Aims: Sleep dysfunction is common in the prodromal stages of Alzheimer’s disease. Several thalamic nuclei are implicated in promoting and maintaining sleep. We investigated the relationship between thalamic nuclei volumes and sleep in people without dementia with respect to dementia family history (FHD) and apolipoprotein e4 allele (APOE4) carriership.

Methods: 700 participants aged 40–59 years were recruited into the PREVENT Dementia study. 645 participants underwent T1-weighted 3T MRI scans. The thalamus was segmented into six regions; 1) anterior, 2) lateral, 3) ventral, 4)intralaminar, 5) medial and 6) posterior using Freesurfer 7.1.0 and underwent ComBAT harmonisation. Subjective sleep data was assessed using the Pittsburgh sleep quality index, which quantifies sleep using seven components and a total score. 586 participants were included for analysis with respect to FHD and 590 for APOE4 carriership. Logistic regression or robust linear regression with age, sex, total intracranial volume and depression as covariates and false discovery rate correction (FDR) for multiple comparisons was used.

Results: Smaller volumes of the whole thalamus (p=0.0391), posterior region (pFDR=0.042), and within the posterior region the lateral geniculate (pFDR=0.019), and pulvinar anterior (pFDR=0.019) and medial nuclei (pFDR=0.019), were associated with worse perceived quality of sleep in the FHD positive group. Smaller volumes of the thalamus (p=0.041) in the FHD positive group were associated with greater sleep disturbances. We did not find any relationship between thalamic volumes and FHD in predicting total scores, sleep duration, latency, efficiency, use of medications to aid sleep or daytime dysfunction.

However, larger thalamic volumes were associated with a significantly lower total Pittsburgh score, indicating less overall sleep dysfunction (p=0.014) in non-carriers. A similar trend was seen with the lateral, ventral and intralaminar subregions, but they did not survive correction for multiple comparisons. We did not find any association between thalamic volumes and APOE4 carriership in predicting sleep quality, duration, latency, efficiency, sleep disturbances, use of sleep medications or daytime dysfunction.

Conclusion: Our results suggest some early sleep changes related to thalamic volume, particularly in individuals with dementia family history. It is possible the thalamus and nuclei within the posterior thalamus may exert beneficial effects in preserving the quality of sleep in this group.

Aims: Bipolar disorder (BD) is a severe psychiatric illness characterized by alternating depressive and manic episodes. The exact cause of BD remains unclear, but inflammatory and immunological processes are believed to play a significant role in its pathophysiology. Immune system dysregulation is a key factor, with pro-inflammatory markers like CRP, TNF-α, and IL-6 being elevated during mood episodes. Interleukin 27 (IL-27), which has both pro-inflammatory and anti-inflammatory properties, has not been extensively studied in BD. This study aims to investigate the levels of IL-27 and its subunit EBI3 in BD patients to better understand their role in the disease.

Methods: A cross-sectional study was conducted at Panj-Azar Hospital in Gorgan, Iran, from March 2023 to August 2023. The study included 75 patients with bipolar disorder (depression, mania) and 30 healthy controls. Participants were aged 18–65, diagnosed with bipolar disorder by two psychiatrists using DSM–V criteria, and undergoing treatment with atypical antipsychotics. Exclusion criteria included other psychiatric illnesses, substance use disorder, corticosteroid use, autoimmune/inflammatory diseases, pregnancy/breastfeeding, chronic schizophrenia, and other mental diseases. Blood samples were collected and stored at −80°C, and serum levels of IL-27 and EBI3 were measured using high-sensitivity ELISA kits. Descriptive and inferential statistics were applied to analyse the data, including normality tests, one-sample t-tests, independent t-tests, and Pearson correlation. The study followed the STROBE checklist to ensure high-quality reporting of observational studies.

