BJPsych Open

Introduction: Blackpool, England's most deprived local authority, has the highest drug-related death rate in the country. People in police custody with problem substance use are a key Core20PLUS5 inclusion-health group, yet referral from the police into structured drug and alcohol treatment is fragmented and relies heavily on self-report. We evaluated the current police-to-treatment route in Blackpool and designed an evidence-informed unified pathway. Materials and Methods: A mixed-methods service evaluation and pathway-design project was conducted during a six-month General Practice / Public Health rotation. Routinely collected referral data from Horizon (the local specialist drug and alcohol service) covering the 47-month period from December 2019 to October 2023 were analysed. Findings were triangulated with national policy, the Project ADDER and Liaison and Diversion evaluations, and the international evidence on police-led pre-arrest diversion. Results: Of 5,900 total referrals into Horizon over 47 months, only 269 (4.56%) originated from the police. Police referrals accounted for fewer than 5% of monthly referrals in 30 of 47 months, for 5 to 9.9% in 16 months, and for >/= 10% in only one month (10.8%, December 2022). Blackpool recorded 76 drug-misuse deaths in 2019-21 (19.4 per 100,000, approximately four times the England rate). A six-step unified pathway is proposed: Initiate Referral (opt-out, from ADDER Police and Liaison and Diversion); Initial Assessment; Tailored Treatment Plan; Continuous Support; Collaboration and Monitoring; and Evaluation and Adjustment. Conclusions: Police contact is markedly under-used as a gateway to treatment despite Blackpool having the highest drug-related mortality in England. An opt-out, multi-agency pathway anchored in Core20PLUS5 has the potential to narrow the treatment gap, reduce re-offending, and address the structural health inequalities that drive premature mortality.

Background Little is known about the provision of diagnoses to young people with mental health disorders. We investigated diagnosis provision by NHS mental health services, focusing on 17-year-olds in South London between 2009-2024, and compared with estimated disorder prevalence. Methods To examine diagnosis provision in the population, we extracted diagnosis data from records of the NHS mental healthcare provider serving South London, using the Maudsley Biomedical Research Centre Clinical Record Interactive Search application; we then compared these data with the corresponding population size, obtained from the Office for National Statistics. To assess diagnosis provision in those with mental health disorders, we compared diagnosis data with the number of young people estimated to have met criteria for a disorder, derived from epidemiological interview data collected in the Environmental Risk (E-Risk) Longitudinal Twin Study and weighted according to characteristics of 17-year-old South Londoners. To assess diagnosis provision in those with mental health disorders within health services, we compared diagnosis data with the number estimated to have met criteria for a disorder and used any health service for their mental health, again derived from weighted E-Risk Study data. Findings Of 17-year-olds from South London in 2009-2024, 4.0% (n=8,958/223,404) had a diagnosis in mental health records during the previous year. This diagnosis provision covered <1 in 16 of those estimated to have had a mental health disorder, and <1 in 4 of those estimated to have also used health services. Diagnosis provision was lower in girls than boys and in young people with Black/Asian/Mixed/Other ethnicity than those with White ethnicity, in those estimated to have had a mental health disorder and used health services. Interpretation These findings demonstrate gaps and biases in mental health diagnosis provision for young people, including within health services, and reveal the imperative need to strengthen young people's mental healthcare.

