BJPsych Open

BackgroundDepression and anxiety are common mental health conditions in the UK. NHS Talking Therapies offers evidence-based therapies and is the largest provider of treatment, yet, only 50% of patients recover. Accurate outcome prediction could identify those at risk of poor outcomes and support more personalised care. This study aimed to develop and internally validate multivariable prediction models using routinely collected data from a large, ethnically diverse sample to enable fair, data-driven treatment decisions. MethodsData included 30,999 adults who completed high-intensity therapy at a single NHS trust between 2018 and mid-2024. Seven NHS post-treatment outcomes were modelled: reliable improvement, recovery, and reliable recovery for both depression and anxiety, and also functional impairment at the end of treatment. Predictors measured at baseline included sociodemographic and clinical characteristics. Models were developed using elastic net logistic regression and internally validated using bootstrap resampling. ResultsThe sample was predominantly female (73%) with a median age of 34; 57% identified as White and 22% as Black. Models showed moderate to good discrimination (AUC 0.63-0.77) and strong calibration. Key predictors aligned with clinical expectations, including baseline symptom severity, unemployment, benefit receipt, reporting a disability or long-term condition, psychotropic medication use among other sociodemographic factors. ConclusionsThis study highlights the potential of data-driven tools to inform clinical decisions and treatment stratification in NHS Talking Therapies. Early identification of patients less likely to benefit from standard care could support timely review, monitoring, or tailored interventions. External validation and implementation research are needed to ensure generalisability and equity in care.

BackgroundThe Antidepressant Medications: Biology, Exposure & Response (AMBER) research programme was established to investigate the biological mechanisms underlying antidepressant action and variability in treatment response. Generation Scotland holds detailed genomic, clinical, and health information with recontacting consent, making this cohort ideal for investigating these aims. MethodsWe deployed a questionnaire, developed with input from a Lived Experience panel, to the Generation Scotland cohort to gather data on their depressive symptoms, medication history, efficacy, and side effects to develop clinically meaningful phenotypes of antidepressant response. Invitations were sent to 15,117 Generation Scotland participants who were 18 years or older and consented to be recontacted. Between July and November 2025, 1,180 participants with a history of antidepressant treatment for depression completed the questionnaire. ResultsThe sample was predominantly female (78.1%), self-identified as White (98.6%), and older (median age 57 years) than the wider Generation Scotland cohort (median 49 years) and Scottish population (median 41.3 years). Participants reported heterogeneous depressive symptom profiles spanning mood, anxiety, cognitive, sleep, behavioural, and physical domains. One-third of participants (31.1%) had taken three or more different antidepressants. Selective serotonin reuptake inhibitors (SSRIs) were the most common class (89.1%). Using self-reported treatment duration, discontinuation patterns, and efficacy, we developed a stringent classification system to capture treatment response extremes, where 23.8% were classified as responders and 1.5% as non-responders, with the majority unclassified. ConclusionsQuestionnaire data will be linked with electronic health records to validate antidepressant response classifications. Following validation, 25 responders and 25 non-responders will provide biological samples for DNA methylation profiling and generation of patient-derived cell lines. These models will be exposed to SSRIs to identify gene expression signatures and biological pathways distinguishing treatment response, integrating with genomic and clinical data across the AMBER project. These findings will provide a valuable resource for future antidepressant response research. Plain Language SummaryDepression is a common mental health condition affecting millions of people worldwide. Antidepressant medications are the primary medication treatment, but response is highly variable with only about one-third of individuals achieving full symptom remission after their first medication trial. We dont fully understand why some people respond well while others dont. To help answer this question, the Antidepressant Medications: Biology, Exposure & Response (AMBER) research programme was established. This study utilised the Generation Scotland cohort, a large health study in Scotland. Between July and November 2025, we invited 15,117 Generation Scotland participants to complete a detailed questionnaire about their experiences with antidepressant medications. A total of 1,180 participants answered detailed questions about their depression symptoms, which medications they tried, how long they were on a medication, how well the medications worked, and what side effects they experienced. We found that peoples experiences with depression and antidepressants varied considerably. About one-third had tried three or more different antidepressants. Using strict criteria based on treatment duration, effectiveness ratings, and medication changes, we identified 281 people (24%) who responded very well to SSRIs (the most common type of antidepressant) and 18 people (1.5%) who did not respond despite trying multiple SSRIs. A key limitation is that all information was self-reported, so we will validate findings by linking questionnaire responses with medical records. In the future, we will collect blood samples from some participants to study the biological differences between responders and non-responders. This research will help us better understand why antidepressants work for some people but not others, which could lead to more personalised treatment approaches for depression.

