The effectiveness of systematic quality improvement initiatives in psychiatric care remains unclear.

To examine whether quality of care has changed following implementation of a systematic monitoring programme of hospital performance measures.

In a nationwide population-based cohort study, we identified 14 228 patients admitted to psychiatric departments between 2004 and 2011 from The Danish Schizophrenia Registry. The registry systematically monitors the adherence to guideline recommended processes of care.

The overall proportion of all relevant recommended processes of care increased from 64 to 76% between 2004 and 2011. The adherence to individual processes of care increased over time, including assessment of psychopathology using a diagnostic interview (relative risk (RR): 2.01, 95% CI: 1.51–2.68), contact with relatives (RR: 1.44, 95% CI: 1.27–1.62), psychoeducation (RR: 1.33, 95% CI: 1.19–1.48), psychiatric aftercare (RR: 1.06, 95% CI: 1.01–1.11) and suicide risk assessment (RR: 1.31, 95% CI: 1.21–1.42).

Quality of care improved from 2004 to 2011 among patients hospitalised with schizophrenia in Denmark.

Problem Management Plus (PM+) is a psychological intervention that seeks to address common mental disorders among individuals exposed to adversity. Thus far, the potential for delivering PM+ by mobile phones has not been evaluated.

To adapt PM+ for telephone delivery (ten weekly sessions of about 45 min each) and preliminarily evaluate its acceptability and feasibility with young people living with HIV (YLWH) in coastal Kenya.

This was a mixed-method formative research. Qualitative data collection included consultations with stakeholders, conducting key informant interviews with HIV care providers and focus group discussions with potential end-users, i.e. YLWH. Moreover, brief exit interviews with recipients of the adapted PM+ were conducted. Quantitative acceptability and feasibility indicators and outcome measures were tracked/assessed during PM+ preliminary implementation involving 70 YLWH.

From the qualitative inquiries, the adapted PM+ emerged as contextually appropriate, acceptable and feasible for mobile phone delivery, despite some concerns around missing nonverbal cues and poor network connectivity. High recruitment (85%) and fair programme retention (69%) were observed. Intervention sessions over the telephone lasted 46 min on average (range 42–55 min). Preliminary feasibility data indicated that the adapted PM+ has the potential of reducing common mental disorders among YLWH from the Kenyan coast.

PM+ is acceptable and can feasibly be delivered via mobile phone to YLWH in coastal Kenya. This study sets the stage for a future fully powered, randomised controlled trial assessing the efficacy of the adapted PM+ in this or a similar setting.

Involuntary admission can be traumatic and is associated with negative attitudes that persist after the episode of illness has abated.

We aimed to prospectively assess satisfaction with care at the points of involuntary admission and symptomatic recovery, and identify their sociodemographic, clinical and service experience predictors.

Levels of satisfaction with care, and clinical and sociodemographic variables were obtained from a representative cohort of 263 patients at the point of involuntary admission and from 155 of these patients 3 months after termination of the involuntary admission. Data were analysed with multiple linear regression modelling.

Higher baseline awareness of illness (B = 0.19, P < 0.001) and older age (B = 0.05, P = 0.001) were associated with more satisfaction with care at baseline and follow-up. Transition to greater satisfaction with care was associated with improvements in awareness of illness (B = 0.13, P < 0.001) and in symptoms (B = 0.05, P = 0.02), as well as older age (B = 0.04, P = 0.01). Objective coercive experiences were not associated with variation in satisfaction with care.

There is wide variation in satisfaction with coercive care. Greater satisfaction with care is positively associated with clinical variables such as increased awareness of illness.

None.

Moral injury has been found to be prevalent among healthcare professionals during the COVID-19 public health crisis.

The present study examines the relationship between spirituality, moral injury, and mental health among physicians and nurses in mainland China during the COVID-19 pandemic.

An online cross-sectional study was conducted involving 3006 physicians and nurses in mainland China, where the COVID-19 pandemic has caused high rates of hospital admission and death. The Moral Injury Symptoms Scale-Health Professional was administered, along with measures of mental health and spirituality. Hierarchical linear regression modelling was used to examine the mediating and moderating role of moral injury in the relationship between spirituality and mental health.

