Despite the availability of effective therapies, many patients with major depressive disorder (MDD) develop treatment-resistant depression (TRD).

To evaluate and compare prescribing patterns, contact with specialist services and treatment outcomes in patients with MDD and TRD.

This was a retrospective analysis of linked primary and secondary care National Health Service data in the north-west London Discover-NOW data-set. Eligible patients were adults who had diagnostic codes for depression and had been prescribed at least one antidepressant between 2015 and 2020.

A total of 110 406 patients were included, comprising 101 333 (92%) with MDD and 9073 (8%) with TRD. Patients with TRD had significantly higher risks of suicidal behaviour and comorbidities such as anxiety, asthma, and alcohol or substance misuse (all P < 0.0001). Citalopram, sertraline, fluoxetine and mirtazapine accounted for 83% of MDD and 71% of TRD prescriptions. Use of antidepressant switching (1% MDD, 7% TRD) and combination therapy (1%, 5%) was rare, whereas augmentation occurred more frequently in the TRD group (4%, 35%). Remission was recorded in 42 348 (42%) patients with MDD and 1188 (13%) with TRD (P < 0.0001), whereas relapse was seen in 20 970 (21%) and 4923 (54%), respectively (P < 0.0001). Mean times from diagnosis to first contact with mental health services were 38.9 (s.d. 33.6) months for MDD and 41.5 (s.d. 32.0) months for TRD (P < 0.0001).

There appears to be a considerable difference between treatment guidelines for depression and TRD and the reality of clinical practice. Long-term treatment with single antidepressants, poor remission, and high relapse rates among patients in primary care highlight the need to optimise treatment pathways and access to newer therapies.

Mental health services are encouraged to use language consistent with principles of recovery-oriented practice. This study presents a novel approach for identifying whether clinical documentation contains recovery-oriented rehabilitation language, and evaluates an intervention to improve the language used within a community-based rehabilitation team.

This is a pilot study of training to enhance recovery-oriented rehabilitation language written in care review summaries, as measured through a text-based analysis of language used in mental health clinical documentation.

Eleven case managers participated in a programme that included instruction in recovery-oriented rehabilitation principles. Outcomes were measured with automated textual analysis of clinical documentation, using a custom-built dictionary of rehabilitation-consistent, person-centred and pejorative terms. Automated analyses were run on Konstanz Information Miner (KNIME), an open-source data analytics platform. Differences in the frequency of term categories in 50 pre-training and 77 post-training documents were analysed with inferential statistics.

The average percentage of sentences with recovery-oriented rehabilitation terms increased from 37% before the intervention to 48% afterward, a relative increase of 28% (P < 0.001). There was no significant change in use of person-centred or pejorative terms, possibly because of a relatively high frequency of person-centred language (22% of sentences) and low use of pejorative language (2.3% of sentences) at baseline.

This computer-driven textual analysis method identified improvements in recovery-oriented rehabilitation language following training. Our study suggests that brief interventions can affect the language of clinical documentation, and that automated text-analysis may represent a promising approach for rapidly assessing recovery-oriented rehabilitation language in mental health services.

Young people's mental health and well-being is an important concern in the UK. Provision of education and support to schools has been highlighted as an area for improvement; however, evidence-based programmes are scarce and costly.

To provide an acceptable education programme to improve pupils' confidence and knowledge of mental health and well-being. It covered the mental and emotional well-being outcomes set by the Scottish Government in their schools' curriculum.

Lessons were designed by A.P. and delivered by volunteer doctors and medical students, and supervised by a psychiatrist. Outcomes were measured using questionnaires before and after lessons with optional comments.

PsychEd was piloted in 2016 in six schools to pupils between the ages of 11 and 18. There was a statistically significant improvement in pupil confidence and knowledge after the lessons (P < 0.001). Of the pupils 84% felt that having lessons on mental health was useful. Qualitative feedback was also collected and coded into positive, constructive and negative comments. In total, 72% of pupil comments were positive.

PsychEd showed promising results. Future areas of development include reaching a greater number of local authority schools, longer training for volunteers and provision of teaching materials to teachers for their own use.

None.

Sleep problems associated with poor mental health and academic outcomes may have been exacerbated by the COVID-19 pandemic.