Background Autistic people experience disproportionately high rates of co-occurring mental illness and suicide, yet mental healthcare services routinely fail to meet their needs. Patients unrecognised as autistic are at risk of ineffective or harmful treatment. Autistic psychiatrists occupy a unique position: as members of both medical and autistic communities, they offer dual insider perspectives that may directly shape patient outcomes. Despite being the second largest specialty group in Autistic Doctors International (ADI), this workforce remains largely unrecognised and underutilised. This study examines autistic psychiatrists' perspectives on mental healthcare for autistic people. Methods Loosely structured interviews were conducted with seven senior autistic psychiatrists across child and adolescent, adult, and liaison psychiatry, recruited from a psychiatry-specific subgroup of ADI. Data were analysed using reflexive thematic analysis: codes related to patient care and mental health services were extracted and analysed as a focused subset. Outcomes Nine themes were identified: autistic-to-autistic therapeutic rapport; benefit of recognition and diagnosis; early recognition and education as preventive factors; iatrogenic harm from non-recognition and systemic pathways to misdiagnosis; knowledge gaps and stereotypes; inaccessible services; resource constraints and diagnostic thresholds; autistic psychiatrists as an underutilised resource; and pathways to change. Interpretation Autistic psychiatrists' dual insider positionality affords a unique and under-acknowledged vantage point on what autistic patients experience and where mental healthcare fails them. The mental health burden autistic people carry is substantially shaped by systems not designed for them. Embedding neurodiversity-affirmative practice, closing training gaps, reforming diagnostic pathways, and recognising autistic psychiatrists as a clinical and epistemic resource offer a coherent pathway to improving mental health outcomes for autistic people.

Introduction: Youth mental health presentations are largely heterogenous, making it difficult to match individuals to the most appropriate interventions. Personalised, measurement-based care has the potential to improve clinical decision-making and support shared decision-making, but remains challenging to implement in routine practice. Advances in digital monitoring and causal modelling offer new opportunities to identify individual-level processes driving mental health difficulties and to generate personalised decision-support. This pilot study aims to evaluate the feasibility and acceptability of the Minding Your Mind computational decision-support approach, a newly developed approach integrating routine outcome monitoring, individual-level causal modelling, and personalised feedback to support shared decision-making between young people and their clinicians. Methods and analysis: The study involves two phases. Phase 1 will recruit young people aged 15-25 years and mental health clinicians to participate in workshops to co-design the decision-support approach and its implementation into routine practice. Phase 2 is a prospective, single-arm feasibility study involving young people receiving mental health care and their treating clinicians. Primary outcomes include feasibility, acceptability, appropriateness, and usability of the decision-support approach, assessed via self-report and objective process indicators. Secondary outcomes include changes in use and experiences with shared decision-making, and clinical and functional outcomes. Quantitative analyses will be primarily descriptive, with exploratory pre-post comparisons and sensitivity analyses. Qualitative interviews will explore user experiences and implementation barriers and facilitators. Ethics and dissemination: This study has been approved by the Sydney Local Health District (RPAH Zone) Human Research Ethics Committee (X25-0341). All participants will provide informed consent prior to participation. Findings will be disseminated through peer-reviewed publications, conference presentations, and accessible summaries co-developed with young people with lived experience.

Background. There is growing evidence to suggest a clinically significant overlap between autism spectrum conditions and psychotic disorders. Preliminary evidence suggest that autism diagnoses and autistic traits are associated with poorer outcomes following a first episode of psychosis. Methods. This study used data from the Cambridgeshire and Peterborough National Health Service Foundation Trust (CPFT) Research Database to examine clinical outcomes in autistic and non-autistic people following a first episode of psychosis. We describe patterns of community and inpatient service use, using descriptive statistics , Cox regression, binomial logistic regression, and negative binomial regression. Results. Data from 282 autistic and 7127 non-autistic people with psychosis were analysed. Autism was associated with greater community service use (use of mental health emergency lines, mental health detentions by police), as well as greater likelihood of psychiatric hospital admission (adjusted hazard ratio 1.34, 95% confidence interval 1.05 -1.7, p<0.05) and longer inpatient stays (median 111 versus 48 days, p<0.0001). Learning disability played a significant role in the utilisation of community and inpatient services, with lower rates of community service use but longer inpatient admissions. Conclusions. This study indicates a differing pattern of service use between autistic and non-autistic people following psychosis that warrants further research into how best to support autistic people with psychosis.

