In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown.

To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm.

Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment.

Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) −30.2% to −2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI −3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI −11.6% to 25.5%).

Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04–1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94–2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32–1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41–3.57, P < 0.001).

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients.

We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns.

This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded.

Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included.

A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

Several studies suggest significant relationships between migration and autism spectrum disorder (ASD) but there are discrepant results. Given that no studies to date have included a pathological control group, the specificity of the results in ASD can be questioned.

To compare the migration experience (premigration, migratory trip, postmigration) in ASD and non-ASD pathological control groups, and study the relationships between migration and autism severity.

Parents’ and grandparents’ migrant status was compared in 30 prepubertal boys with ASD and 30 prepubertal boys without ASD but with language disorders, using a questionnaire including Human Development Index (HDI)/Inequality-adjusted Human Development Index (IHDI) of native countries. Autism severity was assessed using the Child Autism Rating Scale, Autism Diagnostic Observation Schedule and Autism Diagnostic Interview-Revised scales.

The parents’ and grandparents’ migrant status frequency did not differ between ASD and control groups and was not associated with autism severity. The HDI/IHDI values of native countries were significantly lower for parents and grandparents of children with ASD compared with the controls, especially for paternal grandparents. Furthermore, HDI/IDHI levels from the paternal line (father and especially paternal grandparents) were significantly negatively correlated with autism severity, particularly for social interaction impairments.

In this study, parents’ and/or grandparents’ migrant status did not discriminate ASD and pathological control groups and did not contribute either to autism severity. However, the HDI/IHDI results suggest that social adversity-related stress experienced in native countries, especially by paternal grandparents, is potentially a traumatic experience that may play a role in ASD development. A ‘premigration theory of autism’ is then proposed.

We have previously shown increased anticipatory and consummatory neural responses to rewarding and aversive food stimuli in women recovered from anorexia nervosa (AN).

To determine whether these differences are trait markers for AN, we examined the neural response in those with a familial history but no personal history of AN.

Thirty-six volunteers were recruited: 15 who had a sister with anorexia nervosa (family history) and 21 control participants. Using fMRI we examined the neural response during an anticipatory phase (food cues, rewarding and aversive), an effort phase and a consummatory phase (rewarding and aversive tastes).

Family history (FH) volunteers showed increased activity in the caudate during the anticipation of both reward and aversive food and in the thalamus and amygdala during anticipation of aversive only. FH had decreased activity in the dorsal anterior cingulate cortex, the pallidum and the superior frontal gyrus during taste consumption.

Increased neural anticipatory but decreased consummatory responses to food might be a biomarker for AN. Interventions that could normalise these differences may help to prevent disorder onset.

Depression is characterised by negative views of the self. Antidepressant treatment may remediate negative self-schema through increasing processing of positive information about the self. Changes in affective processing during social interactions may increase expression of prosocial behaviours, improving interpersonal communications.

To examine whether acute administration of citalopram is associated with an increase in positive affective learning biases about the self and prosocial behaviour.

Healthy volunteers (n = 41) were randomised to either an acute 20 mg dose of citalopram or matched placebo in a between-subjects double-blind design. Participants completed computer-based cognitive tasks designed to measure referential affective processing, social cognition and expression of prosocial behaviours.

Participants administered citalopram made more cooperative choices than those administered placebo in a prisoner's dilemma task (β = 20%, 95% CI: 2%, 37%). Exploratory analyses indicated that participants administered citalopram showed a positive bias when learning social evaluations about a friend (β = 4.06, 95% CI: 0.88, 7.24), but not about the self or a stranger. Similarly, exploratory analyses found evidence of increased recall of positive words and reduced recall of negative words about others (β = 2.41, 95% CI: 0.89, 3.93), but not the self, in the citalopram group.

Participants administered citalopram showed greater prosocial behaviours, increased positive recall and increased positive learning of social evaluations towards others. The increase in positive affective bias and prosocial behaviours towards others may, at least partially, be a mechanism of antidepressant effect. However, we found no evidence that citalopram influenced self-referential processing.

