BJPsych Open

Background: Various explanations have been proposed for increasing trends in diagnosed depression in the UK, including increases in the proportion of the population that experience symptoms, changes in the threshold for seeking treatment and changes in clinical recognition or coding practices. Identifying trends over time for the relationship between the experiences of psychological distress and receiving a diagnosis can help explain wider trends in the incidence of clinical depression, such as whether the threshold for seeking treatment and receiving a diagnosis of depression has changed. Aims: This study aims to examine trends in the incidence of diagnosed depression, and relationships between psychological distress and recent depression diagnosis among UK adults between 2011 and 2022. We also assess whether the difference in psychological distress between adults with and without a recent depression diagnosis has changed over time and examine these relationships across subgroups (sex, ethnicity, age, cohort, education and financial stress). Methods: Data were from 66,360 adults (341,764 observations) aged 16 or older from the UK Household Longitudinal Study (UKHLS) across nine fieldwork periods spanning 2011-2022. Psychological distress was reported with the GHQ-12 used as a continuous variable and as a binary variable indicating caseness. Recent depression diagnoses were self-reported. Analyses we run for the overall population and stratified by different sociodemographic characteristics. Results: Incidence of diagnosed depression has not increased over time in the overall sample, but there was a notable increase in some sub-groups, most clearly seen for women aged 16 to 24. There has been a clear increase in the number of cases of psychological distress, but who have not received a recent diagnosis of depression. The level of psychological distress experienced by adults recently diagnosed with depression has slightly increased over time, whilst the difference in psychological distress experienced by adults with and without a recent depression diagnosis remained stable. Subgroup analyses show differences in the distress experienced by those with and without a recent diagnosis based on sex, age, cohort, ethnicity, education and financial situation: temporal trends were mostly similar across groups. Conclusions: Stable trends in (a) the distress experienced by adults recently diagnosed with depression, and (b) the difference in psychological distress experienced by adults with a recent depression diagnosis compared to adults without suggests little support for the hypothesis that depression is being diagnosed at lower levels of psychological distress. Instead, our findings suggest there may be a growing population who are not receiving clinical support for high levels of distress.

Background: Young people impacted by adverse childhood experiences (ACEs) are often underrepresented in mental health research. Aims: This paper aims to advance inclusive research on ACEs by 1) describing co-designed recruitment and engagement methods in a national project on ACEs (Attune), 2) characterising a highly marginalised cohort of young people using identity descriptors co-designed with participants, and 3) reporting associations between ACEs, identity characteristics and mental health outcomes. Methods: A trauma-aware approach to engage under-represented young people was co-developed with a national youth advisory group, lived experience researchers, and trusted community partners. Our co-created purposive sampling strategy recruited 74 young people, aged 10 to 24 years, across England, seeking representation by age, sex, gender identity, sexual orientation, ethnicity, neurodivergence, and geographic location. Participants completed validated self-report measures of ACEs, life events, and mental health. Descriptive, correlational and regression analyses examined cohort characteristics and associations between ACEs, identity characteristics, and mental health measures. Results: The final cohort included participants identifying as non-White British (39.5%), non-binary/other gender (25%), and neurodivergent (30%). Half of participants reported exposure to at least one ACE. Analyses identified patterns consistent with prior literature. In addition, ACEs and barriers related to being neurodivergent were associated with increased depression and anxiety symptom severity. Non-binary gender identity was associated with anxiety. We did not observe associations of ACEs or mental health measures, with sex or ethnicity. Conclusions: Under-represented groups can be reached via co-created engagement methods informed by lived experience. We identified important associations between ACEs, identities, and mental health outcomes.