Depression is accompanied by considerable comorbidity and excess mortality. We examined multimorbidity data using the validated pharmacy-based Rx-Risk Comorbidity Index and examined healthcare costs associated with chronic illness burden in the Australian Genetics of Depression Study (AGDS). Australian Pharmaceutical Benefits Scheme (PBS) record linkage for 15,890 AGDS participants was available from 01/07/2013-31/12/2017. Forty-six health morbidities were inferred by mapping the prescription data using Anatomical Therapeutic Chemical Classification System codes and PBS Item Codes. Morbidity prevalence rates were then compared with an unselected 10% Australian representative population sample (10PCT) with PBS claims data available from 01/07/2010-31/12/2014. The average number of inferred comorbidities was higher among AGDS participants (4.6 {+/-} 2.9) than 10PCT individuals (3.0 {+/-} 3.0). Excluding depression, 89.1% of AGDS participants had one or more inferred comorbidity, most commonly pain (51.0%), inflammation/pain (40.3%), and anxiety (32.3%). In the AGDS, the number of comorbidities was higher among women compared to men and positively correlated with participant age, BMI, number of depressive episodes experienced, and annual health care costs. Compared to participants with no inferred comorbidities, the median annual health care costs were ~65% higher among those with 2-3 comorbidities. This study highlights the patterns of health morbidities experienced by individuals living with depression and shows that this chronic disease burden is significantly associated with increased health costs to the individual and the health system.

Background: While growing enthusiasm for the therapeutic potential of classic psychedelics has led to a rise in non-clinical use, attention to persisting adverse effects has emerged with delay. A subset of individuals reports persisting complications such as hallucinogen persisting perception disorder (HPPD), depersonalization/derealization disorder (DDD), anxiety and depression. Yet few medical services are equipped to address these complications. Aims: This qualitative study examines how societal, medical, and media discourses shape the experiences of individuals with persisting psychedelic-related complications, focusing on help-seeking trajectories. Methods: Thirteen semi-structured interviews with adults experiencing persisting psychedelic-related psychological symptoms (four women, nine men, age 19-49 years; HPPD (n = 10), DDD (n = 6), depression (n = 1), and anxiety (n = 1)) were conducted within a larger study on these complications. Data were analysed using reflexive thematic analysis. Reporting followed the COREQ guidelines. Results: Three interrelated themes emerged: (1) The dissonance between expectation and harm - idealised media and scientific portrayals of psychedelics shaped initial use and complicated recognition of adverse outcomes; (2) Stigma, silence, and self-blame - prohibitionist discourse and internalised shame significantly inhibited help-seeking; and (3) Between systemic absence and self-organised support - participants encountered clinical unpreparedness and epistemic dismissal, which often led them to rely on online peer communities and self-management strategies. Positive clinical encounters, characterised by professional expertise and nonjudgmental engagement, were experienced as helpful. Conclusions: Adequate clinical and conceptual frameworks for persisting psychedelic-related complications are lacking. An interdisciplinary, experience-informed approach integrating realistic risk communication, clinician training, and destigmatisation is required to support affected individuals.

Background High Intensity Use of urgent medical services by patients is widely recognised in urgent and emergency care. Studies of high intensity use of the emergency department have consistently shown features of complex systems behaviour in addition to highly heterogeneous individual patient characteristics. There have been no comparable studies of prehospital care use. Methods We examined the use of prehospital urgent and emergency services (NHS 111 and ambulance dispatch) using routinely collected data from regional service in the UK (population 5 million). We used a complex systems perspective, to examine (1) distribution of contacts per individual; (2) the temporal stability of service use by individuals and at the whole-system level (3) the distribution of bursts of contacts. Results We analysed data from 847555 individuals who contacted NHS111 and 389550 who contacted the ambulance dispatch service. 35120 (4.2%) individuals who contacted NHS111 had 5 or more contacts with the service over the two-year period and accounted for 290625 (20.1%) of contacts. 16755 (4.3%) individuals had 5 or more ambulance dispatch contact days and accounted for 169085 (25.8%) of contacts. The distribution of contacts per individual showed a monotonic distribution between 5 and over 100 contacts that was heavy tailed and compatible with a power law distribution. At any level of use, patients with one or more mental health related contacts had a greater likelihood of further contact than those without. Conclusion Prehospital emergency service use shows multiple statistical features typical of a complex system. Interventions to manage demand need to consider both individual high intensity users (particularly in relation to their mental health) and the behaviour of the whole system.