Community treatment order (CTO) use in Australia and New Zealand ranges from less than 40 per 100 000 population in Western Australia and Canterbury to over 100 per 100 000 in Victoria, South Australia and Waitemata. Recent publications on CTO use now permit a meta-regression to investigate whether differences in CTO use by jurisdiction affect either the possible predictors or outcomes of CTOs.

To assess whether factors associated with CTO placement or subsequent outcomes vary by rates of use.

A systematic search of PubMed/Medline, Embase, CINAHL, the Cochrane Central Register of Controlled Trials and PsycINFO for any Australian or New Zealand study comparing CTO cases with controls receiving voluntary psychiatric treatment. This study was prospectively registered with PROSPERO (protocol registration number: CRD42022351500).

There were 35 articles from 16 studies identified in the search, plus unpublished data from a further study. Of these, 29 publications were included in meta-analyses. Two were from New Zealand. People who were male, single and not engaged in work, study or home duties were significantly more likely to be on CTOs. In addition, those from migrant backgrounds were 47% more likely to be on an order. On meta-regression, cases in jurisdictions with higher CTO rates had higher proportions of females or individuals with diagnoses other than non-affective psychoses. High-use jurisdictions were also less likely to show reductions in readmission rates or bed-days.

There are marked differences in the possible predictors and outcomes of CTO placement between high- and low-use jurisdictions in Australia and New Zealand. These findings may have implications elsewhere and indicate that better-targeted CTO placement might improve outcomes.

Even before the onset of psychotic symptoms, individuals with schizophrenia display cognitive impairments. Simultaneously, increasing amounts of individuals exhibit dysfunction of the blood–brain barrier (BBB). However, the impact of BBB dysfunction on neurocognitive impairment in people with first-episode psychosis has not yet been investigated.

To advance understanding of said relationship, we considered one of the largest first-episode psychosis cohorts with cerebrospinal fluid parameters available, and investigated whether BBB dysfunction is related to working memory, working speed and attention.

We conducted a retrospective chart review of 121 in-patients diagnosed with a first episode of a schizophrenia spectrum disorder. Patients underwent neurocognitive testing and a lumbar puncture within routine clinical care. To define BBB dysfunction, albumin cerebrospinal fluid/serum quotients, immunoglobulin G ratios and oligoclonal band types were evaluated, and gender-specific differences investigated. Neurocognitive functioning was assessed by the Wechsler Adult Intelligence Scale, Test of Attentional Performance and Repeatable Battery for the Assessment of Neuropsychological Status. We performed simple and multiple linear regression analyses to interpret associations of interest.

Of those tested, 16% showed an alteration in albumin quotients and 12% had an oligoclonal band type indicating BBB dysfunction. Notably, male patients were more likely to have an increased albumin quotient and a higher immunoglobulin G ratio than female patients. We found no significant association between BBB dysfunction and neurocognitive assessments.

The hypothesised relationship between BBB and neurocognitive impairments was not detectable in our retrospective cohort. Further cerebrospinal fluid-based studies with a longitudinal assessment of cognitive functioning and disease trajectory are urgently needed.

Shared decision-making encourages patients to explore treatment options/choices in collaboration with their healthcare provider, inclusive of the best available evidence and the patient's values/preferences. Several effective treatments exist for people with anxiety and/or depressive disorders; shared decision-making may be particularly useful in this context.

To investigate whether shared decision-making enhances clinical outcomes in adults with anxiety and/or depressive disorders.

A systematic review was conducted. Five electronic health databases were searched from database inception until August 2019, in addition to reference lists of included studies. Prospective controlled studies of shared decision-making in adults (aged 18–64 years) diagnosed with an anxiety and/or depressive disorder were included. Two reviewers independently conducted each stage of the review process.

Six randomised controlled trials (N = 1834 participants) were included. Patient satisfaction improved in four studies. Patients were more likely to receive adequate treatment for depression in three studies. Anxiety symptoms decreased in one study. Patient involvement in decision-making increased in three studies. Because of the lack of blinded interventions and outcome assessment, the included studies were at moderate risk of bias. The certainty of evidence ranged from low to moderate, per GRADE criteria.