Background: Trauma-informed approaches (TIAs) are increasingly implemented across public-sector settings to improve support for young people affected by adverse childhood experiences (ACEs). However, practitioners often report difficulties translating broad trauma-informed principles into everyday practice, and young people are rarely involved in developing resources intended to support implementation. Aim: To co-design, implement and undertake a preliminary evaluation of a youth-led trauma-informed resource for professionals working with young people in public-sector settings in England. Methods: The study formed part of the UKRI-funded Attune programme and employed Accelerated Experience-Based Co-Design (AEBCD). Eighteen adolescents with lived experience of ACEs and 16 professionals from nine public-sector settings participated in three regional co-design workshops. Findings from a prior arts-based lived experience study informed the workshops. Participants collaboratively developed Validating Voices, a low-cost resource designed to increase validating interactions between professionals and young people. The resource was subsequently introduced into nine organisations and evaluated using staff surveys and semi-structured interviews. Results: Co-design participants identified professional invalidation of young peoples experiences, identities, needs and emotions as an under-recognised contributor to mental health. The resulting resource combined discussion cards, creative activities, role-play and organisational reflection exercises to promote validating practices. Five organisations implemented the resource and reported it to be feasible. Flexible local adaptation was common, while more participatory role-play elements proved harder to implement consistently. Staff observed increased opportunities for disclosure, reflection, peer connection and professional curiosity about young peoples experiences. Staff reported listening differently to young people and, in some settings, implementing changes in response to young people's recommendations. Conclusions: Youth-led co-design identified validation as a practical and meaningful mechanism for operationalising trauma-informed principles in everyday professional practice. With refinements, Validating Voices shows promise as a resource to support more relational, collaborative and trauma-informed responses to young people in public sector settings.

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.

Aims To explore how workplace environments and racialised hierarchies shape racial inequities in career progression and how the Covid-19 pandemic response influenced these inequities. Design Longitudinal and cross-sectional qualitative study using semi-structured interviews. Methods Semi-structured interviews were conducted with 27 student nurses, healthcare assistants and qualified nurses and 24 senior leaders and management staff recruited in England between January 2019 and March 2021. Data were analysed using thematic analysis. Results Data from 51 healthcare professionals were included in the analysis. Guided by sociological theory on inequality diversions and racialised organisations, three main themes were identified: (1) hidden pipelines to career progression highlights how racial positioning influences unequal career trajectories shaped by informal networks, organisational norms and perceptions of competence; (2) impact of the response to the Covid-19 pandemic illustrates how the pandemic disrupted and reinforced racialised career barriers and (3) psychological effects of racialised inequities on racially minoritised staff captures the emotional burden of navigating these inequities. Conclusion NHS staff perspectives on racialised inequities in career progression highlight the power informal networks have in staff accessing managers who control opportunities. While some staff found new opportunities during the Covid-19 response, others, particularly senior racially minoritised staff, felt redeployments and remote working further hindered their development.

People with intellectual disabilities and their communities are rarely involved in setting priorities for research. Our study addressed this gap through consultations with the UK communities of three genetic syndromes in which intellectual disabilities are common: Down syndrome (DS), Fragile X syndrome (FXS) and Williams syndrome (WS). The study aimed to provide an understanding of (1) the views of the DS, FXS and WS communities on current UK research; (2) their priorities for future research; and (3) participants views of engaging with UK research. We conducted focus group discussions with 39 community members including: children and adults with DS, FXS and WS; parent/carers of people with DS, FXS and WS; practitioners and researchers who work with these communities. Our study was carried out in collaboration with a Steering Group and two Advisory Groups of DS, FXS and WS community members. We identified three themes. First, participants shared their dissatisfaction with the current research landscape and wanted a more balanced landscape, with more research with direct application to the daily lives of people with DS, FXS and WS. Second, community members emphasised the importance of translating research into practice, advocating for better access to research and more meaningful participation to research of individuals with lived experience. Third, our study not only identified what should be the focus of future research on DS, FXS and WS, but also how researchers should conduct their research. Whilst including children in our sample was a strength, there were some limitations to the diversity of our sample; children with FXS were not represented and gender, ethnic and geographic diversity could have been broader. Nevertheless, we hope that our findings will change the future of research in this field so that research carried out in the name of individuals with intellectual disabilities such as DS, FXS and WS, is of direct use to these communities.