Introduction: Engagement with mental health services (MHCS) during the first episode of psychosis (FEP) is critical for symptom control, quality of life, and relapse prevention. However, disengagement rates remain high in Uganda with severe consequences for patients and caregivers. This study protocol describes a mixed-methods investigation which aims to examine the relationship between patients and caregivers lived experiences and mental health service engagement during first-episode psychosis. Methods and Analysis. The mixed-methods study will recruit 82 patients with first-episode psychosis and their primary caregivers from Butabika National Referral Mental Hospital in Kampala, Uganda. Inclusion criteria are ages 18-60, less than 12 weeks on antipsychotic medications, living in the greater Kampala Metropolitan Area, with a consenting caregiver. Caregivers must be an adult (> 18years) providing full-time care for at least 6 months prior. Patients with substance use disorders will be excluded. Qualitative data on the lived experiences of patients and caregivers will be collected using the draw-write-and-tell method, while quantitative data on service engagement and associated factors will be collected using semi-structured questionnaires. The data will be analysed using Stata version 18, and participants will be reimbursed for their time. Ethics and Dissemination. Ethical clearance has been obtained from the School of Medicine Research and Ethics Committee (SOMREC) Ref: Mak-SOMREC-2024-1002 and institutional approval from Butabiika National Referral Mental Hospital. All participants will provide informed consent prior to participation. Data will be de-identified and securely stored, with results disseminated through peer-reviewed academic publications, conferences and community stakeholder workshops.

Background Treatment guidelines for borderline personality disorder (BPD) recommend assessment, diagnosis, and psychoeducation. We report on the feasibility and safety of a randomized controlled trial protocol of online psychoeducation, assessment, and personalized feedback as an immediate first step of care for BPD. Methods Newly diagnosed participants were randomized to receive 10 videos about BPD or general mental health for two weeks. Half the participants receiving BPD videos were randomized to receive personalized feedback on changes in symptom ratings and cognitive performance. Ecological momentary assessment (EMA) evaluated interpersonal interactions, emotions, and behaviors for 30 days. BPD symptoms, depression, and personality functioning were assessed at baseline, after videos, after feedback, and one month later. Results Eighty-two participants were randomized into three conditions that did not differ significantly in terms of demographics or baseline variables. Dropout occurred for 32.9% of the sample. No differences in rate of emergency room visits, hospitalizations, or other escalations in level of care were reported among groups. Satisfaction was higher for those receiving psychoeducational videos about BPD. Improvement in BPD knowledge in the psychoeducation conditions was significantly greater than the control condition. No statistically significant differences were found regarding reduction of BPD symptoms. The psychoeducation with feedback arm showed significantly greater improvements in self-impairment compared to controls with medium effect size at the final timepoint. Modeling of the relationship between time spent alone and BPD symptoms showed a positive correlation in the control condition, but in the group receiving both psychoeducation about BPD and feedback, this relationship was negative. Conclusion Online psychoeducational videos and assessment were safe, feasible, and acceptable to participants with newly diagnosed BPD. Psychoeducation with personalized feedback appears to be more effective than either BPD or general psychoeducation alone in improving deficits in self-functioning, which may relate to an increased capacity to be alone with fewer symptoms. The protocol was registered with ClinicalTrials.gov (NCT05358925, https://clinicaltrials.gov/study/NCT05358925) on April 28th, 2022.