Ethical consideration: This study was conducted after obtaining ethical approval (IR.GOUMS.REC.1400.010) from the Golestan University of Medical Sciences. Written and oral informed consent was obtained from patients

Results: The study revealed significant changes in the immune system of bipolar disorder (BD) patients, with IL-27 levels showing a notable difference between BD and control groups (p≤0.05). IL-27, which has dual roles in inflammatory reactions, correlated positively with ALP (p=0.05, r=−0.22), FT4 (p=0.01, r=−0.29), and CPK (p=0.03, r=−0.24), and negatively with disease duration (p=0.03, r=−0.26), suggesting its potential as a therapeutic target. EBI3 did not show significant correlations with any variables (p≥0.05).

Conclusion: This study highlights the significant role of immune system dysregulation in bipolar disorder (BD), particularly the elevated levels of IL-27 in BD patients compared with controls. The correlations between IL-27 and various clinical parameters suggest its potential as a biomarker and therapeutic target. Although EBI3 did not show significant correlations, the findings underscore the importance of inflammatory and immune markers in understanding BD’s pathophysiology. Further research is needed to confirm these results and explore the underlying mechanisms, which could lead to the development of new diagnostic and treatment strategies for BD

Aims: Menstrual irregularities (MI) are a frequently overlooked yet clinically significant concern among women with psychiatric disorders. Several psychiatric conditions, particularly schizophrenia and bipolar disorder, involve dopaminergic dysregulation, which may contribute to hormonal disturbances. Antipsychotic medications, especially typical antipsychotics, are known to impact menstrual cycles through their effects on dopamine pathways, leading to hyperprolactinemia and subsequent menstrual dysfunction. However, research on the prevalence of MI and its relationship with psychiatric illness and treatment adherence remains limited, particularly in the Indian context. This study aims to assess the prevalence of MI among female psychiatric inpatients and explore its association with socio-clinical factors, antipsychotic medication use, and treatment adherence.

Methods: A cross-sectional study was conducted at a tertiary care mental health institute, recruiting 100 female inpatients diagnosed with psychiatric disorders. MI was defined as any deviation from a regular menstrual cycle, including oligomenorrhea, amenorrhea, or irregular bleeding. Menstrual distress was assessed using the MEDI-Q (Menstrual Distress Questionnaire) scale, while treatment adherence was evaluated with the Brief Adherence Rating Scale (BARS). Statistical analysis examined associations between MI, antipsychotic use, prolactin levels, psychiatric diagnosis, and treatment adherence.

Results: The mean age of participants was 36.5 years, with an average illness duration of 3.6 years. Psychiatric diagnoses included psychotic disorders (62%), bipolar disorder (22%), depressive disorder (10%), and neurotic disorders (6%). Antipsychotic medication use was recorded in 82% of participants. The overall prevalence of MI was 37%. Among patients with psychotic disorders, 50% exhibited MI, with a significantly higher prevalence in those on typical antipsychotics (80.7%) compared with atypical antipsychotics (27.7%). MI was also observed in 31.5% of bipolar patients on atypical antipsychotics. Patients with poor treatment adherence (<50% on BARS – Brief Adherence Rating Scale) showed significantly higher score for MEDI-Q Total Score (16.51 ± 12.99 vs. 10.86 ± 12.36; p < 0.01) as well as for the subscales MSD (Menstrual Symptom Distress) and MESI (Menstrual Specificity Index). The menstrual distress was associated to being on antipsychotics; in fact, MEDI-Q Total Score was significantly higher in women on antipsychotics as compared with those not on antipsychotics.

Conclusion: Menstrual irregularities are prevalent among female psychiatric inpatients, particularly those with psychotic disorders and those on typical antipsychotics. These disturbances negatively impact medication adherence, highlighting the need for routine menstrual health assessments, prolactin monitoring, and personalized treatment approaches to balance psychiatric stability with reproductive health. Addressing patient concerns regarding menstrual side effects may improve adherence and overall treatment outcomes.