Background: Adverse childhood experiences (ACEs) have life-long detrimental effects on physical and mental health. ACE impacted young people are under-represented in research and cautious about seeking help. Practitioners fear re-traumatisation during assessment and treatment. Innovative approaches to care are needed. To respond, we co-designed a serious game called ACE of Hearts (AoH) focusing on promoting awareness of ACEs and providing guidance and support. This paper reports on a feasibility and acceptability study and a process evaluation of mechanisms. Method: A diverse cohort of young people aged between 12-24 years, reporting three or more ACEs, and living in different geographical areas of England were recruited through trusted partner organisations. Following informed consent, they were provided access to AoH for three months. Feasibility (rates of recruitment, uptake, engagement, retention, and follow-up), acceptability (affective attitude, burden, ethicality, intervention coherence, perceived effectiveness, self-efficacy), demographic and mental health outcome data were collected at baseline, 1- and 3-month follow-up. Process evaluation interviews at 3 months assessed mechanisms, acceptability and feasibility. Results: Of 40 eligible subjects, 36 completed the baseline assessment and 22 downloaded AoH. Twenty participants completed the questionnaires at 1 and 3 months (91% follow-up of those accessing AoH); 19 participants completed all assessments (86%). Many participants valued the central cosy den space and its customisation options. Engagement rates for 4 mini-games ranged from 32% to 73%. Most participants enjoyed playing AoH, found it easy to use, and felt it helped them reflect on their experiences. The process evaluation found positive views of the game design, style, and content along with perceived benefits through education, awareness, emotional connection, and considering help-seeking. Several improvements for access, relevance, acceptability, engagement and retention were recommended. No adverse events were reported. Conclusions: AoH was found to be feasible to use and acceptable and recommendations were given for improvements.

Background: The course of major depressive disorder is heterogeneous, with UK Biobank (UKB) participants reporting episode durations ranging from <1 month to >24 months. Here, we identify predictors of episode duration, characterise its genetic architecture, and examine links to treatment seeking and response. Methods: In UKB participants meeting criteria for major depressive disorder, we examined clinical, sociodemographic, and genetic predictors of short (0-3 months) and long (>24 months) episode duration, fitted in predictor-specific, domain-level, and combined models. We also conducted genome-wide association studies in European-ancestry participants (n = 40,858) and estimated common-variant heritability. Results: Clinical features were most informative: higher childhood trauma scores, a stressful trigger, and recurrence showed the most consistent associations with short and long durations across models (ORcombined: short = 0.75-0.95; long = 1.13-1.45; all p[&le;]0.02). Higher neuroticism scores were also associated with both durations (ORcombined: short = 0.977; long = 1.053; p<0.001). Polygenic risk for depression was associated with episode duration, though its independent contribution was modest. Long episodes were more predictable than short in validation analyses (AUC = 0.705 vs 0.601) and were associated with greater treatment engagement but lower perceived benefit; SNP-based heritability was nominally significant. Conclusions: Clinical features captured most of the predictable variance in episode duration, with the same predictors largely operating in opposite directions for short and long episodes, consistent with a continuum of chronicity. Those at risk for long episodes emerge as a priority for early identification and intervention.

Research on adverse childhood experiences (ACEs) has largely relied on retrospective and predominantly adult-focused models that conceptualize mental health difficulties as outcomes of past adversities operating through linear causal pathways. Less is known about how adolescents themselves understand the mechanisms linking adversity and mental health. This study explored young peoples lived experiences of these mechanisms using participatory arts-based methods. Sixty-two young people aged 10-24 years from diverse and often underrepresented backgrounds across England participated in trauma-informed creative workshops. Workshops incorporated multiple artistic modalities, including visual arts, animation, drama, dance, music, film, and creative writing, generating experiential and conversational data. Data were analysed using Framework Analysis within a critical realist approach. Young people did not primarily describe their mental health through narratives linking past adverse events to current outcomes. Instead, they emphasized present-day relational, environmental, and institutional conditions as the most salient influences on wellbeing. Two interconnected pathways were identified: system failures and seeking restoration. System failures referred to ongoing experiences of invalidation, bullying, sensory overwhelm, masking of identity, and unresponsive educational or mental health systems that generated feelings of unsafety. Seeking restoration encompassed actively pursued experiences of belonging, community, validation, sensory regulation, nature connection, creative expression, trust, and authenticity that supported wellbeing. Across pathways, felt (un)safety emerged as the central organizing mechanism through which experiences affected mental health. Findings suggest that adolescents explain their mental health less in terms of historical adversity and more through current experiences of safety, recognition, and belonging. Trauma-informed research and practice may therefore benefit from complementing questions about past adversity with greater attention to what is happening in young peoples lives now and the conditions that support recovery and flourishing.

