BMC Psychiatry

Background: Self-harm is a frequent and challenging occurrence in adult inpatient psychiatric units. The use of restrictive practice to manage self-harm incidents continues to be widespread within mental health environments despite increasing national and organisational guidance to minimise its use. Aim: The aim of this project was to introduce and evaluate a continuous quality improvement programme to progressively reduce incidents of self-harm and the use of restrictive practice. The project was set in a female acute mental health inpatient unit. The project sought to embed improvements in an inpatient unit interventions, procedures, and culture and staff mindset, and move towards a sustained collaborative and positive therapeutic and communication-based approach. Methods: A retrospective service evaluation design was employed to assess differences in the number of incidents of self-harm, enhanced observation, seclusion, restraint and rapid tranquillisation in the period following the introduction of a continuous whole-systems multimodal interventional initiative in 2019. Pre- and post-initiation data were compared (2017/18 compared to 2019/2025) to evaluate improvement and whether this had been sustained. Data were analysed using descriptive statistics, including frequencies, percentages, and means. Results: Self-harm incidents reduced between 2017/18 and 2019, with a downward trend sustained between 2019 and 2025 (136 to 72 incidents respectively between 2019 and 2025; 47% reduction). A sustained reduction in the use of restrictive practice was shown in all domains pre- and post-initiation (2017/18 compared to 2025). Clinical implications: No one approach will successfully reduce self-harm and the use of restrictive practice. Approaches employed have to be multi-faceted, multi-interdisciplinary, collaborative, and blend together to deliver improvement. Sustained progress requires commitment to an iterative process of continuous collaboration, improvement and adaptation.

Borderline personality disorder (BPD) has traditionally been viewed as one of the most chronic psychiatric disorders. Although longitudinal studies have demonstrated promising rates of symptomatic remission, recovery and other clinical outcome measures often remain comparatively low. Qualitative research offers an important perspective on how individuals with BPD may extend a more representative view of improvement and change. We collected narratives from 41 participants with a self-reported diagnosis of BPD and analyzed them using thematic analysis. Its national, virtual recruitment approach enabled a relatively large qualitative sample diverse in gender identity, age, U.S. geographic region, treatment history, and current clinical severity, extending the range of perspectives represented in prior work. Three central themes were identified. The first, Differing attitudes toward language, reflected participantsexperiences of recovery language as paradoxically both validating and stigmatizing. While individual language preferences varied, participants generally converged on a sharedunderstanding of what recovery meant to them. The second, Recovery as a dynamic and relational process, described recovery as nonlinear, effortful, and closely tied to interpersonal experiences. The third, Crossroads and uneven change over time, highlighted the role of personal agency, critical decision points in seeking treatment, and the persistence of internal distress even as behavioral symptoms improve. Findings from this study both replicate and extend existing qualitative research by discussing how individuals with BPD understand recovery in ways that may not be captured by traditional clinical outcome measures. These results emphasize the importance of incorporating lived-experience perspectives when defining recovery and setting treatment goals.

BACKGROUND: War refugees are prone to psychiatric ailments due to multiple psychosocial stressors. Afghan refugees remain underrepresented in psychiatric studies. Therefore, a study exploring factors contributing to their mental health disorders is essential to guide rehabilitation efforts worldwide. METHODS: This descriptive cross-sectional study evaluates the demographics, psychosocial stressors, psychiatric illnesses, and psychotropic drug use among Afghan refugees visiting the Psychiatry Outpatient Department (OPD) in Islamabad, Pakistan. Convenience sampling was employed on a sample population (n) of 75 participants. Data was collected via a structured questionnaire and analyzed using SPSS v21.0. Qualitative and quantitative variables were analyzed statistically. RESULTS: Nearly 64%(n=48) of the participants were female. About 46.7%(n=35) of participants were uneducated, and 53.3%(n=40) were unemployed. 86.7%(n=65) of participants were married, while 2.7%(n=2) were divorced. 91%(n=61) of the married and divorced participants had an arranged marriage, 46.3%(n=31) had 5-8 children, and 67.2%(n=45) had experienced physical and/or emotional abuse. 74.7%(n=56) of the total participants reported a loss in the family, while 77.3%(n=58) had experienced trauma. 62.7%(n=47) had depression and associated psychotropic use, e.g., SSRIs (42.7%), TCAs (16%), and Benzodiazepines (13.3%). Alarmingly, 37.3%(n=28) reported a previous suicide attempt. CONCLUSION: This study explores the psychosocial stressors faced by Afghan refugees in Pakistan, including displacement, abuse, trauma, and family/income loss. It emphasizes the importance of evidence-based psychiatric care, rehabilitative interventions, and culturally sensitive care to counter psychiatric morbidities and underscores the need for future research to improve the mental health of refugees globally.

