Anxiety and depressive disorders can be chronic and disabling. Although there are effective treatments, only a fraction of those impaired receive treatment. Predictors of treatment-seeking and treatment receipt could be informative for initiatives aiming to tackle the burden of untreated anxiety and depression.

To investigate sociodemographic characteristics associated with treatment-seeking and treatment receipt.

Two binary retrospective reports of lifetime treatment-seeking (n = 44 810) and treatment receipt (n = 37 346) were regressed on sociodemographic factors (age, gender, UK ethnic minority background, educational attainment, household income, neighbourhood deprivation and social isolation) and alternative coping strategies (self-medication with alcohol/drugs and self-help) in UK Biobank participants with lifetime generalised anxiety or major depressive disorder. Analyses were also stratified by gender.

Treatment access was more likely in those who reported use of self-help strategies, with university-level education and those from less economically advantaged circumstances (household income <£30 000 and greater neighbourhood deprivation). Treatment access was less likely in those who were male, from a UK ethnic minority background and with high household incomes (>£100 000). Men who self-medicated and/or had a vocational qualification were also less likely to seek treatment.

This work on retrospective reports of treatment-seeking and treatment receipt at any time of life replicates known associations with treatment-seeking and treatment receipt during time of treatment need. More work is required to understand whether improving rates of treatment-seeking improves prognostic outcomes for individuals with anxiety or depression.

Eating disorders are serious and debilitating mental health conditions associated with high relapse and mortality rates and significant psychiatric comorbidities. Research suggests approximately 50% of patients with an eating disorder dropout prematurely from treatment services, fostering poorer health outcomes and impacting significantly on patients, their families, health services and research quality. The aim of this review is to synthesise the current qualitative literature available on the patient experience of dropout from eating disorder services and understand the reasons motivating early treatment termination.

A systematic search was carried out and articles selected from MEDLINE, PsycINFO, EMBASE and CINAHL. Studies were included if they explored eating disorder treatment dropout using qualitative data collection or analysis methods. Study quality was critically appraised using the Critical Appraisal Skills Programme qualitative research evaluation tool. Thematic synthesis was used to interpret and synthesise themes from the primary studies.

Ten studies met the inclusion criteria for the systematic review. Five studies were scored as high quality and five as medium quality. 13 descriptive sub-themes encompassing the dropout experience were identified under four overarching analytical themes: inner conflict, connection and communication with others, experience of the treatment service, and factors related to progress in treatment.

The decision to drop out from eating disorder treatment is a complex, multi-faceted issue, involving an interplay between individual, social and service-level factors. This review highlights the need for further high quality qualitative investigation into dropout experiences, with an effort to increase representation across ethnic groups and gender identities. This review also identifies the need for a reconsideration of current clinical practice and services provision with an emphasis on the use of patient perspectives to guide decision making in eating disorder services delivery and research. Moreover, the findings emphasise the need for standardised dropout definitions, fostering a unified literature base.

The waiting room in psychiatric services can provide an ideal setting for offering evidence-based psychological interventions that can be delivered through electronic media. Currently, there is no intervention available that have been developed or tested in mental health.

This proof-of-concept study aimed to evaluate a pilot design of RESOLVE (Relaxation Exercise, SOLving problem and cognitiVe Errors) to test the procedure and obtain outcome data to inform future, definitive trials (trial registration at Clinicaltrials.gov NCT02536924, REB Number: PSIY-477-15).

Forty participants were enrolled and equally randomised to the intervention, RESOLVE plus treatment as usual arm (TAU), or to a control group (TAU only). Those in the intervention group watched RESOLVE in a room adjacent to the waiting area. Participants in the control received routine care. Outcome measures included the Hospital Anxiety and Depression Scale; the Clinical Outcomes in Routine Evaluations outcome measure; and the World Health Organization Disability Assessment Schedule. These measures were performed by a masked assessor at baseline and at 6-week follow-up. Additionally, we measured the number of contacts with mental health services during the prior 4 weeks. Both intention-to-treat and per protocol analyses were performed.