Objectives To identify research priorities for improving the mental health of neurodivergent higher education (HE) students by exploring the perspectives of individuals with lived experience. Design Qualitative study using an online survey. Data was analysed using a deductive-inductive, hybrid semantic thematic analysis. Setting UK higher education institutions. Participants 104 current and former neurodivergent HE students with diverse neurodivergent profiles and intersecting identities. Main outcome measures Participant recommendations regarding priorities for future research on neurodivergent student mental health. Results Six themes were identified and were grouped into (1) general recommendations for research and (2) recommendations specific to neurodivergence within a HE context. Participants prioritised a shift away from medical model approaches towards research informed by social and strengths-based perspectives. Key priorities included improving understanding of diagnostic barriers and misdiagnosis, reducing stigma, investigating institutional barriers within HE, evaluating the effectiveness of support and accommodations and examining the experiences of underrepresented and intersectional groups. Participants emphasised the need for research on more flexible teaching practices, sensory-friendly learning environments, integrated mental health and educational support and alternatives to diagnosis-dependent access to services. Conclusions Future research should move beyond descriptive accounts towards evaluating interventions and current support provision to understand if they improve the mental health of neurodivergent students. Adopting intersectional approaches, moving beyond binary deficit- or strengths-based frameworks and focusing on inclusive, needs-based support rather than diagnosis-led systems are likely to produce more equitable and effective outcomes for neurodivergent students in higher education.

People experiencing mental health problems often encounter fragmented systems of care in which physical and mental health needs are addressed separately. Physical activity is an evidence-based approach for improving both physical and mental health and integrating evidence-based psychosocial support with physical activity in community settings may offer a holistic and accessible approach. This study explored interest-holder perspectives on integrating the World Health Organization Doing What Matters in Times of Stress intervention within a trauma-informed, community-based physical activity service. A qualitative study was conducted within a free, community-based, university-run physical activity service in Sydney, Australia. Semi-structured interviews were undertaken with people with lived expertise of mental health challenges, Clinical Exercise Professionals, and mental health service providers. Data were analysed using thematic analysis guided by the Consolidated Framework for Implementation Research. Nineteen participants (11 people with lived expertise, four Clinical Exercise Professionals, and four service providers) took part. Participants generally viewed the future delivery of Doing What Matters in Times of Stress by exercise professionals as acceptable and potentially beneficial for supporting both mental and physical health. Existing rapport with exercise professionals, the disarming nature of physical activity, and practical stress-management strategies were identified as strengths of the model of future delivery. Participants viewed Clinical Exercise Professionals as potentially well-placed to facilitate Doing What Matters in Times of Stress alongside supervised physical activity, as long as it was supported by appropriate training, supervision, referral pathways, and clear professional boundaries. Trauma-informed, inclusive environments, tailoring the intervention, prioritizing service user choice and organisational support were also considered important factors for successful future implementation. Conclusions: Integrating Doing What Matters in Times of Stress within a trusted, community-based physical activity service was perceived as acceptable and potentially meaningful for people experiencing mental health challenges. Findings warrant further piloting and evaluation of integrated physical activity and psychosocial intervention models.

Importance Anxiety and depression frequently co occur and show developmentally patterned co-development from childhood to adolescence. Adult psychiatric outcomes vary according to the timing, sequencing, and persistence of early symptoms, yet it remains unclear whether patterns of co development are comparable across high income and low and middle income country contexts. Objective Examine joint developmental trajectories of anxiety and depression from childhood to adolescence and their associations with anxiety and depression diagnoses in young adulthood. Design, Setting and Participants Population based prospective cohort studies in the UK (Avon Longitudinal Study of Parents and Children [ALSPAC], N=9,586) and Brazil (Pelotas 2004 Birth Cohort, N=3,815). Main Outcomes and Measures Trajectories were derived using parallel process latent growth models and latent class growth analyses of anxiety and depression using the Development and Well Being Assessment at early childhood (6-7 years), middle childhood (10-11 years), and adolescence (13-15 years). Diagnoses of anxiety and depression at 18 years were assessed via the Clinical Interview Schedule (ALSPAC) and the Mini International Neuropsychiatric Interview (Pelotas). Results Prevalence of anxiety and depression from early childhood to adolescence was similar across cohorts. Co-development was stronger in ALSPAC, with modest increases in both conditions, whereas in Pelotas, anxiety increased rapidly while depression showed little average change. In both cohorts, four trajectory classes were identified: stable-low (ALSPAC, 41%; Pelotas, 54%), increasing (31%; 28%), decreasing (23%; 15%), and persistent-high anxiety/increasing depression (5%; 3%). Compared with the stable-low class, youth in the increasing and persistent-high classes had elevated odds of depression (ALSPAC: OR=2.0 [95% CI, 1.4-2.8] and 4.2 [2.6-6.7]; Pelotas: 2.2 [1.5-3.3] and 2.9 [1.4-6.0]) and anxiety in young adulthood (ALSPAC: 1.6 [1.2-2.2] and 4.8 [3.2-7.0]; Pelotas: 1.7 [1.2-2.6] and 2.9 [1.5-5.8]). No increased risk was observed in the decreasing class. Conclusions and Relevance Patterns of anxiety and depression co development were comparable across the UK and Brazil, suggesting shared developmental pathways. However, more rapid increases in anxiety among Brazilian youth may reflect context specific risk factors. Persistence or emergence beyond early childhood was critical for identifying later diagnostic risk in both settings, highlighting the importance of early monitoring and intervention.