Aims: This study aimed to evaluate the implementation of AI scribes in medical practice across Australia and England, focusing on assessing current adoption rates, measuring awareness of perceived benefits and potential risks and developing recommendations for safe and effective deployment.

Methods: A comprehensive survey was conducted across 50 medical practitioners equally distributed between Australia and England. Practitioners were from both urban (60%) and rural (40%) environments, with a representation across experience levels: junior (30%), mid-career (45%), and senior (25%) practitioners. Data was collected over 4 weeks through a semi-structured questionnaire.

Results: The analysis revealed significant insights into AI scribe adoption and perception across both countries. Of the surveyed practitioners, 28% (14) are currently utilising AI scribes in their practice, while nearly half (48%) are actively considering implementation. The remaining 24% expressed no immediate plans to adopt this technology. Reported AI scribe benefits were notably high among respondents, with time-saving potential being the most recognised advantage (90% awareness). Practitioners demonstrated strong recognition of the technology’s ability to reduce administrative burden (84%) and improve patient interaction (76%). However, the assessment of documentation quality improvements was lower at 62%.

Risk awareness varied significantly across different aspects. Privacy concerns dominated the risk perception landscape, with 78% of practitioners expressing awareness of potential privacy issues. Clinical accuracy risks and legal liability concerns were acknowledged by 70% and 64% of responders respectively. A crucial finding was that only 42% of practitioners were aware of their medical defence union’s position on AI scribe usage, revealing a significant knowledge gap in professional liability coverage.

Among current users, satisfaction levels showed a mixed picture. While 64% reported positive experiences (21% very satisfied, 43% somewhat satisfied), a notable portion remained neutral (22%) or expressed dissatisfaction (14%). Implementation concerns centred primarily around training requirements (80%) and system integration challenges (72%), with medical defence coverage emerging as a significant concern (62%).

Conclusion: The study highlights the critical need for healthcare providers to establish comprehensive implementation strategies that address both technical and legal considerations. Practitioners in both regions must prioritise verification of medical defence union coverage before adopting AI scribes. UK medical defence unions have clearer guidelines compared with Australian medical defence organisations. Australian practitioners should align their implementation with RACGP digital health guidelines, while UK practitioners need to ensure NHS Digital compliance.

The findings emphasize that successful AI scribe implementation requires a balanced approach that addresses technical integration, risk management, and insurance coverage. The high level of interest, coupled with significant uncertainty about medical defence coverage, indicates a clear need for professional organisations to provide more detailed guidance on this emerging technology.

Aims: Dementia assessments are time-intensive and often distressing for patients and caregivers. Underdiagnosis of non-Alzheimer’s disease subtypes remains prevalent. This study aimed to develop and evaluate LUMEN (Large Language Model for Understanding and Monitoring Elderly Neurocognition), a prototype conversational AI to automate caregiver-collateral data collection before clinical appointments. Our goals were to reduce clinician time per assessment, improve diagnostic accuracy across dementia subtypes, and standardise caregiver assessments.

Methods: LUMEN’s development integrated a Patient, Public, and Professional Involvement (PPPI) process, incorporating stakeholder workshops, a modified Delphi process with 130 clinicians, and iterative consultations to identify key diagnostic priorities, such as functional impairments, safety concerns, and inclusivity. Four open-source 7B-parameter large language models (LLMs) – Mistral, Llama2, Zephyr, and Phi2 – were evaluated for efficiency (token count), readability (Flesch Reading Ease), and contextual relevance (cosine similarity to clinical dialogues). Mistral:7B was selected and fine-tuned using automated hyperparameter adjustments (GridSearchCV), advanced prompt engineering (chain-of-thought, flipped classroom techniques), and BLEU-scored linguistic refinement. A prototype interface was tested using 16 clinician-simulated caregiver dialogues derived from case vignettes spanning dementia subtypes and normal cognition. LUMEN’s diagnostic outputs were compared with clinician-derived diagnoses using the Area Under the Receiver Operating Characteristic (AUROC) curve and agreement measured via Cohen’s kappa. Usability was assessed via the System Usability Scale (SUS).