Spirituality was positively correlated with moral injury (β = 2.41, P < 0.01), depressive symptoms (β = 0.74, P < 0.01) and anxiety symptoms (β = 0.65, P < 0.01) after controlling sociodemographic variables. Moral injury significantly mediated the relationship between spirituality and both depression and anxiety, explaining 60% (0.46/0.76) of the total association between spirituality and depression and 58% (0.38/0.65) of the association with anxiety. No moderating effect of moral injury was found on the spirituality–mental health relationship.

Although they were the findings of a cross-sectional study, these results suggest that concern over transgressing moral values during the pandemic may have been a driving factor for negative mental health symptoms among Chinese health professionals for whom spirituality was somewhat important. Future longitudinal studies are needed to determine the causal nature of these relationships.

COVID-19 has created many challenges for women in the perinatal phase. This stems from prolonged periods of lockdowns, restricted support networks and media panic, alongside altered healthcare provision.

We aimed to review the evidence regarding the psychological impact on new and expecting mothers following changes to antenatal and postnatal service provision within the UK throughout the pandemic.

We conducted a narrative literature search of major databases (PubMed, Medline, Google Scholar). The literature was critically reviewed by experts within the field of antenatal and perinatal mental health.

Changes to service provision, including the introduction of telemedicine services, attendance of antenatal appointments without partners or loved ones, and lack of support during the intrapartum period, are associated with increased stress, depression and anxiety. Encouraging women and their partners to engage with aspects of positive psychology through newly introduced digital platforms and virtual service provision has the potential to improve access to holistic care and increase mental well-being. An online course, designed by Imperial College Healthcare NHS Trust in response to changes to service provision, focuses on postnatal recovery inspiration and support for motherhood (PRISM) through a 5-week programme. So far, the course has received positive feedback.

The pandemic has contributed to increased rates of mental illness among pregnant and new mothers in the UK. Although the long-term implications are largely unpredictable, it is important to anticipate increased prevalence and complexity of symptoms, which could be hugely detrimental to an already overburdened National Health Service.

People who have suffered the loss of a loved one may subsequently report sensory experiences of the deceased (termed ‘after-death communications’, or ADCs). Such encounters are common and can be a source of comfort to the bereaved. Nevertheless, there has been limited empirical investigation of this phenomenon, and consequently mental health professionals feel ill-equipped to support those who disclose them.

To map the phenomenology of ADCs, and identify covariates and effects upon the recipient.

We conducted an online mixed-methods survey comprising 194 items about all aspects of ADCs. A purposive sample of 1004 respondents across three language groups (English, French and Spanish) completed the survey.

The most common form of ADC was during sleep, but large numbers of cases involved sensory modalities of touch, sight, hearing, smell and sense of presence that externalised the phenomenon for the recipient. Variations in incidence with participant gender and language group suggest a psychosocial component. ADCs were typically regarded by the participant as deeply meaningful and comforting. Respondents reported significant increases in their sense of spirituality, but not religiosity.

ADCs are a common feature of bereavement that occur unexpectedly, and are independent of any underlying pathology or psychological need. For the person experiencing the hallucination, they are important and meaningful events that they interpret in terms of continuing bonds with the deceased. This adaptive outcome may be stymied where mental health professionals trivialise or pathologise disclosures about ADCs.

This study investigated the change in suicidal ideation and its risk factors among employees. A longitudinal cohort study was conducted, starting with the baseline online survey in March 2020 (T1), followed by May (T2), and August (T3). The change in suicidal ideation from T2 to T3 and relevant factors associated with suicidal ideation at T3 were examined. Suicidal ideation significantly increased between May and August 2020 among females, younger (under 39 years old), highly educated population, and those without pre-existing mental health conditions. Factors significantly associated with suicidal ideation were younger age, suicidal ideation at T2, and with pre-existing mental health conditions. Loneliness at T2 showed a significant association with suicidal ideation, if adjusting those without pre-existing mental health conditions. National and community support is needed to target people who are likely to be left behind, such as young people and those with pre-existing mental health conditions, in the pandemic.

A longitudinal study was conducted with a cohort of full-time employees, starting with the baseline online survey in March 2020 (time point 1), followed by May (time point 2) and August (time point 3). The change in suicidal ideation from time point 2 to 3, and relevant factors associated with suicidal ideation at time point 3, were examined.