Background Escalating mental health service demands have created a need to better identify young people most likely to require continued support from mental health services at the transition between childhood and adulthood. Anxiety is the most common adolescent mental health condition, yet its clinical significance and prognosis are not well understood. We aimed to examine the risk of young adult-onset psychiatric disorders in individuals with an adolescent anxiety disorder, and identify stratifiers of risk of subsequent psychiatric disorders in this group. Methods Individuals from the Norwegian Mother, Father, and Child Cohort Study (MoBa) with linked health records and aged 18 or over as of the 31st December 2023 were included. Those diagnosed with any ICD-10 anxiety disorder when aged 10-17 years were defined as having an adolescent anxiety disorder (n=2107, controls n=47,582). Polygenic scores (PGS) for psychiatric and neurodevelopmental conditions were calculated using LDpred2. Anxiety, comorbidities, and parental psychiatric history were defined through linked ICD-10 diagnoses. Sex was defined through linked records. Individuals were defined as having a young adult-onset psychiatric disorder if they first received any new psychiatric diagnosis aged 18-24. Results Adolescent anxiety diagnosis was associated with increased risk of all adult-onset psychiatric disorders (HR= 2.33-8.65). Post-traumatic stress disorder PGS, parental history of severe mental illness, and female sex were associated with increased risk of transition to a young adult-onset psychiatric disorder in people with an adolescent anxiety disorder. Conclusions Adolescent anxiety greatly increases the risk of a psychiatric disorder during the transition to adult life. Clinicians should consider female sex and parental psychiatric history when prioritising young people with anxiety for adult mental health service support. Future research needs to further consider whether polygenic scores would aid risk stratification in clinical practice.

Structured AbstractO_ST_ABSBackgroundC_ST_ABSPost-Traumatic Stress Disorder (PTSD) is a mental health condition affecting people who experience traumatic events. Trauma-exposed occupational groups report higher rates of PTSD than the general population. Current treatments, and access, often take months and may cause distress when people are required to talk about the trauma. ObjectiveTo determine the proof of concept of FIRST, a brief, non-trauma focussed therapy, in two separate populations with employment-associated PTSD. MethodTwo independent, single-arm, experimental therapy pilot trials were conducted. Trial one recruited 20 military veterans who received FIRST therapy via trained third-sector therapists. Trial two recruited 16 health and social care workers with FIRST therapy delivered by healthcare provider therapists. All participants were adults with PTSD (confirmed via CAPS-5 in trial one, and symptom score of [&ge;]33 on the PCL5 in trial two). Primary outcomes were recruitment feasibility, retention, data quality and reduction in PTSD symptoms. Secondary outcomes were anxiety and depression symptoms, daily life functioning and perceived health status. Veterans were followed up at 12 weeks post-enrolment and healthcare workers at 8 weeks. ResultsThe veteran trial progression criteria to main trial were met. Seventy-nine people screened eligible, 43 attended a CAPS-5 assessment; 20 had confirmed PTSD and were enrolled. Seventeen completed therapy and 12-week outcome measures. Mean PCL-5 scores decreased from 48.7 (SD = 13.02, n=20) at baseline to 23.5 (SD = 15.30, n=17) at 12-weeks. The healthcare worker trial obtained informed consent from 16 participants, 10 commenced therapy and were included in analysis with eight completing therapy. Mean PCL-5 scores decreased from 42.60 (12.23, (n=10) at baseline to 22.00 (19.92, n=8) at 8-weeks. ConclusionsProof of concept of FIRST was established. PTSD symptom reductions exceeded the PCL-5 minimal clinically important difference. Undertaking a fully powered randomised controlled trial of FIRST therapy is feasible within both healthcare and third sectors. HighlightsO_LIPost-traumatic stress disorder (PTSD) is more common in military veterans and health workers than the general population C_LIO_LITherapy can be challenging to commence and complete when it requires a focus on the trauma incident C_LIO_LIFIRST offers a promising, brief, non-trauma focused therapy for the treatment of PTSD C_LI