Autistic psychiatrists occupy a paradoxical position: trained to recognise and assess autism in others, yet navigating a professional culture in which their own autistic identity remains largely concealed. Despite growing visibility of autistic clinicians, the barriers autistic psychiatrists face to formal diagnosis and professional disclosure remain unexplored. This study used interpretive phenomenological analysis to examine the experiences of seven autistic psychiatrists in relation to diagnosis and disclosure. Data were generated through in-depth interviews and Retzinger's framework for identifying shame in discourse was applied as an analytical tool within the interpretive process. Shame emerged as the overarching theme across the dataset, operating through four group experiential themes. Its origins lay in childhood experiences of difference and perceived defectiveness, transmitted through family, peers, and the broader social environment. In professional life, shame was sustained and amplified by colleagues' misconceptions about autism, anticipated loss of credibility, and the deficit-based diagnostic criteria - which rendered self-recognition difficult and made formal diagnosis a perceived professional liability. Critically, shame did not only create barriers: it functioned as an override mechanism, rendering the known benefits of disclosure - to participants themselves, to colleagues, and to patients - insufficient to translate into action. This override function was not explained by fear of discrimination or rational career protection alone; it reflected shame's operation as an internal prohibition, dissociated from its original social source and persisting even where stigma had been intellectually processed and rejected. These findings reposition shame not as one barrier among many but as the organising force through which all barriers operate. Interventions aimed at increasing disclosure by raising awareness of its benefits misread the operative mechanism. Creating conditions in which autistic psychiatrists can make decisions about their identities freely requires naming and addressing shame - in research, in clinical training, and in the culture of psychiatry.

Background Emotionally Unstable Personality Disorder (EUPD) is characterised by emotional dysregulation, unstable self-identity, interpersonal difficulties, dissociation, and a high prevalence of non-suicidal self-injury (NSSI). Mental imagery plays a role in emotion processing and autobiographical memory. Yet little is known about the relation between voluntary visual imagery and self-harm in EUPD. The study aimed to examine the imagery characteristics, including visual imagery vividness and synaesthetic-like experiences, and their association with NSSI in EUPD. Method Forty adults aged 18-45 years meeting ICD-10 Diagnostic Criteria for Research (ICD-10 DCR) for EUPD were recruited through purposive sampling. Visual imagery was assessed using the Vividness of Visual Imagery Questionnaire-2 (VVIQ-2). NSSI and its functions were assessed using the Inventory of Statements About Self-Injury (ISAS). Synaesthesia-like experiences were screened using a seven-item questionnaire developed for the study. Group comparisons were performed using independent-samples t-tests, and correlations were assessed using Pearson's correlation coefficient. Results Twenty-nine patients (72.5%) with EUPD had NSSI. Participants with NSSI had significantly higher mean VVIQ-2 scores than those without NSSI (118.48 +/- 24.81 vs. 93.36 +/- 35.66; p = 0.016; Cohen's d = 0.89). VVIQ-2 scores correlated positively with intrapersonal ISAS functions (r = 0.38, p = 0.015) but not interpersonal functions (r = 0.19, p = 0.22). Three participants (7.5%) demonstrated imagery scores compatible with probable hyperphantasia. Four participants reported synaesthesia-like experiences. Conclusions Greater visual imagery was associated with non-suicidal self-harm in patients with EUPD. Imagery vividness was predominantly associated with intrapersonal functions of non-suicidal self-harm, particularly affect regulation, rather than interpersonal motivations. These findings suggest that visual imagery may represent a previously under-recognized cognitive factor contributing to emotional dysregulation and self-injurious behaviour in EUPD. Assessment of imagery characteristics may have clinical relevance when designing psychotherapeutic interventions for EUPD.