BackgroundDespite widespread recognition of the value of lived experience (LE) involvement in healthcare research and increased LE involvement activity, we lack established implementation methods and instruments for reporting and evaluating impact. We present a protocol for an innovative LE-led Impact Log tool and co-production framework, which may help to address some fundamental barriers to co-production. The Impact Log will be implemented within a five-year multidisciplinary transdiagnostic research project on severe mental illness, the Brain and Genomics Hub of the UKRI Mental Health Platform, and is also designed for wider adaptation and use. Part I presents a short narrative review of literature pertaining to defining, evaluating, and enhancing the impact of co-production, to provide in-depth background and aid future development. Part II presents the Impact Log protocol. MethodsThe Impact Log framework is designed to integrate inclusive and impactful co-production throughout all research stages, and to record and evaluate its impact across three domains using an accessible short form. The three research domains are: design and delivery; interpersonal and environmental aspects; systems and processes. Impact Log design and implementation is led by LE study leads and a specialist advisory panel, who are integrated fully within the wider research team, and all have combined research experience and LE of bipolar or psychotic disorders. All Hub research participants will be offered accessible opportunities for remunerated lived experience input, and there will be outreach to ensure diverse representation, aided by the Hubs charity partners. Data collection and analysis will be LE led and will include iterative analysis to inform continuing development. Diverse formal and informal dissemination throughout the project will maximise wider stakeholder engagement. DiscussionThe potential value of this research is to implement a novel tool and framework for facilitating, recording and evaluating co-production in complex mental health research, which can be adapted for wider use. Strengths in design are LE leadership and cross-cutting LE research integration, incorporation of multiple domains, and a focus on facilitating diversity and inclusion within co-production. Potential limitations for this project and wider adaptation may include limited resources, risk of bias and health challenges. Lay SummaryWe have provided a brief lay summary to help people without a research background understand our project. This article explains our plan to develop and test a new way of understanding how research changes when people with personal experience of a mental health condition are part of the research team. We are a team of mental health researchers and many of us have direct experience of bipolar and psychosis. We work alongside other researchers, including people who might also have worked in mental health services or in charities that provide support. Our research project aims to better understand what is happening in the brain, body, lives and experiences of people who have bipolar and psychosis. Many people believe that research is better when it includes the views of people who have direct experience of the health condition being studied. This is called "lived experience". We have developed a structured approach to make sure that people with lived experience are meaningfully involved in our research team. We have also created a simple tool, called the Impact Log, to record when lived experience members contribute and to help us understand how their involvement influences the research. Finally, we wanted to better understand what other researchers have said about lived experience involvement. We reviewed many published academic studies and reports and brought their findings together in what is called a "narrative review". This review summarises what is already known about the difference lived experience involvement can make in research.

Abstract Background: Mental health services are shifting towards person-centred care based on collaboration and shared decision making. Yet evidence indicates that these approaches may not be consistently embedded in the assessment and management of risk or safety. Methods: We conducted a cross-sectional online survey to examine perceived barriers and enablers to shared decision-making in risk assessment and management with people living with severe mental illness. Questionnaire development and data analysis were guided by the Theoretical Domains Framework, a psychological framework used to identify and understand factors influencing behaviour change. Items were rated on a 5 point Likert scale. In total, 243 service users and mental health professionals completed the survey. Results: Most service users reported that risk or safety had been discussed with them, but only half felt involved in the risk assessment or management process. Two thirds reported not receiving a copy of their risk assessment or management plan. Service users strongly agreed that communication with professionals about risk and safety requires improvement, and that risk is a difficult and emotive topic to discuss. Professionals reported high motivation to involve service users but identified time constraints and service user related factors as key barriers. Principal component analysis identified four components: (1) motivation; (2) social influences and memory/decision making; (3) beliefs about consequences; and (4) team, environment and training factors. More experienced professionals reported fewer negative beliefs about consequences, such as concerns about causing distress or disengagement. Conclusion: Findings highlight the need for clearer communication, organisational support and targeted training to enhance shared decision-making in risk assessment and management practices.

BackgroundMajor depression affects at least 10% of adults, yet evidence-based treatments have modest clinical effectiveness and acceptability. In recent years, outdoor swimming has grown increasingly popular and emerging quantitative and qualitative evidence suggests potential as an intervention for depression, however, there is yet to be a full-scale randomised controlled trial (RCT). This is a protocol to assess the safety and test the clinical- and cost-effectiveness of an 8-session outdoor swimming course (in addition to usual care) on depression symptom severity in adults experiencing major depression, in comparison to usual care alone. MethodsThis study is a pragmatic, parallel group, superiority RCT with 1:1 allocation comparing the outdoor swimming intervention (in addition to treatment as usual) with treatment as usual, aiming to recruit 480 adult participants meeting diagnostic criteria for major depression. Recruitment will take place across 21 sites with blind post treatment and follow up assessments. The primary outcome is depression symptom severity at T1 post-intervention, 12 weeks post-randomisation (the primary end point) using the Patient Health Questionnaire 9 (PHQ-9). Secondary clinical outcomes are anxiety (Generalised Anxiety Disorder 7 at T1 and T2 [38 weeks post-randomisation] and PHQ-9 at T2), mindfulness is measured as a potential mechanism at all timepoints (Five Facet Mindfulness Questionnaire 15). Health economic measures at all time points are: EQ-5D-5L, Recovering Quality of Life (ReQoL), Client Service Receipt Inventory and the Productivity Cost Questionnaire. A qualitative study will examine the experience of participants during and after the swim course. DiscussionIf the 8-session outdoor swim course is safe, clinically- and cost-effective, findings will support national implementation, offering an evidence-based intervention to those affected by depression, while potentially reducing healthcare costs. Furthermore, this may pave the way for other outdoor activities to support people with poor mental health to be developed and evaluated as interventions. Trial registrationControlled trial registration number is ISRCTN registration number 24759023. Registered on 21 February 2024 (https://www.isrctn.com/ISRCTN24759023). Administrative informationNote: Numbers enclosed in braces within this protocol correspond to SPIRIT checklist item numbers. The sequence of items has been adjusted to group related content together. (https://www.consort-spirit.org/). O_TBL View this table: org.highwire.dtl.DTLVardef@7f6ff8org.highwire.dtl.DTLVardef@900309org.highwire.dtl.DTLVardef@b75bc0org.highwire.dtl.DTLVardef@1e8d410org.highwire.dtl.DTLVardef@ba71ac_HPS_FORMAT_FIGEXP M_TBL C_TBL Plain Language Summary BackgroundDepression is very common,with at least 1 in 10 people having an episode of depression during their lifetime. Many people believe that outdoor swimming can improve depression. There is some research that suggests outdoor swimming is helpful for depression, but we do not yet have enough evidence to be sure. OUTSIDE 2 is a large research study that aims to find out whether outdoor swimming can help people with depression. AimThe aim of this study is to find out if taking part in an 8-session outdoor swimming course, along with usual care, is safe, helps improve depression, and is good value for money. We will compare people who do the swimming course (alongside their usual care) with people who only receive their usual care. In our study we will also talk to participants about their experiences. We want to understand how the outdoor swimming course affects their depression, and how the activity itself might help them feel better. Describe your research plan, includingPeople who are interested in taking part in the study can visit our website (outside2.co.uk) to read more information and sign up. Once someone agrees to join, they will be randomly placed into one of two groups available at their location to keep the study fair. One group will take part in eight one-hour outdoor swimming sessions in a small group. They will continue with their usual care for depression, which may include talking therapies, antidepressant medication, or community activities. The other group will continue with usual care only during the study. After the study ends, they will be offered the same outdoor swimming course, so no one misses out. The swimming sessions will be led by experienced swimming coaches who will help participants build confidence in the water and learn important water safety skills. During the study, all participants will complete questionnaires about their symptoms of depression, overall mental health, and use of health services. They will do these before they are put in a group, right after the swimming course or usual care period and six months later. Participants in the swimming group will also be asked to keep a diary about their experiences during the course. Researchers may visit some sessions to ask participants about how they are finding the swimming and how it affects their mood. Swim coaches will record attendance at each session and describe what activities were included. This helps the research team understand exactly what took place during each class. Knowledge mobilisationWe want to make sure that the information we learn from this study reaches many different people, not just scientists. To do this, we will share our findings in several ways. We will create a Podcast mini-series, an animated video as well as research papers. Using these different methods helps us share our findings with many groups, including adults in the community, mental health professionals, people working in the swimming industry, scientists, and policymakers. By sharing the results in several ways, more people can understand if and how outdoor swimming might support recovery from depression and mental health more broadly, and it increases the chance that the study will make a real difference, whatever it finds.