Mental health problems, including emotional problems, are linked to adverse educational outcomes among children and adolescents. This study examines the association between early onset of mental health problems generally, and emotional problems specifically, at ages 5-14, and outcomes from the General Certificate of Secondary Education (GCSE), a secondary education qualification, at age 16 for 4,783 students in England, using the Millennium Cohort Study dataset linked to the National Pupil Database. We found that the onset of mental health problems at ages 5, 7, 11 and 14 had a significant and negative association with all GCSE outcomes. We also found negative associations between early onset emotional problems and GCSE outcomes, although results were most stark for emotional problems that onset at age 11, with statistically significant negative associations with all GCSE outcomes. School absence was identified as a potential mediator of the negative association. Furthermore, this study found that the potential loss of productivity related to mental health problems in general and emotional problems in particular was over 23,000 sterling and 11,000 sterling per affected individual, respectively, which could translate into approximately 2.57 billion sterling and 1.6 billion sterling, respectively at the population level for England. These findings highlight the importance of early intervention for children and adolescents with mental health problems to improve educational and future outcomes.

Background: Body-focused repetitive behaviours (BFRBs), including hair pulling, skin picking and nail biting, are common but under-recognised behaviours that often emerge during adolescence. Their prevalence, associated distress, and relationship with mental health and social factors remain poorly characterised. Methods: 5,437 adolescents aged 11-18 years reported engagement in BFRBs, associated distress, and functional interference as part of the 2025 OxWell Student Survey. Participants. Problematic BFRBs were defined as at least one BFRB with moderate or high distress. Associations with gender, neurodivergence, bullying, and internalising symptoms were examined using multivariable logistic regression. Results: Overall, 58.5% of participants reported at least one BFRB. Nail biting was most common (43.6%), followed by skin picking (31.3%) and hair pulling (14.5%). Among those with BFRBs, 22.2% reported moderate-to-high distress, and 3.3% of the total sample reported the highest level of distress. Co-occurrence was common: more than half of those with BFRBs reported multiple behaviours. BFRBs were more common and more distressing in girls and trans/gender-diverse participants than in boys. Problematic BFRBs showed strong associations with internalising symptoms (6.3% in the normal range vs 34.2% in the clinical range) and bullying (9.6% with no bullying vs 27.1% with >weekly bullying). Internalising symptoms were the strongest predictor in multivariable models (OR 1.97 per 10-point increase), alongside independent contributions from gender and frequent bullying. Conclusions: BFRBs are common in adolescents, frequently co-occur, and are strongly associated with emotional distress and social adversity. Recognition of distress, rather than behaviour alone, may be important for identifying unmet need and guiding intervention.

ObjectiveThis study aimed to understand barriers to providing mental health care in Australian prisons and explore factors supporting access to mental health care. MethodsThis qualitative study used focus groups with people with a lived experience of mental illness in prison or caring for someone in prison with mental illness and people involved in providing mental health care in prisons. Focus group transcripts were thematically analysed. ResultsFocus groups were held with eight participants. Identified barriers to providing and accessing mental health care in prison included perceived stigma, insufficient resourcing, logistics driven care, inconsistent standards, and tension between prison- and health-centred systems. Factors supporting access to mental health care in prisons included equivalence of care, individually tailored care, connection, resourcing, and coordinated care. ConclusionsIdentified barriers make providing mental health care in prisons difficult, resulting in unmet needs. Factors that support access highlight mechanisms available to improve outcomes, but their utility depends on addressing all barriers. Implications for Public HealthIdentified barriers and supporting factors can help guide service design to improve access and promote interagency collaboration across justice and health. Identified barriers can also be used to help inform evidence-based policy making, including workforce development and increased funding.

