services. [ABSTRACT FROM AUTHOR]

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 < 0.001). In addition, for the patients hospitalized after the introduction of the emergency hotline there was a trend-level reduction of the average length of stay (9.32 days vs 17.35 days). 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. [ABSTRACT FROM AUTHOR]