Background: The etiology and nosological status of seasonal affective disorder (SAD) as a specifier of depressive episodes versus a transdiagnostic disorder are the subject of debate. In this study, we investigated the underlying etiology of SAD and dimensional seasonality by examining their association with latitude and genetic risk for a range of traits, and investigated gene-environment interactions. Methods: This study included 12,460 adults aged 18-90 with a history of depression from the Australian Genetics of Depression Study. Regression models included predictors for latitude (distance from equator) and polygenic scores for eight traits; major depressive disorder, bipolar disorder, anxiety disorders, chronotype, sleep duration, body mass index, vitamin D levels, and educational attainment. Outcomes were SAD status and general seasonality score. Results: SAD was positively associated with latitude (OR[95%CI] = 1.05[1.03-1.06], padjusted<0.001), and there was nominal evidence of additive and multiplicative interactions between chronotype genetic risk and latitude (OR = 0.99[0.99-0.99], padjusted=0.381; OR=0.98[0.97-0.99], padjusted=0.489). General seasonality score was associated with latitude (IRR=1.01[1.01-1.01], padjusted 0.001) and genetic risk for major depressive disorder (IRR =1.02[1.01-1.03], padjusted<0.001), bipolar disorder (IRR=1.02[1.01-1.03], padjusted=0.001), anxiety disorders (IRR=1.03[1.01-1.04], padjusted<0.001), vitamin D levels (OR=0.89[0.80-0.95], padjusted=0.048), and educational attainment (IRR=0.97[0.96-0.99], padjusted<0.001). Conclusions: These findings enhance understanding of SAD etiology, highlighting contributions of psychiatric genetic risk and geographic measures on seasonal behavior, and support examining seasonality as a continuous dimension.

BackgroundProlonged waiting times for Child and Adolescent Mental Health Services (CAMHS) leave many young people without structured support while awaiting specialist treatment. Social prescribing has been proposed as a community-based adjunct within CAMHS pathways; however, evidence regarding its safety and clinical impact remains limited. MethodsWellbeing While Waiting was a multi-site non-randomised controlled trial embedded within a hybrid type II implementation-effectiveness evaluation conducted across 11 CAMHS in England. The protocol was prospectively published prior to recruitment (BMC Psychiatry; 10.1186/s12888-023-04758-0). Between May 2023 and March 2025, 558 young people aged 11-18 years referred to CAMHS were enrolled (225 usual care; 333 social prescribing). Primary outcomes were anxiety and depression symptoms, total emotional and behavioural difficulties, and perceived stress. Secondary outcomes included resilience and wellbeing. ResultsNo intervention-related adverse events were observed. On average, participants had 5 sessions with a Link Worker. Compared with usual care, no significant differences were observed in anxiety or depression symptoms. However, participants receiving social prescribing demonstrated significant improvements in total emotional and behavioural difficulties over six months, driven by reductions in conduct difficulties, hyperactivity and peer problems. Significant improvements for those receiving social prescribing were also found for prosocial behaviour and resilience. ConclusionsWithin routine CAMHS pathways, no intervention-related adverse events were observed for social prescribing, and social prescribing was associated with improvements in behavioural and resilience-related outcomes, although not in anxiety or depressive symptoms. Findings suggest social prescribing may offer a valuable adjunct during delayed access to specialist treatment, with effects distinct from symptom-focused clinical therapies.

