Highlights of this issue

Those who feel the breath of sadness, sit down next to me¹

I had the privilege of being part of the London Nightingale Hospital, and with colleagues set up and ran the mental health team that supported its staff. Thankfully the Nightingale was never required at anything like its potential – though it remains ready to reactivate – but we think its stepped-care model of staff support and ‘forward psychiatry’ retain wide applicability. Our editorial (pp. 535–536) describes this and the underpinning evidence. Matthew Hotopf and colleagues (pp. 540–542) ask about the broader scope of mental health research during and after the coronavirus disease 2019 (COVID-19) pandemic. Neither the neuropsychiatric nor psychosocial impact are entirely clear at this time, but self-evidently these may be very considerable. All of us have endured the restrictions and losses of social distancing – some far more than others – and economic, employment and educational problems will cut deep for many. The authors propose three key questions: who is most affected; why and how are they affected; and what can be done to intervene?

Iob et al (pp. 543–546) address self-harm and suicidal ideation during the pandemic, taking data from the COVID-19 Social Study of almost 45 000 individuals, which began collecting weekly online data in March. Across the first month's figures, abuse, self-harm, and suicidal ideation were particularly raised against expected levels in women, individuals from Black, Asian and minority ethnic backgrounds, and those suffering socioeconomic disadvantage. Problematically, less than half received any support.

Those who find they're touched by madness, sit down next to me

Inequities continue, starting with Craig Morgan and colleagues (pp. 575–582) who explore how adverse incidents in childhood have an impact on the development of psychotic disorders. A first-episode psychosis cohort, with over 300 cases and controls allowed delineation of the impact of type, timing and severity of insult. Further, other work on the topic has often explored more low-level psychotic experiences in general population samples, and any link with an actual psychotic illness becomes less clear. Here, all forms of early-life adversity were strongly associated with increases in developing a psychotic disorder, with an additive effect where more than one occurred. Threat, hostility and violence were most strongly linked with later psychosis; bullying and sexual abuse were most linked if they first occurred in adolescence.

About 17% of mortality in psychoses comes from ‘unnatural causes’, but there have been fewer data on trauma-related mortality. Taking a French database of over 144 000 admissions for traumatic injuries, Fond et al (pp. 568–574) compared mortality in those with schizophrenia and bipolar affective disorder with matched, otherwise healthy, controls. Interestingly, after adjusting for sociodemographic factors and comorbidities, 30-day in-patient mortality was significantly higher in the bipolar affective group but not those with psychosis, and this appeared to be mediated by increased trauma severity.

Coid et al (pp. 555–561) explore ethnic inequalities in health outcomes. They note that these are often ascribed to socioeconomic factors and poverty, but that this does not account for all the differences seen in psychotic experiences. They test if this might better be accounted for by a syndemic, which is the aggregation and interaction of individuals’ risks and place-based clustering of disadvantages. A cross-sectional survey was used, encompassing 3750 men in the UK aged 18–34, oversampling those from Black and minority ethnic backgrounds and men living in Hackney. The national greater rate of psychotic experiences in Black men was attenuated when adjusted for social position. However, in Hackney this did not hold for Black men, but did for south Asian men. A syndemic of psychotic experiences and anxiety, drug dependence, high-risk sexual behaviour, and violence and criminality, helped explain the disparity in that London borough. More work is required to establish how area-level inner-city syndemics increase rates of psychotic experiences but we are reminded once more that #BlackLivesMatter, and profound systemic injustices remain in society. Bibire Baykeens from Plymouth University writes more in this month's Mental Elf blog at https://elfi.sh/bjp-me26.

Those who find themselves ridiculous, sit down next to me

Any relationship between mental illness and extremist beliefs is a controversial topic. Nevertheless, one could certainly make a rational hypothesis that such vulnerabilities might predispose one to exploitation and radicalisation, although there is little actual evidence on the topic. Kam Bhui and colleagues surveyed (pp. 547–554) 618 individuals of White British and Pakistani heritage across Blackburn, Bradford and Luton, using the ‘sympathies for violent protest and terrorism’ (SVPT) measure. Demographically, SVPT were more common in young adults, White British and those with criminal convictions; clinically they were seen more in those with major depressive disorders, anxiety and post-traumatic stress disorder. Interestingly, no associations were found with life events, social assets or political engagement. The findings support the link with mental illness, and thus potentially roles for mental health services. Clearly care and thoughtfulness are required here, not least considering the reservations many professionals have about the government's ‘Prevent’ programme.

Coid et al (pp. 583–591) use cross-sectional data to look at gang membership, sexual violence, and associations with psychiatric comorbidity. Men with antisocial histories and gang membership had high levels of childhood maltreatment, mental health problems including addictions, and sexual violence. Gang members showed evidence before the age of 15 for a preference for coercive rather than consenting sex. It was saddening to read how perpetrators and gang-affiliated victims often do not identify unwanted sex as rape, and even when they do, victims seldom report it because of fears of retribution. The public health implications are profound, which leads to the work of Chandan et al (pp. 562–567), who note the association between intimate partner violence (IPV) and depression and anxiety. However, this has not previously been shown in UK populations. The authors matched over 18 000 women with histories of IPV to over 74 000 unexposed women, and evaluated rates of anxiety, depression and serious mental illness. A shocking 49.5% of women in the IPV group had some form of mental illness.

Finally, Graham Ash, Honorary Archivist at the College, writes a stimulating editorial with colleagues (pp. 535–536) on why our history matters to us in mental health, and Kaleidoscope (pp. 592–593) asks what it means for doctors to be ‘professional’ in 2020.