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 Despite growing evidence that interventions targeting parental distress are associated with improved outcomes in families of children with life-threatening conditions, mental health research is limited for parents of NICU graduates treated for non-cardiac congenital anomalies. Aims To examine the prevalence and severity of mental health difficulties and post-traumatic stress, including subthreshold trauma-related distress, in these parents. Method Participants were 103 parents (n=86 female) of children, aged 5-16 years, who were treated in the NICU for non-cardiac congenital anomalies (e.g., congenital diaphragmatic hernia [CDH], tracheo-oesophageal fistula and/or oesophageal atresia [TOF-OA], abdominal wall defects) at a large tertiary-level paediatric hospital in Australia. Validated measures of mental health (DASS-21) and post-traumatic stress (PCL-5) were administered using an online cross-sectional survey. Whole group and diagnostic subgroup scores were compared with normative data. Comparisons between parents of primary school and high school-aged children enabled the examination of differences in unmet support needs according to their child's developmental stage. Results Seventy-four percent of parents reported experiencing mental health difficulties since their child's congenital anomaly diagnosis, yet only 44.7% had accessed professional mental health support. The mean DASS-21 'Stress' score was significantly elevated relative to Australian population norms (p<0.0005). Scores on the PCL-5 indicated that 9.4% met DSM-5 criteria for provisional PTSD diagnoses and a further 20.8% met subthreshold PTSD criteria. Importantly, 50% of parents reporting subthreshold PTSD had not accessed professional psychological support. Mental health concerns appeared more prominent among parents of children with TOF-OA and CDH, as well as parents of high school-aged children. Conclusions Parents report elevated stress and clinically meaningful subthreshold PTSD symptoms long after their child's NICU discharge, yet many do not access formal support. These findings highlight the importance of trauma-informed approaches to ongoing mental health surveillance and support for parents of NICU graduates with non-cardiac congenital anomalies.

Although romantic partners tend to resemble each other on many characteristics, the geographical processes underlying partner similarities remain poorly understood. Using Finnish nationwide registry data from cohabiting or married partners (N = 1,500,204 couples; partnerships were formed between 1990-2023), we examined regional differences in partner similarity in mental disorders, educational attainment, and adolescent school performance. We also analysed geographical variation in partner similarity within three major cities. Accounting for local demographic composition of potential partners attenuated the partner similarity from r=0.43 to r=0.34 for highest obtained educational attainment, but increased partner similarity in any mental disorders from r=.40 to r=.42. In urban municipalities partners were more similar in educational attainment, but less in mental disorders, compared to more rural regions. We found no clear within-city variation in partner similarity. These findings highlight the role regional demographic composition plays in partnership formation and suggest different partnering dynamics depending on societal organization.

Introduction People with severe mental illness (SMI) and learning disabilities (LD) experience significant health inequalities, with diet-related conditions contributing substantially to early and preventable death. Despite high levels of nutritional risk, the presence and effectiveness of nutritional screening in mental health (MH) and LD settings remains under-researched. This study aimed to investigate nutritional screening practices in UK inpatient MH and LD services from the perspectives of dietitians. Methods A cross-sectional mixed-methods study was conducted using a novel 22-question online survey. Data was collected via the British Dietetic Association Mental Health Specialist Group (April-June 2025). Quantitative data was analysed descriptively and qualitative data by reflexive thematic analysis. Findings were integrated and presented thematically. Ethical approval was granted by Teesside University (2025Mar26544). Results Forty-seven dietitians participated, most with substantial dietetic experience, from a range of MH settings. Screening practices were widely established and supported by policy and audit. However, participants reported low confidence in screening translating into meaningful patient care. Barriers to screening included appropriateness of available tools, time constraints, difficulty engaging distressed patients and poor prioritisation of physical health. Digital integration and wider infrastructure were also important. Dietitians rarely undertook screening directly, instead holding secondary or leadership roles, while screening was most often completed by nursing staff who were often perceived to place limited importance on the process. Existing tools, particularly the Malnutrition Universal Screening Tool (MUST), were viewed as insufficiently capturing the broader nutritional risks relevant to MH/LD populations, leading some services to adopt bespoke, unvalidated tools. Conclusion Concerns regarding the suitability of existing nutritional screening tools in MH/LD settings are consistent with previous literature. However, we suggest cautious use of unvalidated bespoke tools. Whilst there was no clear front runner, MH specific tools such as the St Andrews Nutrition Screening Instrument (SANSI) and the NutriMental Screener warrant further evaluation. Importantly, findings indicate that optimising tool choice alone is unlikely to improve screening effectiveness. Nutritional screening must be embedded within clear care pathways, supported by organisational leadership, digital infrastructure, and multiprofessional engagement to move beyond procedural completion and support meaningful clinical action to improve patient care.