BackgroundAI-powered cognitive behavioural therapy (AI-CBT) tools hold significant promise for addressing the global mental health treatment gap, yet sustained user engagement remains critically low. While patient attitudes and experiential factors have been qualitatively documented, the psychological mechanisms through which AI literacy translates into long-term engagement remain poorly understood. Existing systematic evidence highlights trust, perceived therapeutic alliance, and stigma as salient themes, but no large-scale quantitative study has modelled these as a mediated pathway. ObjectiveThis study aimed to (1) examine whether trust in AI systems and perceived therapeutic alliance mediate the relationship between AI literacy and sustained AI-CBT engagement, and (2) determine whether mental health stigma moderates these mediated pathways. MethodsA cross-sectional national online survey was conducted in the United Kingdom (N = 1,247). Eligible adults (18+) with a history of anxiety or depression who had used an AI-CBT tool in the preceding 12 months were recruited via stratified random sampling. Structural equation modelling (SEM) with moderated mediation was conducted in R (lavaan 0.6-17). Moderated mediation was evaluated using the PROCESS macro framework adapted for SEM, with 5,000 bootstrap replications for bias-corrected confidence intervals. Model fit was assessed using CFI, TLI, RMSEA, and SRMR indices. ResultsThe final SEM demonstrated excellent fit (CFI = 0.967, TLI = 0.959, RMSEA = 0.043 [90% CI: 0.036-0.051], SRMR = 0.052). AI literacy exerted a significant indirect effect on sustained engagement through trust in AI ({beta} = 0.213, SE = 0.031, p < .001) and perceived therapeutic alliance ({beta} = 0.187, SE = 0.028, p < .001). Mental health stigma significantly moderated the trust[-&gt;]engagement pathway ({Delta}R2 = 0.042, p = .003), with the indirect effect being stronger among individuals with lower stigma scores. The total indirect effect accounted for 58.4% of the total effect of AI literacy on engagement. ConclusionsAI literacy promotes sustained AI-CBT engagement primarily through its effects on trust and perceived therapeutic alliance, pathways that are attenuated by mental health stigma. These findings underscore the need for stigma-reduction interventions and AI literacy programmes as implementation strategies. Findings have direct implications for the design and deployment of AI-CBT tools across UK NHS digital mental health services.

Background: The NHS Improving Access to Psychological Therapies (IAPT) programme, now rebranded as NHS Talking Therapies, faces persistent capacity constraints with average wait times exceeding 90 days for cognitive behavioral therapy (CBT) in many Clinical Commissioning Group areas. AI-powered CBT platforms have been introduced as a digital adjunct within stepped care, yet longitudinal evidence on anxiety symptom trajectories and their predictors in routine NHS settings remains limited. Objective: To model individual anxiety symptom trajectories among patients referred to an AI-powered CBT platform within NHS primary care, identify distinct trajectory classes, and examine patient-level and practice-level predictors of differential treatment response using multilevel growth curve modeling. Methods: A prospective cohort study was conducted using linked clinical and administrative data from 6,284 patients (aged 18-65) referred to the CalmLogic AI-CBT platform across 187 general practices in four NHS England Integrated Care Systems (ICSs) between April 2023 and September 2025. Patients completed GAD-7 assessments at baseline, 4 weeks, 8 weeks, 12 weeks, and 24 weeks. Three-level growth curve models (assessments nested within patients nested within practices) with random intercepts and random slopes were fitted. Growth mixture modeling (GMM) was subsequently applied to identify latent trajectory classes. Predictors were examined at Level 2 (patient demographics, baseline severity, comorbidities, digital literacy, engagement intensity) and Level 3 (practice deprivation index, list size, urban/rural classification, and IAPT wait time). Results: The unconditional growth model revealed a significant average linear decline in GAD-7 scores of -0.94 points per month (p < .001), with substantial between-patient variation in both intercepts (variance = 14.82, p < .001) and slopes (variance = 0.38, p < .001). Significant between-practice variation accounted for 8.7% of intercept variance (ICC = 0.087). Growth mixture modeling identified four distinct trajectory classes: Rapid Responders (28.4%, steep early decline stabilising by week 8); Gradual Improvers (34.1%, steady linear decline through 24 weeks); Partial Responders (22.8%, modest early improvement followed by a plateau at clinically significant levels); and Non-Responders (14.7%, minimal change or slight deterioration). Higher baseline severity, female gender, and greater module completion predicted membership in the Rapid Responder class. Practice-level IAPT wait times exceeding 90 days independently predicted faster improvement trajectories (coefficient = -0.31, p = .003), suggesting that AI-CBT has its greatest incremental value in capacity-constrained areas. Patients in the most deprived quintile showed slower trajectories (coefficient = 0.22, p = .011) despite equivalent engagement levels, indicating a deprivation-related treatment response gap. Conclusions: AI-powered CBT platforms integrated within NHS primary care produce significant anxiety symptom reduction on average, but treatment response is heterogeneous, with four distinct trajectory classes identified. The finding that longer IAPT wait times predict better AI-CBT outcomes supports the platform's positioning as a scalable bridge intervention for capacity-constrained services. The deprivation-related response gap warrants targeted support strategies for patients in the most disadvantaged communities.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSThis mixed-methods study investigated the lived-experience perspectives of receiving a novel, brief digital mental health intervention after psychological trauma. The online gamified imagery-competing task intervention (ICTI) involves one researcher-guided session followed by self-use. Tested in two randomised controlled trials (GAINS-01; GAINS-02), ICTI led to fewer intrusive memories at week-4, with the reduction sustained over 24 weeks, alongside reductions in post-traumatic stress. Here, we contrasted user experiences of ICTI with an Active Control (AC; music-listening task), and explored longer-term impact in qualitative interviews to contextualise GAINS-02 findings. Methods and AnalysisThe GAINS-02 trial randomised healthcare staff experiencing intrusive memories after work-related trauma to ICTI (N=40), AC (N=39), or treatment-as-usual (TAU; N=20). Expectancy was assessed before the researcher-guided session (Day 0), acceptability at week-4, and usage tracked for 24-weeks. Semi-structured interviews (N=27) were conducted in ICTI and AC arms only (15 at week-4; 12 during 12-24-weeks). Interviews were analysed using reflexive thematic analysis. ResultsPrior to use, many trial participants did not think the intervention would work, favouring AC over ICTI. However, after completing the tasks, participants found ICTI more acceptable and relevant to intrusive memories than AC. After the one guided session, median ICTI usage the next four weeks was 4.00 times with little additional use (once more) over the next 20 weeks because of lack of need. Potential implementation facilitators included ease of use, and advantages over existing interventions due to not needing to talk about the trauma, brevity, and lesser resource commitment. Perceived barriers included a lack of staff and manager education about the nature and consequences of intrusive memories, with a need for workplace buy-in and demonstration of organisational benefits. ConclusionHealthcare staff experiencing workplace-related trauma found ICTI to be acceptable and effective for reducing intrusive memories with low effort and emotional burden, even among participants who initially expressed scepticism. Participants highlighted implementation considerations including offering ICTI both within and outside the workplace, and providing a self-guided version of ICTI with optional support. Future work should assess cost-effectiveness, impacts on presenteeism and retention, and real-world implementation including the feasibility and effectiveness of a self-guided ICTI. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSIn a previous randomised controlled trial (GAINS-01) with Intensive Care Unit (ICU) staff exposed to work-related trauma, a brief online gamified imagery-competing task intervention (ICTI) reduced intrusive memories compared to usual care at four-weeks. What this study addsThe GAINS-02 randomised controlled trial replicated GAINS-01 and extended results by comparing ICTI to an active control (AC; music listening) task, enrolling hospital staff from outside ICU, and a follow-up period of 24-weeks. Qualitative interviews found that, despite initial scepticism from healthcare staff prior to using the intervention, ICTI was more acceptable than an AC due to specific effects on swiftly reducing intrusive memories and requiring minimal support or usage after an initial researcher-guided session. After one guided session, ICTI was used 4 more times in the first four weeks, with little additional usage (once) thereafter because of lack of need (i.e., no longer experiencing intrusive memories). How this study might affect research, practice or policyICTI is an efficacious scalable intervention to relieve staff of intrusive memories with effects sustained for at least 6-months. It was found to be more acceptable to participants than alternatives, requiring less time commitment than standard psychological treatments.