The study proved feasible. We were able to recruit the required number of participants. There was a statistically significant improvement in depression (P < 0.001), anxiety (P < 0.001), general psychopathology (P < 0.001) and disability (P = 0.0361) in favour of the intervention group. People in the intervention group were less likely to contact the service (P = 0.012) post-intervention.

Findings provide preliminary evidence that evidence-based psychosocial interventions can be delivered through electronic media in a waiting-room setting. The outcome data from this study will be used for future definitive trials.

None.

Off-label ketamine treatment has shown acute antidepressant effects that offer hope for patients with therapy-resistant depression. However, its potential for integration into treatment algorithms is controversial, not least because the evidence base for maintenance treatment with repeated ketamine administration is currently weak. Ketamine is also a drug of misuse, which has raised concerns regarding the target population. Little is known about which patients would seek ketamine treatment if it were more widely available.

To explore some of the characteristics of the patients actively seeking ketamine treatment.

An online survey containing questions about duration of current depressive episode, number of antidepressants used and other comments was completed by patients who were exploring the internet regarding the possibility of ketamine for depression.

Of the 1088 people who registered their interest, 93.3% reported depression, 64.3% reported a chronic course of their symptoms and in the past 10 years, 86.3% had tried at least two antidepressants. Desperation was a common theme, but this appeared to be competently expressed. A small minority (<8%) reported experience of illegal ketamine use.

It cannot be ruled out that patients with different degrees of treatment resistance and comorbidities will seek treatment with ketamine. This stresses the urgency to perform larger randomised controlled trials as well as to systematically monitor outcomes and adverse effects of ketamine, that is currently prescribed off-label for patients in need.

R.M. is consulting and is Principal Investigator for Janssen trials of esketamine and is consulting for Eleusis.

There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects.

To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms.

Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert.

Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned.

Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.

The structure of negative symptoms of schizophrenia is still a matter of controversy. Although a two-dimensional model (comprising the expressive deficit dimension and the motivation and pleasure dimension) has gained a large consensus, it has been questioned by recent investigations.

To investigate the latent structure of negative symptoms and its stability over time in people with schizophrenia using network analysis.

Negative symptoms were assessed in 612 people with schizophrenia using the Brief Negative Symptom Scale (BNSS) at baseline and at 4-year follow-up. A network invariance analysis was conducted to investigate changes in the network structure and strength of connections between the two time points.

The network analysis carried out at baseline and follow-up, supported by community detection analysis, indicated that the BNSS's items aggregate to form four or five distinct domains (avolition/asociality, anhedonia, blunted affect and alogia). The network invariance test indicated that the network structure remained unchanged over time (network invariance test score 0.13; P = 0.169), although its overall strength decreased (6.28 at baseline, 5.79 at follow-up; global strength invariance test score 0.48; P = 0.016).

The results lend support to a four- or five-factor model of negative symptoms and indicate overall stability over time. These data have implications for the study of pathophysiological mechanisms and the development of targeted treatments for negative symptoms.

Black and minority ethnic (BME) groups are known to have higher prevalences of psychotic disorders and are over-represented in western penitentiaries and forensic psychiatric institutions. Research from regular mental healthcare settings suggests that they could show different and more severe psychotic symptoms.

To explore ethnic variations in severity of symptomatology of BME and non-BME detainees with psychotic disorders.

In this study, 824 patients with psychotic disorders from seven different ethnic groups, imprisoned in a penitentiary psychiatric centre in the Netherlands, were compared on symptom severity and symptom representation using the BPRS-E clinical interview. Data were analysed by means of a multilevel analysis.

BME patients with psychotic disorders are over-represented in forensic psychiatry, and symptom profiles of prisoners with psychotic disorders vary by ethnicity. Additionally, severity levels of overall psychopathology differ between ethnic groups: patients with an ethnic majority status show more severe levels of psychopathology compared with BME patients.