To describe sleep in undergraduate students during the COVID-19 pandemic.

This longitudinal analysis included data from 9523 students over 4 years (2018–2022), associated with different pandemic phases. Students completed a biannual survey assessing risk factors, mental health symptoms and lifestyle, using validated measures. Sleep was assessed with the Sleep Condition Indicator (SCI-8). Propensity weights and multivariable log-binomial regressions were used to compare sleep in four successive first-year cohorts. Linear mixed-effects models were used to examine changes in sleep over academic semesters and years.

There was an overall decrease in average SCI-8 scores, indicating worsening sleep across academic years (average change −0.42 per year; P-trend < 0.001), and an increase in probable insomnia at university entry (range 18.1–29.7%; P-trend < 0.001) before and up to the peak of the pandemic. Sleep improved somewhat in autumn 2021, when restrictions loosened. Students commonly reported daytime sleep problems, including mood, energy, relationships (36–48%) and concentration, productivity, and daytime sleepiness (54–66%). There was a consistent pattern of worsening sleep over the academic year. Probable insomnia was associated with increased cannabis use and passive screen time, and reduced recreation and exercise.

Sleep difficulties are common and persistent in students, were amplified by the pandemic and worsen over the academic year. Given the importance of sleep for well-being and academic success, a preventive focus on sleep hygiene, healthy lifestyle and low-intensity sleep interventions seems justified.

Physiological brain function depends on tight glucose regulation, including transport and phosphorylation, the first step in its metabolism. Impaired glucose regulation is increasingly implicated in the pathophysiology of Alzheimer's disease (AD). Glucose hypometabolism in AD may be at least partly due to impaired glucose transport at the blood-brain barrier (BBB). Glucose transporters (GLUTs) are an integral component of the BBB. There is evidence of a significant reduction in vascular and non-vascular forms of GLUT1 and GLUT3 in AD brains compared to age-matched controls. Glucose transport, as well as phosphorylation, appears to be a rate limiting step for glucose metabolism in the brain. We have reviewed the literature on glucose transport abnormalities in AD and the effect such abnormalities have on the brain.

Published literature between 1st January 1946 and 1st November 2019 was identified using EMBASE and MEDLINE databases and titles and abstracts were scanned. Human studies (autopsy and imaging) and data from animal models were included while reviews, letters and cellular or molecular studies were excluded from the search.

Autopsy studies in AD patients show significant reductions in GLUT3 in areas of the brain closely associated with AD pathology. Patients with AD and diabetes showed greater reductions of GLUT1 and GLUT3. A longitudinal study showed significant reductions in GLUT3 levels which correlated with greater amyloid-β (Aβ) and neurofibrillary tangle pathological burden in participants with AD pathology at post-mortem but without evidence of cognitive dysfunction in their lifetime. Some studies showed increased GLUT1, with others showing reduced GLUT1, levels in AD brain. A newly recognised GLUT12 appears to be increased in AD. Animal studies showed similar results with GLUT1 and GLUT3 knockout animal models exhibiting AD pathology, while overexpression of GLUT1 or treatment with metformin decreased Aβ toxicity in a Drosophila model of AD. GLUT2 levels were increased in both human AD brain and in an animal model of AD. Imaging studies using fluorodeoxyglucose [18F]FDG with positron emission tomography (FDG-PET) in AD subjects show reductions in glucose transport and glucose metabolism in areas most affected in AD. A small randomised control trial showed anti-diabetic medications improved the glucose transport in AD subjects.

GLUTs play a significant role in AD pathology with evidence suggesting that GLUT3 reductions may precede the onset of clinical symptoms, while GLUT2 and GLUT12 may have a compensatory role. Repurposing anti-diabetic drugs shows promising results in both animal and human studies of AD.

Various effective psychotherapies exist for the treatment of depression; however, only approximately half of patients recover after treatment. In efforts to improve clinical outcomes, research has focused on personalised psychotherapy – an attempt to match patients to treatments they are most likely to respond to.

The present research aimed to evaluate the benefit of a data-driven model to support clinical decision-making in differential treatment allocation to cognitive–behavioural therapy versus counselling for depression.