Aim Anxiety disorders in older adults are commonly underdiagnosed and undertreated, especially among minority ethnic groups. This UK multicultural qualitative study aimed to explore and compare beliefs about anxiety among self-reporting White British, South Asian, African and Caribbean older adults, using Leventhal's Common-Sense Model. Methods Individual interviews were conducted with 52 older adults who self-reported anxiety (current or past). Data were managed and analysed using the Framework Method. Professional interpreters facilitated interviews with non-English speakers. Findings The study incorporated the perspectives of 27 older adults with distressing anxiety and 25 with non-distressing anxiety. Participants' beliefs mapped onto the illness-related dimensions in Leventhal's Common-Sense Model. Beliefs about anxiety differed across and within cultural groups, with notable distinctions between participants with distressing and non-distressing anxiety. Those with distressing anxiety neither normalised anxiety nor considered it as an illness trajectory. Overall, participants had a fragmented understanding of anxiety disorders. Specific aspects of older adults' beliefs were influenced by their salient identities rather than their cultural background. Two new dimensions were identified: aggravating factors, believed to trigger or exacerbate anxiety symptoms; protective factors, believed to alleviate or prevent mental health problems. Conclusions Applying Leventhal's Common-Sense Model to anxiety has yielded new insights with significant implications for understanding potential causes of low mental health services use among older adults. Grouping people into broad categories of cultural groups disregards the diversity among individuals within the same group. Cross-cultural research should embrace this diversity and employ nuanced approaches to provide meaningful, person-centred insights into people's perceptions of illness.