Shared decision-making shows promise for enhancing quality-of-care outcomes such as patient satisfaction, without increasing consultation time, but appears unlikely to improve symptoms of depression. However, it appears to be understudied in patients with anxiety disorders. Heterogeneity regarding definition and measurement of shared decision-making posed challenges for interpreting the results. More research is recommended to advance the field.

Time-limited psychotherapy for depression is effective. However, comorbid personality disorders affect therapy outcomes negatively. Studies of follow-up effects and results relating to the influence of comorbid personality disorder and treatment modality are scarce.

To determine the influence of comorbid personality disorder and treatment modality on outcomes after cognitive–behavioural therapy (CBT) or short-term psychodynamic supportive psychotherapy (SPSP) for depression.

This study draws on data from a previously published randomised clinical trial contrasting SPSP and CBT for depression (both 16 sessions). We compared the effectiveness of these psychotherapies for patients with and without personality disorder (n = 196). The primary measure was depression outcome; the secondary measurements were interpersonal functioning and quality of life. Collected data were analysed using multilevel analysis. Trial registration: ISRCTN31263312 (http://www.controlled-trials.com).

Although participants with and without comorbid personality disorder improved at treatment termination (d = 1.04, 95% CI 0.77–1.31 and d = 1.36, 95% CI 0.97–1.76, respectively) and at follow-up (d = 1.15, 95% CI 0.87–1.43 and d = 2.12, 95% CI 1.65–2.59 respectively), personality disorder had a negative effect on depression outcome at both measurement points (P < 0.05). A similar negative effect on interpersonal functioning was no longer apparent at follow-up. Comorbid personality disorder had no influence on social functioning or quality of life outcomes, irrespective of treatment modality.

CBT and SPSP contribute to the improvement of depressive symptoms and interpersonal problems in depressed patients with and without comorbid personality disorder. Both treatments are an effective first step in a stepped care approach, but – given remaining levels of depression in patients with personality disorder – they are probably inadequate for large numbers of patients with this comorbidity.

None.

The assessment of resilience as an outcome in adolescents remains a challenge, with few instruments available. Some studies have focused on risk factors, but few have focused on protective factors as a formula for measuring resilient outcomes.

To adapt a new Suicide Attempt Resilience Scale (SRSA-18) for use with adolescents, analysing its structural validity, the gender and age invariance of the measure, and divergent and convergent validity, together with its reliability.

The psychometric properties of the scale were assessed in 628 participants aged between 13 and 18 years, of whom 342 (54.5%) were girls.

After a process of adaptation for adolescents, exploratory and confirmatory factor analysis yielded a three-dimensional structure with adequate goodness-of-fit indices, invariance of the measure according to gender and age, adequate levels of reliability (ω = 0.91), high convergent validity with the 14-Item Resilience Scale and high divergent validity with the suicidal act/planning subdimension of the Adolescent Suicidal Behavior Assessment Scale.

There is a need to create and adapt instruments to measure resilience in some populations with high psychosocial vulnerability as a key aspect for measuring the impact of prevention and mental health promotion programmes in adolescents.

Schizophrenia is a severe and complex psychiatric disorder that needs treatment based on extensive experience. Antipsychotic drugs have already become the cornerstone of the treatment for schizophrenia; however, the therapeutic effect is of significant variability among patients, and only around a third of patients with schizophrenia show good efficacy. Meanwhile, drug-induced metabolic syndrome and other side-effects significantly affect treatment adherence and prognosis. Therefore, strategies for drug selection are desperately needed. In this study, we will perform pharmacogenomics research and set up an individualised preferred treatment prediction model.

We aim to create a standard clinical cohort, with multidimensional index assessment of antipsychotic treatment for patients with schizophrenia.