The present analysis used electronic healthcare records from primary care psychological therapy services for patients receiving cognitive–behavioural therapy (n = 14 544) and counselling for depression (n = 4725). A linear regression with baseline sociodemographic and clinical characteristics was used to differentially predict post-treatment Patient Health Questionnaire (PHQ-9) scores between the two treatments. The benefit of differential prescription was evaluated in a held-out validation sample.

On average, patients who received their model-indicated optimal treatment saw a greater improvement (by 1.78 PHQ-9 points). This translated into 4–10% more patients achieving clinically meaningful changes. However, for individual patients, the estimated differences in benefits of treatments were small and rarely met the threshold for minimal clinically important differences.

Precision prescription of psychotherapy based on sociodemographic and clinical characteristics is unlikely to produce large benefits for individual patients. However, the benefits may be meaningful from an aggregate public health perspective when applied at scale.

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.

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.

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.

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.

Severe mental illness (SMI) is associated with significant morbidity. Frailty combines biological ageing, comorbidity and psychosocial factors and can predict adverse health outcomes. Emerging evidence indicates that frailty is higher in individuals with SMI than in the general population, although studies have been limited by sample size.

To describe the prevalence of frailty in people with SMI in a large cohort using three different frailty measures and examine the impact of demographic and sociodemographic variables.

The UK Biobank survey data, which included individuals aged 37–73 years from England, Scotland and Wales from 2006 to 2010, with linked in-patient hospital episodes, were utilised. The prevalence of frailty in individuals with and without SMI was assessed through three frailty measures: frailty index, physical frailty phenotype (PFP) and Hospital Frailty Risk Score (HFRS). Stratified analysis and dichotomous logistic regression were conducted.

A frailty index could be calculated for 99.5% of the 502 412 UK Biobank participants and demonstrated greater prevalence of frailty in women and an increase with age. The prevalence of frailty for those with SMI was 3.19% (95% CI 3.0–3.4), 4.2% (95% CI 3.8–4.7) and 18% (95% CI 15–23) using the frailty index, PFP and HFRS respectively. The prevalence ratio was between 3 and 18 times higher than in those without SMI.

As a measure, frailty captures the known increase in morbidity associated with SMI and may potentially allow for earlier identification of those who will benefit from targeted interventions.

The boundary between services for children and adolescents and adults has been identified as problematic for young people with mental health problems.

To examine the use and cost of healthcare for young people engaged in mental healthcare before and after the child/adolescent and adult service boundary.

Data from 772 young people in seven European countries participating in the MILESTONE trial were analysed. We analysed and costed healthcare resources used in the 6-month period before and after the service boundary.

The proportion of young people engaging with healthcare services fell substantially after crossing the service boundary (associated costs €7761 pre-boundary v. €3376 post-boundary). Pre-boundary, the main cost driver was in-patient care (approximately 50%), whereas post-boundary costs were more evenly spread between services; cost reductions were correlated with pre-boundary in-patient care. Severity was associated with substantially higher costs pre- and post-boundary, and those who were engaged specifically with mental health services after the service boundary accrued the greatest healthcare costs post-service boundary.

Costs of healthcare are large in this population, but fall considerably after transition, particularly for those who were most severely ill. In part, this is likely to reflect improvement in the mental health of young people. However, qualitative evidence from the MILESTONE study suggests that lack of capacity in adult services and young people's disengagement with formal mental health services post-transition are contributing factors. Long-term data are needed to assess the adverse long-term effects on costs and health of this unmet need and disengagement.

Depression is highly prevalent in children and adolescents in Pakistan, yet, factors affecting depression have not been widely studied. This study aims to assess the demographic and clinical characteristics of depression in children and adolescents and identify associations between parental marital status and confounding factors for depression.

A descriptive retrospective study was undertaken at the Aga Khan University Hospital in Karachi, Pakistan. Patient records of children and adolescents (aged under 18 years), presenting to the psychiatry clinic with depression from 2015-2019 were reviewed. The diagnosis of clinical depression was made based on clinical assessment according to international guidelines. Patients whose medical records had missing information were excluded. Data were analysed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Continuous data are presented as mean +/- standard deviation, whereas categorical data are presented as percentages (%). Pearson Chi-square test of association has been used to assess the association between parental factors and confounding factors. In instances where Pearson's Chi-square test could not be applied, Fisher's exact test is used instead. Associations at p <0.05 (95% confidence limit) are considered statistically significant.