BackgroundExternal validations of existing risk models is an efficient step towards potential implementation, obviating the need to develop new models. However, validation in new clinical settings poses several challenges. ObjectiveTo externally validate the OxSATS tool using data from the Oxford Monitoring System for Self-harm in England. OxSATS is a validated tool to predict suicide after self-harm developed using Swedish population registers. MethodsWe selected episodes of self-harm (ICD-10 codes X60-84; Y10-34) by individuals aged 10-64 years who presented to a large regional hospital between 1 January 2000 and 31 December 2018, and were followed up until 31 December 2019. We applied the OxSATS tool to estimate each individuals suicide risk within 12 months after their index self-harm. We assessed model performance using discrimination (Harrells c-index) and calibration measures (calibration plot and the observed-to-expected events ratio, O:E). We assessed the effects of missing predictors on calibration and subsequently recalibrated the model. FindingsWe identified 16,120 individuals who presented to hospital with self-harm, of whom 101 (0.6%) died by suicide in the 12-month follow-up period. The OxSATS model showed good discrimination in external validation (c-index=0.72, 95% CI=0.67, 0.77). Recalibration was required because initial calibration reflected a lower outcome rate in the new data. After recalibration, calibration performance was excellent (O:E=1.00, 95% CI=0.80, 1.20). ConclusionsDespite differences in clinical services and outcome ascertainment, suicide risk models can maintain good predictive performance in new settings. However, recalibration should be considered when applying prediction models in new settings, and the impact of missing predictors should be assessed using sensitivity analyses. KEY MESSAGESO_ST_ABSWhat is already known on this topicC_ST_ABSSuicide risk is substantially elevated after hospital presentation for self-harm, but most existing risk assessment tools rely on rating scales or binary cut-offs, show limited predictive accuracy, and rarely report calibration. OxSATS is a prognostic model developed using Swedish register data that provides continuous risk estimates and demonstrated good discrimination and calibration in its original setting. External validation in new healthcare systems is essential before implementation, but is often complicated by differences in predictor definitions, missing variables, and outcome prevalence. What this study addsThis study provides the first external validation of OxSATS in an English clinical setting using routinely collected hospital data. The model retained good discrimination but initially overpredicted suicide risk due to a lower baseline event rate and one missing predictor, highlighting the importance of calibration assessment. How this study might affect research, practice or policyFuture research and implementation strategies should routinely incorporate external validation, sensitivity analyses for missing predictors, and local recalibration before clinical or policy adoption.

BackgroundMajor depressive disorder (MDD), a leading cause of disability worldwide, exhibits substantial heterogeneity in treatment outcomes. Patients who do not respond to standard antidepressant therapy account for the majority of MDDs disease burden. Risk factors have been implicated in treatment response, including genes impacting on how antidepressants are metabolised. Yet, despite its clinical importance, risk factors for treatment-resistant depression (TRD) remain unexplored in low- and middle-income countries (LMIC). We used data from the DIVERGE study on MDD to investigate the risk factors of TRD in Pakistan. MethodsDIVERGE is a genetic epidemiological study that recruited adult MDD patients ([&ge;]18 years) between Sep 27,2021 to Jun 30, 2025, from psychiatric care facilities across Pakistan. Detailed phenotypic information was collected by trained interviewers and blood samples taken. Infinium Global Diversity Array with Enhanced PGx-8 from Illumina was used for genotyping followed by DRAGEN calling to infer metaboliser phenotypes for Cytochrome P450 (CYP) enzyme genes. We defined TRD as minimal to no improvement after [&ge;]12 weeks of adherent antidepressant therapy. We conducted multi-level logistic regression to test the association of demographic, clinical and pharmacogenetic variables with TRD. FindingsAmong 3,677 eligible patients, polypharmacy was rampant; 86% were prescribed another psychotropic drug along with an antidepressant. Psychological therapies were uncommon (6%) while 49% of patients had previously visited to a religious leader/faith healer in relation to their mental health problems. TRD was experienced by 34% (95%CI: 32-36%) patients. The TRD group was characterised by more psychotic symptoms and suicidal behaviour (OR=1.39, 95%CI=1.04-1.84, p=0.02; OR=1.03, 95%CI=1.01-1.05, p=0.005). Social support (OR=0.55, 95%CI=0.44-0.69, p=1.4x10-7) and parents being first cousins (OR=0.81, 95%CI=0.69-0.96, p=0.01) were associated with lower odds of TRD. In 1,085 patients with CYP enzyme data, poor (OR=1.85, 95%CI=1.11-3.07, p=0.01) and ultra-rapid (OR=3.11, 95%CI=1.59-6.12, p=0.0009) metabolizers for CYP2C19 had increased risk of TRD compared with normal metabolisers. InterpretationThere was an excessive use of polypharmacy in the treatment of depression while psychological therapies were uncommon highlighting the need for more evidence-based practice. This first large study of MDD from Pakistan uncovered the importance of culture-specific forms of social support in preventing TRD, highlighting opportunities for interventions in low-income settings. Pharmacogenetic markers can be leveraged to predict TRD.

BackgroundThe COVID-19 pandemic, coupled with concurrent social instabilities, has raised concerns about the long-term impact on the population mental health. While existing studies have primarily focused on the acute phase, less is known about how anxiety and depression symptoms have evolved throughout prolonged societal disruption. This study aimed to identify distinct anxiety and depression symptom trajectories and to determine the individual, relational, and societal protective and risk factors that influence anxiety and depression scores among Belgian adults from 2020 to 2024. MethodsWe used longitudinal data from five waves of the COVID-19 Health Surveys and the BELHEALTH study (n = 10,063) among Belgian adults, collected between April 2020 and June 2024. Anxiety and depression were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9, respectively. Covariates were selected based on the social-ecological framework and included both time-invariant and time-dependent variables. Latent class linear mixed models identified subgroups with distinct trajectories. Multilevel linear mixed effects models examined associations between symptom severity and predictors across individual, relationship, and societal levels. The final model, selected based on the lowest AIC (Akaike Information Criterion), included the full set of covariates. ResultsFour depression and five anxiety trajectories were identified. While most participants maintained stable mild symptoms, 11.3% experienced increasing depression and 8.4% showed increasing anxiety over time. Financial difficulty, female gender, and younger age were overrepresented in moderate and severe symptom trajectories. Protective factors such as social support, satisfying social contact, and life satisfaction were associated with lower symptom severity. Over time, life satisfaction demonstrated an increasing protective effect, while the influence of social contact on reducing symptoms weakened progressively. Risk factors included financial and job-loss worry, loneliness, psychotropic medication use, and high mental health stigma. ConclusionsOur results demonstrate persistent heterogeneity in mental health responses, with a substantial share of the population experiencing worsening symptoms years after the pandemic began. Public mental health strategies must therefore go beyond short-term crisis response, address long-term risks such as financial insecurity, social isolation, and stigma, while fostering individual and collective resilience.