Importance: The menopausal transition is associated with an increased risk of depression. Prior depression is a well-established risk factor, but studies do not distinguish between prior reproductive and non-reproductive depression. Objective: To compare the associations of reproductive (i.e., premenstrual mood disorder and perinatal depression) and non-reproductive (i.e., not related to hormonal transitions) histories of depression with depressive symptoms during the menopausal transition. Design: Cross-sectional analysis of questionnaire data from the Multidisciplinary Menopausal Outpatient Care Project (MOPP) collected between February 2023 and October 2025. Setting: Menopause outpatient clinics Amsterdam, the Netherlands, including a specialized multidisciplinary menopause clinic. Participants: In total 364 individuals were approached; 244 enrolled at baseline. After exclusions for age <40 (n=3), premature ovarian insufficiency (n=2), premenopausal status (n=1), age >58 with final menstruation >10 years earlier (n=12), bipolar disorder (n=5), and missing survey data (n=41), 180 participants were included. Exposures: Premenstrual mood disorder measured with Premenstrual Symptom Screening Tool, perinatal depression with Edinburgh Postnatal Depression Scale Lifetime version, and reported prior non-reproductive depression in medical records. Main outcome and measures: Depressive symptom severity measured with Inventory of Depressive Symptomatology-Self Rated. We used univariable and multivariable linear regressions; multivariable models accounted for overlap between exposures. Results: Among 180 participants (median age 51; 61% perimenopausal and 39% postmenopausal), premenstrual mood disorder showed the strongest association with depressive symptom severity (B = 9.0, 95% CI 5.1-12.9, p < 0.001), followed by perinatal depression (B = 7.8, 95% CI 3.4-12.1, p < 0.001) and prior non-reproductive depression (B = 4.7, 95% CI 0.7-8.7, p = 0.021). In multivariable analysis, only premenstrual mood disorder (B = 7.2, 95% CI 2.4-12.1, p = 0.0037) and perinatal depression (B = 5.7, 95% CI 1.2-10.1, p = 0.013) remained associated with depressive symptom severity. Conclusions and Relevance: Prior reproductive depression, but not prior non-reproductive depression, was associated with greater depressive symptom severity during the menopausal transition. A history of premenstrual mood disorder and/or perinatal depression may therefore help identify individuals at increased vulnerability to depressive symptoms during this period. Future studies should replicate these findings in population-based samples.

Objectives To explore caregiver and clinicians perspectives on implementing mental health conversations and supports for caregivers of children with chronic conditions in paediatric outpatient clinics. Specifically, views were sought on (a) screening approaches and measures (phase 1) and (b) how feedback and support could be provided to caregivers experiencing mental health difficulties (phase 2). Methods Caregivers and clinicians from two outpatient clinics (neuromuscular and diabetes) at a tertiary paediatric hospital in Melbourne, Australia participated in online focus groups in July and August 2024. Caregivers were recruited from outpatient clinics and clinicians were recruited via email. Both groups were combined for phase 1 before separating into breakout rooms for phase 2. Two authors conducted reflexive thematic analysis of transcripts using NVivo. Results Sixteen participants (caregivers n = 8; and clinicians n = 8) took part in in two semi-structured focus groups. Analysis generated two overarching domains, each comprising multiple themes. Domain 1, Addressing caregiver mental health, captured themes of overwhelm and invisibility, diverse caregiving roles, and the need for time and resources to support wellbeing conversations. Domain 2, Housing the mental health conversation, encompassed themes of screening preferences, caregiver agency in confidentiality, delivery of feedback, and access to tailored supports. Conclusions Caregivers and clinicians support routine caregiver mental health discussions in paediatric outpatient settings. Caregivers favour screening at diagnosis and key transitions, with clear, and actionable feedback delivered away from the child. Questions about record-keeping warrant further exploration, as do the perspectives of fathers.