Suicidal ideation significantly increased between time points 2 and 3 among women, younger people (aged <39 years), those who were highly educated and those without pre-existing mental health conditions. Factors significantly associated with suicidal ideation were younger age, suicidal ideation at time point 2 and pre-existing mental health conditions. Loneliness at time point 2 showed a significant association with suicidal ideation when adjusting for those without pre-existing mental health conditions.

National and community support is needed to target people who are likely to be left behind, such as young people, those with pre-existing mental health conditions and those experiencing loneliness, in the COVID-19 pandemic.

The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding.

To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset.

A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed.

Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types.

Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality.

None.

There is a substantial burden on global mental health as a result of the Coronavirus disease 2019 (COVID-19) pandemic that has become putting pressure on healthcare systems. There is increasing concern about rising suicidality consequential to the COVID-19 pandemic and the measures taken. Existing research about the impact of earlier epidemics and economic crises as well as current studies about the effects of the pandemic on public mental health and populations at risk indicate rising suicidality, especially in the middle and longer term.

This study investigated the early impact of the COVID-19 pandemic on suicidality by comparing weekly in-patient admissions for individuals who were suicidal or who attempted suicide just before admission, for the first 6 months after the pandemic's onset in Switzerland with corresponding 2019 control data.

Data was collected at the Psychiatric University Hospital of Zurich. An interrupted time-series design was used to analyse the number of patients who were suicidal.

Instead of a suggested higher rate of suicidality, fewer admissions of patients with suicidal thoughts were found during the first 6-months after the COVID-19 outbreak. However, the proportion of involuntary admissions was found to be higher and more patients have been admitted after a first suicide attempt than in the corresponding control period from 2019.

Although admissions relating to suicidality decreased during the pandemic, the rising number of patients admitted with a first suicide attempt may be an early indicator for an upcoming extra burden on public mental health (and care). Being a multifactorial process, suicidality is influenced in several ways; low in-patient admissions of patients who are suicidal could also reflect fear of contagion and related uncertainty about seeking mental healthcare.

Symptoms of serious mental illness are multidimensional and often interact in complex ways. Generative models offer value in elucidating the underlying relationships that characterise these networks of symptoms.

In this paper we use generative models to find unique interactions of schizophrenia symptoms as experienced on a moment-by-moment basis.

Self-reported mood, anxiety and psychosis symptoms, self-reported measurements of sleep quality and social function, cognitive assessment, and smartphone touch screen data from two assessments modelled after the Trail Making A and B tests were collected with a digital phenotyping app for 47 patients in active treatment for schizophrenia over a 90-day period. Patients were retrospectively divided up into various non-exclusive subgroups based on measurements of depression, anxiety, sleep duration, cognition and psychosis symptoms taken in the clinic. Associated transition probabilities for the patient cohort and for the clinical subgroups were calculated using state transitions between adjacent 3-day timesteps of pairwise survey domains.

The three highest probabilities for associated transitions across all patients were anxiety-inducing mood (0.357, P < 0.001), psychosis-inducing mood (0.276, P < 0.001), and anxiety-inducing poor sleep (0.268, P < 0.001). These transition probabilities were compared against a validation set of 17 patients from a pilot study, and no significant differences were found. Unique symptom networks were found for clinical subgroups.

Using a generative model using digital phenotyping data, we show that certain symptoms of schizophrenia may play a role in elevating other schizophrenia symptoms in future timesteps. Symptom networks show that it is feasible to create clinically interpretable models that reflect the unique symptom interactions of psychosis-spectrum illness. These results offer a framework for researchers capturing temporal dynamics, for clinicians seeking to move towards preventative care, and for patients to better understand their lived experience.

There is limited data on the recovery of factors associated with decisional capacity in patients with psychosis.

To study the relationship between changes in mental capacity, symptoms and global functioning using structured measures during treatment for psychosis.

Fifty-six patients with psychosis were assessed for capacity to consent to treatment on admission and at 6 and 12 weeks following treatment. The MacArthur Competence Assessment Tool – Treatment, the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale were used to measure mental capacities, symptom severity and global functioning respectively. Treating consultants rated capacity to consent, masked to these measures.