Digital therapeutics for mental health often face low patient engagement, which limits their clinical impact. Interventions that deliver treatment using a video game medium may improve engagement and therapeutic efficacy, but the putative emergence of gaming-related problems remains a concern among clinical stakeholders. We examined whether long-term engagement with Meliora, a video game therapeutic for adult major depressive disorder, was associated with changes in gaming-related problems in a three-arm randomized controlled trial. The intention-to-treat cohort (n = 1,001) had a mean age of 33.4 years (SD 9.3) and 64% were female. The Gaming Addiction Scale (GAS-7) scores decreased from baseline (week 0) to post-intervention (week 12) in the Meliora arm (p = 8.1x10-4) and in the treatment-as-usual arm (p = 6.0x10-6), with no significant change observed in the Sham arm (p = 0.39). Changes in GAS-7 scores were not associated with intervention use hours (Meliora: p = 0.17; Sham: p = 0.28) or with experienced immersion (Meliora: p = 0.93; Sham: p = 0.19). Deterioration analysis found worsening rates from baseline to post-intervention low and comparable across study arms. Analyses in the per-protocol completer cohort ([&ge;]24 h use) corroborated these findings, indicating that even higher use did not lead to increases in gaming-related problems. These results provide evidence that long-term use of a video game therapeutic does not increase gaming-related problems when risks are properly mitigated, suggesting that video games may provide a safe medium for digital therapeutics. Author summaryMany patients use digital therapeutics insufficiently or drop out early, which limits their effectiveness and applicability in healthcare. Video game therapeutics deliver the treatment using an interactive video game as a medium to improve both engagement and therapeutic efficacy. However, extended use of video game therapeutics could inadvertently increase gaming-related problems. We examined whether long-term use of Meliora, a video game therapeutic for adults living with depression, was associated with increased gaming-related problems. We found that using Meliora or a highly similar Sham device did not increase gaming-related problems. Changes in gaming-related problems were not associated with the amount of time participants used the interventions, suggesting that typical use patterns are safe. We also found no relationship between experienced immersion and changes in gaming-related problems, suggesting that subjective immersion is distinct from problematic gaming. This study provides the first clinical evidence that extended engagement with a video game therapeutic does not increase gaming-related problems. These findings suggest that video games can be a safe medium for digital therapeutics in healthcare.

AIM Older adults experiencing anxiety disorders, particularly those from minority ethnic backgrounds, are less likely to use formal mental health services compared to their younger counterparts. This UK multicultural qualitative study aimed to explore and compare beliefs underpinning coping strategies for anxiety among self-reporting White British, South Asian, African and Caribbean older adults, using Leventhal's Common-Sense Model of Self-Regulation. METHODS Individual semi-structured interviews were undertaken with 52 older adults aged 65 and over who self-reported (current or past) anxiety. Professional interpreters supported interviews with non-English-speaking participants (n=10). Eight public contributors collaborated on different aspects of the study. The Framework Method was used to manage and analyse the data. FINDINGS The study drew on the perspectives of 27 older adults with distressing anxiety and 25 with non-distressing anxiety. Across all cultural groups, participants adopted different strategies to manage anxiety, the most prominent of which were self-help strategies. Help-seeking behaviour was influenced by a complex interplay of factors not recognised by Leventhal's Common-Sense Model. Notably, older adults' salient identities, rather than their cultural backgrounds, influenced their selection of coping strategies. CONCLUSIONS Interventions that empower older adults to use self-help strategies more effectively can serve as acceptable adjuncts to formal therapy. Nevertheless, addressing barriers to formal help-seeking is essential, particularly among those with a perceived need to seek help. No one model can depict the complexity of coping behaviours. While applying Leventhal's Common-Sense Model yielded novel insights, it could not fully capture the motivational factors underlying participation in specific coping behaviours. To provide nuanced and accurate insights, cross-cultural research should acknowledge heterogeneity within groups rather than impose boundaries of purportedly homogeneous entities.

BackgroundChildhood maltreatment is a major risk factor for depression and may contribute to sex differences in depression prevalence. We examined sex-specific associations between childhood maltreatment and depression and estimated the proportion of depression cases attributable to specific maltreatment subtypes. MethodsWe analyzed baseline data from 159,045 participants (49.4% women; aged 19-72) in the German National Cohort (NAKO). Childhood maltreatment was assessed via the Childhood Trauma Screener; depression via self-reported physicians diagnosis and MINI classification (lifetime) and the PHQ-9 (current). Associations, including sex interactions, were modeled using binary logistic regressions. Mediation analyses and sex-stratified population attributable fractions (PAFs) quantified the contribution of maltreatment to depression. ResultsMaltreatment was associated with increased odds of lifetime (ORphysicians diagnosis=2.45 [2.38,2.53]; ORMINI=2.30 [2.18,2.43]) and current depression (OR=2.90 [2.79,3.02]). Sex interactions were observed for the physicians diagnosis: physical abuse and neglect had stronger associations in women (ORphysical abuse=2.74 [2.59,2.90]; ORphysical neglect=1.36 [1.28,1.44]) than men (ORphysical abuse=2.36 [2.21,2.52]; ORphysical neglect=1.08 [1.00,1.16]), whereas sexual abuse showed stronger associations in men (OR=3.23 [2.91,3.57]) than women (OR=2.61 [2.48,2.75]). Overall, childhood maltreatment accounted for 21.2-26.2% of lifetime and 33.4% of current depression. PAFs were higher in women than men for lifetime (24.5-28.5% vs. 16.0-20.9%) and current depression (36.1% vs. 28.2%). Emotional abuse and neglect contributed the highest PAFs (up to 10.2%). Maltreatment mediated 18.9-30.0% of the association between sex and depression. ConclusionMaltreatment, especially emotional subtypes, account for a substantial proportion of depression in both sexes, with stronger overall associations in women. Sex-specific prevention may help reduce depression prevalence.