Background: Childhood adversity (CA) is recognized as a distal risk-factor for suicide attempts (SA) in individuals with psychiatric disorders. However, not all individuals with experiences of CA will engage in SA. Contributing to this relationship may be proximal factors such as impulsivity, inward anger and self-aggression. However, these factors are often conceptually blended and measured in different samples. We sought to clarify association among CA and personality factors in persons with SA. Methods: Participants from two studies comprised individuals with a diagnosed psychiatric disorder and history of SA (n= 139) and individuals with depressive disorder (clinical controls, CC; n= 24). We investigated self-reported levels of CA, impulsivity, inward anger, and self-aggression between the SA and CC (pcorr< .012). We tested the relationship among the factors using regression (pcorr<.017) and mediation model (indirect effects, p<.05) within the SA group. Sensitivity models were run controlling for age, gender, symptom severity, trait anger, and externally oriented aggression. Results: SA group had higher impulsivity (pcorr=.067) in a model controlled for age and gender. Other factors did not differ among groups. Within the SA group the analyses revealed positive association among CA and personality factors (pcorr<.06) in basic and model with age and gender, however the association was not specific for internally (self) oriented factors (coefficient comparison, p<.07). Parallel mediation model indicated that CA had indirect effect on self-aggression through impulsivity (p=.001) and to a lesser extent through inward anger (p=.066). Generally, models controlling for cognitive depression symptoms showed less prominent effects (pcorr>.1). Limitations: The study was cross-sectional and did not include behavioral tasks (state) measures of proximal factors. Conclusions: CA and personality factors showed similar severity levels among the SA and CC groups suggesting they may relate to broader psychopathologies, rather than specifically to SA. The association of CA with anger and aggression was unspecific to internally oriented factors indicating the need for more precise measuring instruments developed specifically for individuals with SA. Overall, the study highlights personality factors as being associated with risk in broader vulnerable populations.

Objective: Biopsychosocial models recognize multiple determinants of post-trauma mental disorders, but their relative and interactive effects remain unclear. We quantified the independent contribution of traumatic event severity, preexisting vulnerability, social support, and coping capacity, and tested mediation pathways. Methods: In a Brazilian clinical sample reporting traumatic or stressful events (N = 612), constructs were operationalized as composite scores and a dichotomous clinical outcome was derived from intake assessments. Logistic regression (n = 594) and structural equation modeling evaluated prediction and mediation. Results: Vulnerability was the strongest risk factor (OR = 1.46, p < .001) and social support the main protective factor (OR = 0.60, p < .001). Traumatic event severity remained an independent predictor (OR = 1.39, p < .001), whereas coping capacity was not significant (OR = 0.94, p = .410). Discrimination was good (AUC = 0.80). Mediation indicated vulnerability reduced social support and coping capacity, with a significant indirect effect via social support. Conclusions: Findings support a multifactorial model centered on a triad of vulnerability, social support, and traumatic exposure. Risk is shaped primarily by preexisting vulnerability and relational context, alongside a direct trauma effect, providing a clinically relevant framework for assessment and intervention.

Aim: Schema Therapy (ST) is an evidence-based treatment for complex mental health problems rooted in early Adverse Childhood Experiences (ACEs). Although both individual and group formats have shown effectiveness, little is known about which format works best for whom. This question is particularly relevant for adolescents given their unique developmental needs. Despite over a decade of clinical experience with ST in adolescents, current research offers limited guidance on how to tailor the format to individual needs - resulting in a persistent gap between research and practice. This study aims to develop practice-based indication criteria for individual versus group schema therapy by integrating therapists expertise with experiences from adolescents who underwent ST. Methods: This qualitative study employs a constructivist Grounded Theory approach. Data will be gathered through focus group discussions with schema therapists and individual interviews with adolescents. Therapists will be purposively selected based on experience with both therapy formats and with traumatized adolescents. Adolescents are eligible if they have experienced ACEs and have completed at least 20 sessions of ST. Results: The analysis will result in a theoretical model that integrates therapists clinical reasoning and adolescents preferences. Conclusions: This study integrates schema therapists expertise and adolescents lived experiences to develop actionable indication criteria for choosing between individual and group ST. By supporting informed clinical decision-making, the findings contribute to treatment personalization in adolescent ST and address key challenges such as suboptimal outcomes and treatment dropout. Moreover, the identified criteria provide a foundation for future quantitative validation.