Results: LUMEN demonstrated strong performance in distinguishing dementia from normal cognition (AUROC=0.89) but moderate subtype differentiation (AUROC=0.66). Agreement between LUMEN and clinician evaluations was substantial (Cohen’s κ=0.82). However, Lewy body dementia (DLB) identification lagged due to symptom-reporting inaccuracies. System Usability Scale (SUS) scores (mean=82/100) exceeded the ‘excellent’ threshold (≥80). PPPI feedback highlighted LUMEN’s potential to standardise assessment and reduce waiting times.

Conclusion: LUMEN is a promising conversational AI tool for improving dementia diagnostics. Gathering caregivers’ collateral input before appointments could streamline workflows within existing outpatient systems and improve clinical accuracy. Real-world trials would help assess workflow integration and mitigate vignette-based biases from simulated testing, such as the overrepresentation of typical phenotypes.

This study was conducted in collaboration with Mr Bede Burston, Dr Elizabeth Robertson, and Dr Donncha Mullin, whose contributions were invaluable.

Aims: The spiritual dimension to an individual’s presentation is rarely considered in psychiatric assessments despite the RCPsych’s position statement on spirituality/religion (S/R) and a growing body of evidence. A 2024 SABP trust survey of Resident Doctors indicated a significant disconnect between trainees perceived importance of S/R clinically and actual practice. An audit was thus completed with the following Aims: gather baseline data exploring the frequency with which Resident Doctors are recording spirituality in inpatient admissions clerking; provide educational intervention to Resident Doctors tailored to training needs highlighted in survey; following intervention, re-audit to ascertain whether there have been any improvements.

Methods: The baseline audit was a retrospective review of admissions clerking recorded for all new admissions over February–March 2024 to 3 inpatient wards at SABP Trust. Each record was manually searched for key words, including spiritual*, religio*, spiritual or religious faith. Anonymised findings were recorded onto an Excel spreadsheet on a secure trust network.

Interventions were then carried out in August and October 2024. Following this, the same wards were re-audited between mid-October and mid-December 2024 using baseline audit criteria.

Results: Baseline audit: 1 of 53 new admission records mentioned patient’s S/R beliefs – this was the patient’s own description of their pre-morbid personality. Intervention 1: Segment dedicated to encouraging “spiritual history” taking in the “History Taking” presentation of the SABP Resident Doctors induction programme in August 2024. Intervention 2: An external speaker (Consultant and executive member of RCPsych’s Spirituality SIG) was invited to provide an interactive session at the trust-wide academic programme for Doctors in October 2024, addressing key survey findings. Re-audit: 2 of 45 admission records had mention of patient’s S/R beliefs. One was the patient describing own religiosity in context of religious delusions. In the other, the Doctor had created a “Spirituality” subheading in their clerking record to record patient’s beliefs.

Conclusion: This audit indicates that Resident Doctors are still not routinely including spirituality/religious beliefs in clinical assessments despite tailored interventions. Ongoing barriers include reluctance to consider the role of spirituality within mental health care; this being rooted in pervasive cultural stigmas that cannot be fully addressed through one-off interventions.

A cultural shift may only manifest if spiritual history enquiry is recognised as a deserved and crucial component of psychiatric history taking. We thus call for medical educators to consider a “Spiritual History” subheading in their Psychiatry history proforma to promote a collective shift toward more holistic mental healthcare.