There are differences in symptom severity and symptom profiles between BME patients and non-BME patients. Disregarding these differences could have an adverse effect on the outcome of the treatment. Possible explanations and clinical impact are discussed.

None.

Behaviour that challenges in people with intellectual disability is associated with higher healthcare, social care and societal costs. Although behavioural therapies are widely used, there is limited evidence regarding the cost and quality-adjusted life-years (QALYs).

We aimed to assess the incremental cost per QALY gained of therapist training in positive behaviour support (PBS) and treatment as usual (TAU) compared with TAU using data from a cluster randomised controlled trial (Clinical Trials.gov registration: NCT01680276).

We conducted a cost-utility analysis (cost per QALY gained) of 23 teams randomised to PBS or TAU, with a total of 246 participants followed up over 36 months. The primary analysis was from a healthcare cost perspective with a secondary analysis from a societal cost perspective.

Over 36 months the intervention resulted in an additional 0.175 QALYs (discounted and adjusted 95% CI −0.068 to 0.418). The total cost of training in and delivery of PBS is £1598 per participant plus an additional cost of healthcare of £399 (discounted and adjusted 95% CI −603 to 1724). From a healthcare cost perspective there is an 85% probability that the intervention is cost-effective compared with TAU at a £30 000 willingness to pay for a QALY threshold.

There was a high probability that training in PBS is cost-effective as the cost of training and delivery of PBS is balanced out by modest improvements in quality of life. However, staff training in PBS is not supported given we found no evidence for clinical effectiveness.

Norway authorised out-patient commitment in 1961, but there is a lack of representative and complete data on the use of out-patient commitment orders.

To establish the incidence and prevalence rates on the use of out-patient commitment in Norway, and how these vary across service areas. Further, to study variations in out-patient commitment across service areas, and use of in-patient services before and after implementation of out-patient commitment orders. Finally, to identify determinants for the duration of out-patient commitment orders and time to readmission.

Retrospective case register study based on medical files of all patients with an out-patient commitment order in 2008–2012 in six catchment areas in Norway, covering one-third of the Norwegian population aged 18 years or more. For a subsample of patients, we recorded use of in-patient care 3 years before and after their first-ever out-patient commitment.

Annual incidence varied between 20.7 and 28.4, and prevalence between 36.5 and 48.9, per 100 000 population aged 18 years or above. Rates differed significantly between catchment areas. Mean out-patient commitment duration was 727 days (s.d. = 889). Use of in-patient care decreased significantly in the 3 years after out-patient commitment compared with the 3 years before. Use of antipsychotic medication through the whole out-patient commitment period and fewer in-patient episodes in the 3 years before out-patient commitment predicted longer time to readmission.

Mechanisms behind the pronounced variations in use of out-patient commitment between sites call for further studies. Use of in-patient care was significantly reduced in the 3 years after a first-ever out-patient commitment order was made.

None.

The causes of delayed post-traumatic stress disorder (PTSD) are debated, and the validity of late-onset PTSD has been questioned.

We aimed to examine predictors of delayed PTSD in a community sample of survivors of a natural disaster.

Norwegian survivors of the 2004 Indian Ocean tsunami (n = 532) responded to a questionnaire at 6 and 24 months post-disaster. The questionnaire measured PTSD symptoms, recalled exposure and immediate stress responses to the disaster, recalled perceived life threat, personality dimensions, social support and other subsequent adverse life events.

When dichotomising PTSD symptom scores, 331 participants had low and 194 had high PTSD scores (early-onset PTSD) at 6 months. Of those with initially low scores, 43 (13.0%) had high symptom scores (delayed PTSD) at 24 months. The delayed PTSD group had a lower degree of initially assessed threat and witness experiences of death or suffering, lower immediate stress response and higher degree of memory inflation of perceived threat than the early-onset PTSD group. Among those with low PTSD scores at 6 months, onset of delayed PTSD was associated with neuroticism and memory inflation of life threat, but not with the degree of initially assessed disaster exposure or reports of subsequent adverse life events.