This trial is designed as a randomised clinical trial comparing treatment with different kinds of antipsychotics. A total sample of 2000 patients with schizophrenia will be recruited from in-patient units from five clinical research centres. Using a computer-generated program, the participants will be randomly assigned to four treatment groups: aripiprazole, olanzapine, quetiapine and risperidone. The primary outcomes will be measured as changes in the Positive and Negative Syndrome Scale of schizophrenia, which reflects the efficacy. Secondary outcomes include the measure of side-effects, such as metabolic syndromes. The efficacy evaluation and side-effects assessment will be performed at baseline, 2 weeks, 6 weeks and 3 months.

This trial will assess the efficacy and side effects of antipsychotics and create a standard clinical cohort with a multi-dimensional index assessment of antipsychotic treatment for schizophrenia patients.

This study aims to set up an individualized preferred treatment prediction model through the genetic analysis of patients using different kinds of antipsychotics.

Mental health crisis presentations are common in those who have a diagnosis of borderline personality disorder (BPD), and psychosocial interventions should be provided. However, there is limited evidence outlining what a crisis-focused psychosocial intervention for this population should include.

To conduct a systematic review and narrative synthesis of crisis-focused psychosocial interventions for people diagnosed with BPD.

Three databases (MEDLINE, Embase, PsycInfo) were searched for eligible studies. Studies were included if they were quantitative studies comparing a crisis-focused intervention with any control group and they included adults (18+ years of age) who were diagnosed with BPD (or with equivalent experiences). A narrative synthesis was undertaken to analyse results.

A total of 3711 papers were initially identified, 95 full texts were screened and 5 studies were included in the review. Two of five studies reported on the same trial, so four individual trials were included. Overall moderate risk of bias across studies was identified. The review tentatively demonstrated that crisis-focused psychosocial interventions are feasible and acceptable to people with BPD and that they have potential impacts on outcomes such as self-harm and number of days spent in hospital. There is limited consensus on what outcome measures should be used to assess the impact of interventions.

There is presently insufficient data to recommend any specific psychosocial crisis intervention for people with BPD. Given the relationship between BPD and the high frequency of crises experienced by this group, further large-scale trials examining crisis-focused psychosocial interventions are required.

We acknowledge that the term personality disorder can be controversial and stigmatising. As the term borderline personality disorder has been retained in DSM-5 and is used in the research evidence base we have decided to use this term throughout this review. However, we recognise that this term may not be acceptable to all.

Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce.

To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews.

This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR.

About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder.

This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma.

It is preferable that children and adolescents requiring in-patient care for mental health problems are managed in age-appropriate facilities. To achieve this, nine specialist Child and Adolescent Mental Health Services (CAMHS) in-patient units have been commissioned in New South Wales (NSW) since 2002.

To examine trends in child and adolescent in-patient admissions since the opening of these CAMHS units.

Analysis of separation data for under 18-year-olds to CAMHS, adult mental health and paediatric units for the period 2002 to 2013 in NSW, comparing districts with and without specialist CAMHS units.

Separations from CAMHS, adult and paediatric units rose with time, but there was no interaction between time and health district type (with/without CAMHS unit). Five of eight health districts experienced increased separations of under 18-year-olds from adult units in the year of opening a CAMHS unit. Separations from related paediatric units increased in three of seven health districts.

Opening CAMHS units may be followed by a temporary increase in separations of young people from adult units, but it does not influence the flow of patients to non-CAMHS facilities in the longer term.

The authors conducted a thematic review on the effectiveness of Telepsychiatry in light of the COVID-19 pandemic. The study aimed to clarify the effectiveness of Telepsychiatry, providing an evidence base for the growing use of Telepsychiatry.

The authors searched three databases - Cochrane, PubMed and PsychINFO - using the terms virtual consultation/telepsychiatry/video consultation AND psychiatry/mental illness.

The authors excluded all papers that were not in English and that did not focus on the psychiatric consultation.

961 papers were identified, reduced to 321 using exclusion criteria and removal of duplicates. Using thematic analysis the authors found five themes that occurred across all papers in relation to the effectiveness of Telepsychiatry.

Patient & Clinician Satisfaction

There is consistently high patient satisfaction with telepsychiatry but lower clinician satisfaction, often as a result of cynicism and a lack of familiarity. Clinician satisfaction increases when clinicians trial Telepsychiatry and become more positive about its uses.