In modern healthcare, decision-making favours neatly delineated, categorical imperatives. We prefer to say: ‘This practice is good’ and ‘That one is bad’, believing that each decision has a straightforward yes-or-no resolution. However, medicine thrives in uncertainty, partial improvements and small steps that can lead to life-altering gains. Harm reduction, whether for tobacco use, opioid dependence or beyond, embodies the acceptance of imperfect solutions. It is precisely in these areas that black-or-white thinking can be most destructive. Insisting on total cessation or complete eradication of risk, rather than supporting incremental progress, alienates many patients and perpetuates preventable morbidity and mortality. Recognising this pattern and transcending ‘all-or-nothing’ mindsets is crucial for compassionate, evidence-based care. Accordingly, we ask: ‘How does binary thinking in medical decision-making impact the effectiveness of harm reduction strategies?’ Such an inquiry addresses how well we can truly meet patient needs in real-world practice, especially amid complexity.

Aims: This study explores the historical roots of Obsessive–Compulsive Disorder (OCD) through an analysis of a ninth-century treatise Sustenance of the Soul by Abu Zayd al-Balkhi. It aims to compare al-Balkhi’s descriptions and treatments of OCD with the modern-day classification and understanding of ICD–11. We hypothesise that al-Balkhi could offer a more nuanced, holistic understanding of OCD, including recognition of its physical, psychological, and social aspects, and that this historical perspective can offer valuable insights into current psychiatric practices.

Abu Zayd al-Balkhi, a notable Muslim polymath of the ninth-century, authored Sustenance of the Soul, a treatise addressing mental health and wellbeing. Al-Balkhi connected mental and physical health, describing psychological issues that resemble what we now classify as OCD. His work anticipated aspects of modern therapeutic approaches, such as cognitive-behavioural techniques, social support, and activity engagement, to manage obsessive-compulsive symptoms. This historical analysis seeks to illustrate the relevance of early descriptions of mental health disorders in shaping current diagnostic and treatment approaches.

Methods: A reading of the text took place in 3 stages, firstly to gain an overview of the key themes in the chapter, secondly to extract key psychological terms being explored and their understanding and lastly to compare and contrast with sections in the ICD–11 classification. The analysis explored themes such as symptomatology, aetiology, and therapeutic techniques, mapping these historical perspectives to contemporary understandings of OCD. The process was checked with another researcher.

Results: Al-Balkhi identified obsessional behaviours as stemming from both psychological and physical factors, whilst also suggesting that OCD has a strong heritable component. He recognised that obsessive thoughts could harm physical health and that sufferers might experience cognitive distortions, such as catastrophic thinking – an approach now central to cognitive-behavioural therapy (CBT). Al-Balkhi also noted the aggravation of symptoms through isolation and inactivity, highlighting social and behavioural strategies to mitigate symptoms, which resonates with modern therapeutic recommendations.

Conclusion: This study reveals that al-Balkhi’s observations on OCD correlates to a significant degree with the ICD–11 classification. His writings integrated social, psychological, and physical treatments, which is argued to be advanced for his time. His insights offer a framework that complements and deepens current understandings of OCD, underscoring the potential benefits of examining historical perspectives in psychiatry. Al-Balkhi’s work demonstrates the value of integrating historical knowledge into modern practice, promoting a more holistic approach to treating psychiatric disorders.

Attention-deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in adolescents, and a full syndrome diagnosis requires a combination of persistent symptoms. In a multicentre cross-sectional study from Italy using a non-clinical sample from a secondary school comprising 440 adolescents, published in this issue of BJPsych Open, Gostoli et al examined whether unhealthy lifestyle habits are linked to both clinical manifestation of ADHD and subclinical symptomatology. In line with the literature, the authors demonstrate an association between clinical ADHD diagnosis, unhealthy lifestyle behaviours and psychosocial impairments. Modifiable, adverse lifestyle behaviours are also prevalent in subclinical ADHD manifestations. This observation may be important for child and adolescent psychiatry when considering targeted health promotion approaches that delay or prevent progression from subclinical to clinical ADHD. In this article, we discuss from a clinical perspective the putative relevance of addressing subclinical ADHD symptoms in the context of the existing literature.