BackgroundLiving with multiple long-term conditions (MLTC) is becoming increasingly common with far-reaching consequences for individuals and healthcare systems. People with MLTC often face complex care pathways through health systems - especially hospitals, which are largely configured for specialist treatment of single conditions - yet evidence on people with MLTCs lived experience in the hospital setting is limited. This study aimed to understand the hospital care experiences of people living with MLTC who had recently had an inpatient stay. MethodsPeople with MLTC who had experienced an inpatient stay in hospital within the previous six months were recruited via three hospitals in England and via patient networks. Semi-structured one-to-one interviews were conducted with each participant, focussing on their experiences of care from admission to discharge. An inductive thematic analysis was undertaken. ResultsA total of 44 people (mean age 68.4 years, 23 women) who reported living with between 2 and 11 long-term conditions, the majority of whom (96%) reported that their most recent hospital stay was unplanned, participated in the study. Three themes were constructed from the interview data, reflecting perceptions at individual, interpersonal and organisational levels. Participants experiences were shaped by internalised narratives of hospital care, where care was expected to be focussed primarily on single conditions within a resource-constrained environment. Relationally, the degree of alignment between clinician and patient knowledge on conditions was a key contributor to whether hospital care was experienced positively or negatively, and participants perceptions of organisational constraints to holistic care gave insights into their views on system-level barriers shaping the provision of care for MLTC in the hospital setting. ConclusionExperiences of inpatient hospital care for people with MLTC are complex, diverse and shaped by expectations of care in a specialist setting configured to provide care for single conditions. Healthcare professionals should incorporate patients experiential expertise into decision-making processes through consultation with people with lived experience of MLTC. Redesigning hospital services to provide holistic care will require flexibility to respond to the wide spectrum of MLTC experiences.

ObjectiveThis study aimed to identify characteristics that define population need groups with similar mental health service needs within prisons and describe the mix of services required to meet those needs. MethodsMixed methods were used, including three iterative, semi-structured focus groups, followed by an online survey, seeking information on the characteristics that define service needs, how these can identify groups of people who require mental health care in prisons and the services required by each group. Participation was sought from prison health services, prison mental health services, non-government service partners and people with a lived experience. Focus group transcripts and free text survey responses were thematically analysed. Descriptive statistics were generated for online survey responses to Likert Scales to determine the levels of agreement with survey content. ResultsThe characteristics and service needs of four distinct population groups who require mental health care in prisons were defined: indicated prevention, mild, moderate, severe and complex. These groups were delineated using characteristics including presence of a diagnosed mental illness, level of functional impairment, presence of added complexity and service response required. The required service mix varied across need groups, however service types common across all groups included assessments, psychological therapies, peer support, lifestyle interventions and carer support. ConclusionsThe identified need groups and service descriptions will contribute to the evidence required for needs-based planning of mental health care in Australian prisons. This information can be used for planning a responsive, equitable, and needs-based mental health service system within custodial environments.

BackgroundUp to one-third of medical inpatients experience clinically relevant mental distress, yet many remain untreated. Stepped and collaborative care (SCC) models may improve access to mental health care, but predictors of service uptake are unclear. We examined patient- and ward-level predictors of psychosomatic-psychiatric consultation (PPC). MethodsWe analyzed data from SomPsyNet, a stepped-wedge cluster randomized trial targeting SOMatic inpatients across three Swiss tertiary hospitals, to prevent PSYchosocial distress by a care NETwork. Analyses focused on inpatients screening positive for mental distress. Multiple-imputed logistic regressions assessed predictors of four sequential service-use stages: PPC considered, offered, accepted, and received. ResultsAmong 589 distressed patients, 93.9% were offered PPC, 63.1% accepted, and 83.9% of acceptors received PPC, yielding a 50% overall receipt rate. Patients without Swiss citizenship showed higher odds of acceptance (odds ratio [OR]=1.82 [1.10, 3.00]) and eventual receipt (OR=1.62 [1.01, 2.62]). Being in a Geriatric ward facilitated PCC uptake, while patients from gynecology showed reduced progression through the care pathway. Age, gender, income, education, marital status, and living arrangement showed no statistically robust associations. ConclusionsAlmost two-thirds of mentally distressed medical hospital inpatients accepted an offered PPC, indicating high acceptability. About half ultimately received a consultation, highlighting substantial attrition along the SCC pathway. Ward specialty and nationality were key determinants of PPC uptake. These findings suggest that proactive, ward-oriented consultation-liaison models embedded in routine inpatient care may improve timely and equitable access to mental healthcare, including for migrant and minority patients who are otherwise less likely to access such care. HighlightsO_LIPsychosomatic-psychiatric consultation pathway of medically hospitalized inpatients C_LIO_LI63% accepted such a consultation when offered; overall 50% reached receipt. C_LIO_LINon-Swiss nationality increased odds of acceptance (OR 1.8) and receipt (OR 1.6). C_LIO_LIPatients at geriatrics wards showed higher, at gynecology wards lower transitions. C_LIO_LIResults support low-threshold, ward-oriented consultation-liaison models. C_LI