Greater impairments on all measures were found in patients assessed as lacking capacity. These improved with treatment over 12 weeks with significant effect sizes (0.5 to 0.6). Stronger correlations between mental capacities, positive symptoms (-0.47) and global functioning (0.56) were noted in the first 6 weeks.

Impairments in capacity in acute stages of psychosis are related to symptom severity and functional impairment. They improve during treatment, particularly in the first 6 weeks.

Use of second-generation antipsychotics (SGA) has increased in recent years; however, their use and effect on metabolic outcomes has been poorly characterised in population-level studies.

This study aimed to determine the associations between SGA use and metabolic indicators in a general population.

We used data from the Canadian Health Measures Survey, a cross-sectional survey of Canadian households. Participants were Canadians aged 3–79 years, living in one of the ten provinces. Several metabolic indicators were examined, including weight, body mass index, waist circumference, hypertension, diabetes and two definitions of metabolic syndrome.

The proportion of Canadians taking an SGA tripled over the study period. SGA use was significantly associated with hypertension (odds ratio 1.94, 95% CI 1.07–3.55) and abdominal obesity in adults, as defined by the National Cholesterol Education Program–Adult Treatment Panel III (odds ratio 2.62, 95% CI 1.45–4.71).

Evidence of metabolic dysfunction with SGAs is seen in the Canadian population, along with a rapid increase in prevalence of use since 2007.

None.

Alcohol use is a risk factor for suicidal behaviour, yet the nature of the relationship is unclear. Most research on the topic is conducted in clinical populations, with few studies exploring this association across the general population.

We investigated the association between specific domains of alcohol use and suicide attempt, suicidal thoughts and non-suicidal self-harm in a general population sample.

A total of 14 949 adults who completed the 2007 or 2014 Adult Psychiatric Morbidity Survey were included. We measured alcohol use with the Alcohol Use Disorders Identification Test (AUDIT). Domains of alcohol use relating to risk categories, weekly consumption, binge drinking, dependence symptoms, harmful effects and concern from others were derived from relevant AUDIT items. Self-reported past year suicide attempt, suicidal thoughts and non-suicidal self-harm were measured with the Clinical Interview Schedule, Revised.

We found a linear association between total AUDIT score and outcomes. Three of six specific domains of alcohol use (dependence symptoms, harmful effects of drinking and binge drinking) were associated with increased odds of all three outcomes. There was no association of outcomes with the other domains of alcohol use.

We found evidence of a linear association between total AUDIT score and suicide attempt, suicidal thoughts and non-suicidal self-harm in a representative English general population sample. Our analyses suggest that where alcohol use significantly disrupts day-to-day functioning, this may underpin the relationship between alcohol use and suicide-related outcomes to a greater extent than higher alcohol consumption. Longitudinal research is needed to further understand these relationships.

Hypomanic symptoms may be a useful predictor of mood disorder among young people at high risk for bipolar disorder.

To determine whether hypomanic symptoms differentiate offspring of parents with bipolar disorder (high risk) and offspring of well parents (control) and predict the development of mood episodes.

High-risk and control offspring were prospectively assessed using semi-structured clinical interviews annually and completed the Hypomania Checklist-32 Revised (HCL-32). Clinically significant sub-threshold hypomanic symptoms (CSHS) were coded.

HCL-32 total and active or elated scores were higher in control compared with high-risk offspring, whereas 14% of high-risk and 0% of control offspring had CSHS. High-risk offspring with CSHS had a fivefold increased risk of developing recurrent major depression (P=0.0002). The median onset of CSHS in high-risk offspring was 16.4 (6–31) years and was before the onset of major mood episodes.

CSHS are precursors to major mood episodes in high-risk offspring and could identify individuals at ultra-high risk for developing bipolar disorder.

Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan.

Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons.

We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria.

Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide (‘wheat pills’) was a preferred agent in North Punjab, whereas paraphenylenediamine (‘kala pathar’) was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison.

Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.

There is currently debate about when a clinician should consider neuroimaging for patients with a known psychiatric illness. We consider this topic and propose a set of ‘red flags’ to use to aid decision-making.

None.

The volitional help sheet for self-harm equips people with the means of responding automatically to triggers for self-harm with coping strategies. Improving acceptability may be crucial to increasing effectiveness and reach. The Theoretical Framework of Acceptability (TFA) was developed to guide the assessment of intervention acceptability, but to date, no studies have applied the TFA to understand acceptability of interventions for self-harm.