Diagnostic Reliability

Telepsychiatry was found to have high levels of inter-rater reliability equivalent to face-to-face consultations for common disorders including mood and psychotic disorders, substance misuse and dementia. It was also found to have high levels of diagnostic reliability across age groups.

Outcomes

Telepsychiatry has been found to reduce symptoms of common psychiatric disorders and improve quality of life in a variety of environments including emergency departments, inpatient units and prisons. Telepsychiatry increases access to specialised services resulting in quicker access to treatment and reduction in admissions.

Technology

Without adequate internet connectivity clinicians are unable to conduct an appropriate mental state examination and the therapeutic relationship becomes challenging. Inadequate technology can impact the effectiveness of Telepsychiatry amongst those who are socioeconomically disadvantaged and may not have access to appropriate technology.

Professional Guidance

There is a concerning lack of guidance around the use of Telepsychiatry. Without clear protocols there is a lack of standardisation and clinicians are unwilling to integrate Telepsychiatry into their practice. Main concerns raised are around confidentiality, consent, the appropriateness of certain patient groups and emergencies.

This review found evidence for the effectiveness of Telepsychiatry with greatest emphasis on technology and patient satisfaction. The main barrier is the reluctance amongst clinicians to facilitate Telepsychiatry into their practice, often due to cynicism and a lack of familiarity. The authors recommend training in the uses of Telepsychiatry and the provision of professional guidance from medical bodies to allay concerns and provide clear standards.

Biomedical research from low- and middle-income countries (LMICs) is poorly represented in Western European and North American psychiatric journals.

To test the feasibility of trialling a capacity-building intervention to improve LMIC papers' representation in biomedical journals.

We designed an enhanced peer-review intervention delivered to LMIC corresponding/first authors of papers rejected by the British Journal of Psychiatry. We conducted a feasibility study, inviting consenting authors to be randomised to intervention versus none, measuring recruitment and retention rates, outcome completion and author/reviewer-rated acceptability.

Of the 26/121 consenting to participate, 12 were randomised to the intervention and 14 to the control arms. Outcome completion was 100% but qualitative feedback from authors/reviewers was mixed, with attrition from 5/12 (42%) of intervention reviewers.

Low interest among eligible authors and variable participation of expert reviewers suggested low feasibility of a full trial and a need for intervention redesign.

A.P., P.T. and M.Y. are British Journal of Psychiatry editorial board members. During this study P.T. was British Journal of Psychiatry Editor, A.P. was a trainee editor and A.H. was an editorial assistant.

Severe health anxiety is a chronic and costly disorder if untreated. Patient self-referral may lower barriers to treatment and decrease diagnostic delay.

This study evaluated the accuracy of self-referral for severe health anxiety and compared characteristics of patients self-referred to internet-delivered treatment with patients referred by a clinician to face-to-face treatment.

Two trials in the same clinic employed different referral methods for health anxiety, namely self-referral and clinician-referral (trial registration: clinicaltrials.gov: NCT01158430 and NCT02735434). The trials were conducted at different time points but with largely comparable eligibility criteria. The accuracy of the recruitment methods was compared by looking at the number of eligible patients in the two trials. Patients completed a baseline questionnaire and subsequently underwent a diagnostic interview by experienced clinicians. Mean differences in self-report and clinical data explored between-group demographic and clinical characteristics.

In total, 101/151 (67%) self-referred patients were eligible compared with 126/254 (50%) clinician-referred patients (P = 0.001). Self-referred patients were 3.4 years older (P = 0.008) and had a somewhat higher educational level (P = 0.030). Patients who self-referred reported significantly higher levels of health anxiety, emotional distress and somatic symptoms compared with clinician-referred patients. Yet, they had less clinician-assessed comorbid anxiety disorders (P<0.001) and better physical health-related quality of life (P<0.001) suggesting a more distinct symptom profile.

Self-referral was found to be an accurate method to recruit highly relevant patients with treatment-demanding health anxiety. Thus, both self-referral and clinician-referral seem feasible and valid referral methods, but they may recruit patients with slightly different characteristics.

None.