Lack of association between trauma exposure and delayed onset of PTSD symptoms casts doubt on whether the traumatic event is actually the primary causative factor for delayed PTSD. Our findings suggest that delayed PTSD may be a manifestation of personality factors and memory inflation of the severity of an event.

Early-life interpersonal stress, particularly childhood maltreatment, is associated with neurobiological abnormalities. However, few studies have investigated the neural effects of peer victimisation.

This study examines common and specific associations between childhood maltreatment, peer victimisation and brain structural alterations in youths.

Grey matter volume (GMV) and cortical thickness data were collected from 105 age- and gender-matched youths (age range: 17–21 years). Region-of-interest and whole-brain analyses were conducted.

For the region-of-interest analyses, the childhood maltreatment group had smaller GMV than controls in left inferior frontal gyrus, bilateral anterior insula, postcentral and lingual regions, which were associated with greater emotional abuse, along with smaller insular GMV than the peer victimisation group, who had smaller left lingual and postcentral GMV than controls. At the whole-brain level, both childhood maltreatment and peer victimisation groups had smaller GMV than controls in a cluster comprising left post/precentral, inferior frontal gyrus, insula, superior parietal and supramarginal gyri. The peer victimisation group alone had increased cortical thickness in a cluster comprising left superior frontal, anterior cingulate and medial orbitofrontal gyri, which was related to greater cyberbullying.

Early-life interpersonal stress is associated with common structural alterations of the inferior frontal-limbic, sensory and lingual regions involved in cognitive control, emotion and sensory processing. The findings of childhood-maltreatment-related reduced anterior insular GMV and peer-victimisation-related increased cortical thickness in the left medial prefrontal-anterior cingulate cluster underscore the distinctive negative effects of childhood maltreatment and peer victimisation, and suggest that peer victimisation, particularly cyberbullying, could be as detrimental as childhood maltreatment.

There are no longitudinal studies investigating determinants of incident and persistent depressive symptoms in Southeast Asia.

To estimate the proportion and correlates of incident and persistent depressive symptoms in a prospective cohort study among middle-aged and older adults (≥45 years) in Thailand.

We analysed longitudinal data from the Health, Aging, and Retirement in Thailand (HART) surveys in 2015 and 2017. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Logistic regression was used to calculate predictors of incident and persistent depressive symptoms.

In total, 290 of 4528 participants without depressive symptoms in 2015 had incident depressive symptoms in 2017 (9.8%) and 76 of 640 adults had persistent depressive symptoms (in both 2015 and 2017) (18.3%). In adjusted logistic regression analysis, having diabetes (adjusted odds ratio AOR = 1.48, 95% CI 1.07–2.05), musculoskeletal conditions (AOR = 1.56, 95% CI 1.01–2.41) and having three or more chronic conditions (AOR = 2.55, 95% CI 1.67–3.90) were positively associated and higher subjective economic status (AOR = 0.47, 95% CI 0.31–0.72) and social participation (AOR = 0.66, 95% CI 0.49–0.90) were inversely associated with incident depressive symptoms. Having a cardiovascular disease (AOR = 1.55, 95% CI 1.01–2.39) and having three or more chronic conditions (AOR = 2.47, 95% CI 1.07–5.67) were positively associated and social participation (AOR = 0.48, 95% CI 0.26–0.87) was inversely associated with persistent depressive symptoms.

One in ten middle-aged and older adults had incident depressive symptoms at 2-year follow-up. The prevalence of incident and/or persistent depression was higher in people with a lower subjective economic status, low social participation, diabetes, musculoskeletal disorders, cardiovascular conditions and a higher number of chronic diseases.

There are few very brief measures that accurately identify multiple common mental disorders.