Background For people with bipolar disorder, recovery from manic or mixed episodes is frequently complicated by depression. Depression after manic/mixed episodes may occur within a broader episode sequence pattern of mania-depression-euthymic interval, proposed as a bipolar disorder subtype for which lithium is effective. However, the window of risk for mania/mixed-to-depression transition remains unclear, as is the relationship with clinical factors and outcomes. Methods In this retrospective cohort study, we identified a cohort of 10,437 people with bipolar disorder (42,314 mood episodes; 90,727 person-years) within the NeuroBlu health record database (United States) with records from 1959 to 2025. We quantified the transition time from manic/mixed episodes to depression, and investigated associations with clinical features, medications and outcomes. Outcomes 25% of all manic episodes and 22% of all mixed episodes transitioned to depression within 1 month: an incidence >11-times higher than the overall per-month depression rate. By 6 months, the depression transition rate had plateaued. Short depression transition time ([&le;]1 month) was associated with previous short transition times (post-mania RR=3.08, 95%CI: 2.65-3.58; post-mixed RR=2.52, 95%CI: 2.12-3.00), higher manic/mixed severity (post-mania RR=1.30 per 1 point CGI-S increase, 95%CI: 1.18-1.44; post-mixed RR=1.35, 95%CI: 1.15-1.57) and hospitalisation for the mania/mixed episode (post-mania RR=1.22, 95%CI: 1.09-1.37; post-mixed RR=1.71, 95%CI: 1.52-1.94). Among medications prescribed during hospital-associated manic/mixed episodes, lithium (post-mania RR=0.75, 95%CI: 0.62-0.91; post-mixed RR=0.72, 95%CI: 0.54-0.95), first-generation sedating antihistamines (post-mania: RR=0.74, 95%CI: 0.63-0.87) and other mood stabilisers (post-mania RR=0.82, 95%CI: 0.71-0.94, post-mixed RR=0.82, 95%CI: 0.72-0.94) were associated with longer transition time. Antipsychotics, antidepressants and benzodiazepines were not. Shorter transition time was associated with more depression-related hospital days (16% fewer days per month delay to depression, 95%CI: 4-25%, p=0.010). Interpretation It is important to monitor for depression soon after manic/mixed episodes. This depression may be predictable, and might be preventable with some medications prescribed during the manic/mixed episode.

Cognitive deficits in depression often persist despite pharmacological and psychotherapeutic treatment. Existing cognitive retraining programs are typically time- and resource-intensive, and place limited emphasis on addressing subjectively perceived cognitive difficulties or generalization of gains. This proof-of-concept study aimed to adapt the Integrated Cognitive Control Training (ICCT) into a brief format for patients with depression and to generate preliminary evidence of feasibility and effectiveness. The intervention was adapted into a manualized five-session program through a literature review, expert surveys involving clinicians and individuals with lived experience of depression, and a trial run. The study followed a single-group, open-label pre-post design (N = 16). Significant improvements were observed in cognitive flexibility (Color Trails Test-2: t = 3.52, p = 0.003, d = 0.88), depression severity (Montgomery-[A]sberg Depression Rating Scale: t = 6.66, p < 0.001, d = 1.67), and subjective cognition (Perceived Deficits Questionnaire: t = 5.06, p < 0.001, d = 1.3). The intervention demonstrated high acceptability and demand. These findings suggest that the Brief ICCT is a feasible and potentially effective approach for addressing cognitive deficits, with improvements extending to depressive symptom severity and socio-occupational functioning. These proof-of-concept findings justify further evaluation of Brief ICCT in adequately powered randomized controlled trials.