A total of 133 participants were included, of which 78 (58.6%) were female, and 55 (41.4%) were male, with a mean age of 15.5 +/- 2.4 (Range: Ages 4–18). The population had a 50.4% prevalence of suicidal ideation, 21.1% of self-harm, 15% of substance abuse and 14.3% of suicide attempts. Academic stress (54.9%), inter-parental conflict (30.1%) and child abuse (29.3%) were the most common confounding factors reported. Other confounding factors include a family history of depression (20.3%), experience of bullying (16.5%) witnessing domestic violence (16.5%), substance abuse (15.0%) and experiencing sexual abuse (6.0%). There is a statistically significant association between children having parents with non-intact marriages and experiencing sexual abuse (p < 0.001, Odds Ratio (OR) = 21.48), having a family history of depression (p < 0.001, OR = 7.04), child abuse (OR = 3.78). Children of non-traditional (not living with both parents) families were more likely to witness domestic violence (p < 0.001, OR = 4.28), have a family history of depression (p < 0.001, OR = 3.44), abuse substances (OR = 3.20) and experience child abuse (OR = 2.48).

This study identifies factors that may put children at an increased risk of developing depression and performing high-risk behaviours. The findings can help develop better screening programs and counselling for children and adolescents, allowing prevention and ensuring early diagnosis and care.

Violence is a common problem in prisons. Post-traumatic stress disorder (PTSD), a prevalent disorder in prison populations, has been identified as a risk factor for violent behaviour in community and military populations. Although cross-sectional associations between PTSD and prison violence have been documented, prospective cohort studies are required.

To investigate whether PTSD is an independent risk factor for prison violence, and examine the potential role of PTSD symptoms and other trauma sequelae on the pathway from trauma exposure to violent behaviour in prison.

A prospective cohort study was conducted in a large, medium security prison in London, UK. A random sample of sentenced prisoners arriving into custody (N = 223) took part in a clinical research interview, which assessed trauma histories, mental disorders including PTSD, and other potential sequelae of trauma (anger, emotion dysregulation). Incidents of violent behaviour were measured with prison records covering the 3 months after reception into custody. Stepped binary logistic regression and a series of binary mediation models were performed.

Prisoners who met current (past month) criteria for PTSD were more likely to engage in violent behaviour during the first 3 months of imprisonment, after adjusting for other independent risk factors. The relationship between lifetime exposure to interpersonal trauma and violent behaviour in custody was mediated by total PTSD symptom severity. Hyperarousal and negatively valenced cognitive and emotional appraisal symptoms were particularly implicated in this pathway.

The identification and treatment of PTSD has the potential to reduce violence in prison populations.

Suicide is one of the leading causes of mortality worldwide, and the majority of suicide deaths occur in low- and middle-income countries.

To evaluate the demographic and clinical characteristics of individuals who have presented to health services following self-harm in Pakistan.

This study is a cross-sectional baseline analysis of participants from a large multicentre randomised controlled trial of self-harm prevention in Pakistan. A total of 901 participants with a history of self-harm were recruited from primary care clinics, emergency departments and general hospitals in five major cities in Pakistan. The Beck Scale for Suicide Ideation (BSI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS) and Suicide Attempt Self Injury Interview assessment scales were completed.

Most participants recruited were females (n = 544, 60.4%) in their 20s. Compared with males, females had lower educational attainment and higher unemployment rates and reported higher severity scores on BSI, BDI and BHS. Interpersonal conflict was the most frequently cited antecedent to self-harm, followed by financial difficulties in both community and hospital settings. Suicide was the most frequently reported motive of self-harm (N = 776, 86.1%). Suicidal intent was proportionally higher in community-presenting patients (community: N = 318, 96.9% v. hospital: N = 458, 79.9%; P < 0.001). The most frequently reported methods of self-harm were ingestion of pesticides and toxic chemicals.

Young females are the dominant demographic group in this population and are more likely to attend community settings to seek help. Suicidal intent as the motivator of self-harm and use of potentially lethal methods may suggest that this population is at high risk of suicide.