The aim of this study was to develop and assess the psychometric properties of a new composite measure to screen for five common mental disorders.

Two cross-sectional psychometric surveys were used to develop (n = 3175) and validate (n = 3620) the new measure, the Rapid Measurement Toolkit-20 (RMT20) against diagnostic criteria. The RMT20 was tested against a DSM-5 clinical checklist for major depression, generalised anxiety disorder, panic disorder, social anxiety disorder and post-traumatic stress disorder, with comparison with two measures of general psychological distress: the Kessler-10 and Distress Questionnaire-5.

The area under the curve for the RMT20 was significantly greater than for the distress measures, ranging from 0.86 to 0.92 across the five disorders. Sensitivity and specificity at prescribed cut-points were excellent, with sensitivity ranging from 0.85 to 0.93 and specificity ranging from 0.73 to 0.83 across the five disorders.

The RMT20 outperformed two established scales assessing general psychological distress, is free to use and has low respondent burden. The measure is well-suited to clinical screening, internet-based screening and large-scale epidemiological surveys.

The video-based free social media app, TikTok, has grown in popularity during the COVID-19 pandemic, with half of British children using Tik Tok regularly. With more than 2 billion downloads, it was the most downloaded app of 2020. Child and Adolescent Mental Health Services (CAMHS) is currently found on TikTok via the hashtag #CAMHS. The aim of this study was to explore how CAMHS is represented on TikTok through reviewing the hashtags associated with CAMHS and exploring the themes of videos with the #CAMHS hashtag.

The Tik Tok app was downloaded and a search for the hashtags which featured the word #CAMHS was undertaken. A thematic analysis of the top 100 most popular uploaded videos featuring the #CAMHS was conducted. The number of likes, views and shares of the videos featuring each theme was recorded.

Videos with the hashtag #CAMHS had 203.9 million views, followed by: #camhsmeme(s) totalling 43.1 million views, #camhsjokes with 21.4 million views and #camhskids, 12.5 million views. The top 100 most popular videos represented 24% of total viewed videos with the hashtag #CAMHS.

The most popular recurrent themes associated with the hashtag #CAMHS in our sample were: raising awareness of mental health symptoms and management (40% of videos), reference to self-harm (27% of videos) and negative perception of CAMHS (27% of videos).

Raising awareness of mental health symptoms and management had the most likes (3,694,700) and views (17,435,900). This was followed by videos with themes of reference to self-harm (3,006,300 likes and 14,382,700 views). The most shared themes were: reference to suicide (shared 56,763 times) and videos which portrayed a theme of negative perception of CAMHS (40,628 shares). Videos with themes of a negative perception of CAMHS also garnered 1,762,500 likes and 8,666,900 views.

CAMHS is actively represented on TikTok through freely accessible unregulated videos. Videos with themes of raising awareness of mental health symptoms and management can potentially allow young people to share their experiences. Nonetheless, popular hashtags such as #CAMHSmemes and #CAMHSjokes, as well as videos featuring themes of negative perception of CAMHS, could potentially undermine the reputation of CAMHS to existing and future service users. The content of these videos should be taken seriously by CAMHS clinicians as it can potentially provide an insight into service users’ experiences of CAMHS on a scale that has not been observed before. Presently these videos are not screened or modulated by the NHS CAMHS service.

Individuals with eating disorders who self-harm are a vulnerable group characterised by greater pathology and poorer outcomes.

To explore healthcare utilisation and mortality in those with a record of: self-harm only; eating disorders only; and both co-occurring.

We conducted a retrospective whole population e-cohort study of individuals aged 10–64 years from 2003 to 2016. Individuals were divided into: record of self-harm only; eating disorders only; both self-harm and eating disorders; and no record of self-harm or eating disorders. We used linked routinely collected healthcare data across primary care, emergency departments, hospital admissions and out-patient appointments to examine healthcare contacts and mortality.