To apply the TFA to (a) explore people's experiences of a brief intervention to reduce repeat self-harm; and (b) understand the most prominent aspects of intervention acceptability, to make recommendations for intervention refinements and successful implementation.

Sixteen semi-structured interviews were conducted with people who had previously self-harmed. The TFA informed a framework analysis in which findings were mapped onto the TFA.

Four TFA domains were identified that were associated with acceptability of the volitional help sheet for self-harm: affective attitude, burden, intervention coherence and perceived effectiveness. People were generally positive about using the volitional help sheet (affective attitude), understood the volitional help sheet and how it worked (intervention coherence), highlighted engagement as a motivating factor in using the volitional help sheet (perceived burden) and described how the volitional help sheet could be implemented by healthcare professionals (perceived effectiveness).

Further modifications could still be made, but it is hoped that this intervention provides a useful tool for individuals to construct their own personalised implementation intentions, and as part of longer-term support for preventing self-harm as delivered by healthcare professionals.

Lithium has long been recognised as an effective treatment for bipolar disorder. Its relative efficacy has been measured with a diverse range of clinical outcomes, resulting in differences in efficacy reporting that have not been systematically reviewed.

We aimed to identify and compare the various measures of lithium efficacy employed in interventional studies for people with bipolar disorder.

Database (PubMed, Web of Science) and hand searches were performed to identify studies that assessed a clinical response in patients with bipolar disorder who received lithium, up to the end of 2021. We included primary human interventional studies without excluding specific study designs, bipolar disorder subtypes, duration or dosage of lithium treatment. Continuous outcome effects were meta-analysed; binary outcomes were synthesised visually and narratively. The Cochrane risk-of-bias tool was used to assess study-level risk of bias.

Seventy-one studies were included (N = 30 542). Approximately two-thirds of participants attained a clinically significant improvement in manic or depressive symptoms, and over 50% achieved remission. About a third required hospital admission (study length 2–12 years) and around 50% needed further treatment to stay well or had recurrence of symptoms; the latter two outcomes tended to be assessed over long-term maintenance periods.

An abundance of measurements have been used to assess lithium's clinical effects, across several study designs. Despite the resultant high heterogeneity, an overall picture of lithium's effects emerges that supports previous literature; between half and two-thirds of patients respond well to lithium across varying outcome measures, baseline mood states, study durations and bipolar disorder subtypes.

Since 2012 England has seen year-on-year reductions in people accessing specialist community alcohol treatment, and year-on-year increases in alcohol-related hospital admissions.

We examined perceived barriers to accessing specialist treatment, and perceived reasons behind hospital admission increases.

We conducted focus groups (n = 4) with service users and semi-structured interviews (n = 16) with service providers and service commissioners at four specialist community alcohol services in England, which experience either high or low rates of alcohol dependence prevalence and treatment access. Themes and subthemes were generated deductively drawing upon Rhodes’ risk environment thesis. Data were organised using the framework approach.

Data reveal a treatment sector profoundly affected at all levels by changes implemented in the Health and Social Care Act (HSCA) 2012. Substantial barriers to access exist, even in services with high access rates. Concerns regarding funding cuts and recommissioning processes are at the forefront of providers’ and commissioners’ minds. The lack of cohesion between community and hospital alcohol services, where hospital services exist, has potentially created an environment enabling the reduced numbers of people accessing specialist treatment.

Our study reveals a treatment sector struggling with a multitude of problems; these pervade despite enaction of the HSCA, and are present at the national, service provider and individual service level. Although we acknowledge the problems are varied and multifaceted, their existence is echoed by the united voices of service users, service providers and service commissioners.

In pharmacological doses, lithium successfully treats bipolar disorder and it can reduce violent crimes committed by individuals with this disorder.

To investigate whether naturally occurring lithium in drinking water lowers rates of violent crime in the general population.

We examined lithium levels in the drinking water of the 274 municipalities of Kyushu Island in Japan and compared these with the crime rates in each municipality.

We found that lithium levels were significantly and inversely associated with crime rates in 2009.

Our findings suggest that even very low levels of lithium in drinking water may play a role in reducing crime rates in the general population.