We identified 82 627 individuals: n = 75 165 with self-harm only; n = 5786 with eating disorders only; n = 1676 with both combined. Across all groups and settings significantly more individuals attended with significantly more contacts than the rest of the population. The combined group had the highest number of contacts per person (general practitioner, incident rate ratio IRR = 3.3, 95% CI 3.1–3.5; emergency department, IRR = 5.2, 95% CI 4.7–5.8; hospital admission, IRR = 5.2, 95% CI 4.5–6.0; out-patients, IRR = 3.9, 95% CI 3.5–4.4). Standardised mortality ratios showed the highest excess mortality overall in the self-harm only group (SMR = 3.2, 95% CI 3.1–3.3), particularly for unnatural causes of death (SMR = 17.1, 95% CI 16.3–17.9). SMRs and years of life lost showed an increased risk of mortality in younger age groups in the combined group. Adjusted hazard ratios showed increased mortality across all groups (self-harm only, HR = 5.3, 95% CI 5.2–5.5; eating disorders only, HR = 4.1, 95% CI 3.4–4.9; combined group, HR = 6.8, 95% CI 5.4–8.6).

Individuals in all groups had higher healthcare service utilisation than the general population. The increased mortality risk in young people with a record of both eating disorders and self-harm highlights the need for early specialist intervention and enhanced support.

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

Our findings highlight practitioners’ views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

While up to 45% of individuals with intellectual and developmental disabilities (IDD) have a comorbid psychiatric disorder, and antipsychotics are commonly prescribed, gender differences in the safety of antipsychotics have rarely been studied in this population.

To compare men and women with IDD on medical outcomes after antipsychotic initiation.

Our population-based study in Ontario, Canada, compared 1457 women and 1951 men with IDD newly initiating antipsychotic medication on risk for diabetes mellitus, hypertension, venous thromboembolism, myocardial infarction, stroke and death, with up to 4 years of follow-up.

Women were older and more medically complex at baseline. Women had higher risks for venous thromboembolism (HR 1.72, 95% CI 1.15–2.59) and death (HR 1.46, 95% CI 1.02–2.10) in crude analyses; but only thromboembolism risk was greater for women after covariate adjustment (aHR 1.58, 95% CI 1.05–2.38).

Gender should be considered in decision-making around antipsychotic medications for individuals with IDD.

Triple chronotherapy (sleep deprivation for 36 h, followed by 4 days of advancing the time of sleep and daily morning bright-light therapy for 6 months) has demonstrated benefits for the rapid treatment of depressive symptoms in four small controlled trials of in-patients.

To test the feasibility of recruitment and delivery of triple chronotherapy for out-patients with depression (ISRCTN17706836; NCT03405493).

In a single-blind trial, 82 participants were randomised to triple chronotherapy or a control intervention. The primary outcome was the number of participants recruited per month and adherence to the protocol. Secondary outcomes included the 6-item Hamilton Rating Scale for Depression (HRSD-6) at 1 week. Timings of observer ratings were baseline and 1, 2, 4, 8 and 26 weeks after randomisation.

The triple chronotherapy group stayed awake for the planned 36 h and 89.9% adhered to the plan of phase advance of their sleep over the following 4 days. We achieved our recruitment target (60 participants completed the trial within 13 months). There were no reported adverse side-effects. We found a significant difference between the groups by intention-to-treat analysis for the HRSD-6 at weeks 1, 8 and 26. There was a large effect size of Cohen's d = 0.8 on HRSD-6 score at week 1, increasing to d = 1.30 at week 26. A response (≥50% reduction in symptoms) was achieved by 33.3% in the triple chronotherapy group and 16.2% in the control group. This stayed relatively steady until week 26 (35.9 v. 13.9%).

Triple chronotherapy produced a significant and rapid benefit after 1 week in out-patients with depression that was sustained at 26 weeks. Cost-effectiveness trials with a larger clinical sample are required.