Those leaving military service frequently present with complex psychosocial problems, but military veterans are often reluctant to engage with statutory healthcare provision. Specialist mental health services have recently been established in the UK to specifically support military veterans with their psychological and social wellbeing. We explored the treatment and support provided by the London branch of a military veterans mental health and wellbeing service (Op COURAGE) from the perspectives of the multidisciplinary service team and their partner organisations and collaborators. We conducted semi-structured interviews with multidisciplinary service staff and members of their partner organisations and external agencies. Qualitative data were analysed using framework analysis.?A total of 16 professionals participated in this study, comprising five service staff, eight collaborators and three partner agency participants. Five themes with subthemes were identified, including (1) blended networks, (2) staff inclusivity and sensitivity, (3) spectrum of psychosocial interventions and holistic support, (4) referral mechanisms, and (5) (in)visibility of the service and advertising. Our evaluation highlighted the advantages of a multidisciplinary team and collaborative partnerships to meet the psychosocial needs of veteran and their significant others. We have proposed that service improvement could include increasing advertisement about this specialist service, deepening knowledge about veterans among staff and further involving veterans and key stakeholders in service decisions.

Introduction: In 2020, Oregon became the first US state to legalize state-regulated psilocybin services. This study aims to examine: 1) the clinical and demographic characteristics, 2) psilocybin use motivations, and 3) differences in preparedness among patients seeking care in a Oregon- based pilot consult service specializing in psilocybin risk reduction. Methods: This retrospective chart review abstracted sociodemographics, trauma history, and medical and psychiatric risks of patients (November 2023 - September 2025). The Psychedelic Preparedness Scale (PPS), a validated self-report questionnaire, measured preparedness. Two sample t-tests examined associations of PPS scores by insurance, consult motivations, and prior psychedelic use. Results: Patients (N=29) had a mean age of 47.14 years (SD=15.9), were majority female (55.2%); White (82.8%); and privately insured (62.1%). Patients mostly sought psilocybin to address only a psychiatric concern (75.9%); 27.6% anticipated naturalistic (non-state regulated) use. Most patients were deemed low risk for adverse events. Prevalence of prior challenging psychedelic experiences (CPE) was 17.2%; 58.6% reported lifetime psilocybin use. 86.2% endorsed >1 form of lifetime trauma. Of PPS completers (N=23, 79%), mean score was 91.3 (SD = 23.99). Scores did not significantly differ by insurance; consultation motivation; CPE; prior psilocybin or psychedelic use. Conclusion: Patients utilizing a novel consultation service demonstrate a high prevalence of trauma, prior psilocybin use, and baseline preparedness. While preliminary, this is among the first descriptions of patients seeking medical and psychiatric consultation when considering psilocybin and highlight the potential role of healthcare systems in providing evidence-based patient education and risk reduction as interest in psychedelics grows.

Background Youth involved in child protection systems are at increased risk of psychiatric disorders and are overrepresented in inpatient mental health services. However, few studies have directly compared the clinical characteristics and mental health service use of youth across different child protection pathways. Objective To compare clinical characteristics, psychosocial risk factors, clinical complexity, and mental health service use among psychiatrically hospitalised youth in foster care, adoption, and child welfare supervision. Participants and Setting This retrospective observational study included 236 children and adolescents across three child protection pathways admitted to a Child and Adolescent Inpatient Psychiatry Unit between 2018 and 2024. Methods Clinical, psychosocial, and service-use data were extracted from medical records and compared using univariate analyses, multilevel mixed-effects models, logistic regression, and time-to-event analyses. Results All groups showed high comorbidity and clinical severity, but distinct clinical profiles emerged. Youth in foster care more frequently presented with externalising disorders, trauma exposure, and substance use; adopted youth showed higher rates of neurodevelopmental and prenatal adversity-related conditions; and youth under child welfare supervision more often presented with affective symptoms and suicidal ideation. Post-discharge emergency department re-consultation differed significantly between groups (p = 0.007) and was most frequent among adopted youth, who also had higher odds of psychiatric readmission. Youth in foster care had the shortest median time to emergency re-consultation, although time-to-event differences were not significant (p = 0.476). Conclusions Distinct clinical and service-use profiles across child protection pathways support trauma-informed, placement-sensitive mental health care and stronger coordination between child protection and mental health services.

Abstract Background To estimate the frequency of likely, often undiagnosed autism and attention deficit hyperactivity disorder (ADHD) in UK adults of working age (18-66 years) who are not in education, employment, or training (NEET), and to examine whether neurodivergent traits are associated with NEET status directly and indirectly via health burden and educational attainment. Design Frequency-matched online case-control study. Setting UK general population, recruited via online research platform Prolific. Participants Six hundred adults of working age (18-66 years); 300 NEET, 300 in education, employment, or training (EET) matched at the marginal level on age, sex assigned at birth, and ethnicity. Primary and secondary outcome measures Autistic traits (Ritvo Autism and Asperger Diagnostic Scale-14, RAADS 14) and ADHD traits (Adult ADHD Self Report Scale, ASRS 5) indexed likely autism and ADHD (cut off [≥]14 on each). Physical and mental health conditions were self reported and aggregated into composite indices of health burden. NEET status was the primary outcome; educational attainment and health burden were tested as parallel mediators of the association between neurodivergent traits and NEET status. Results NEET participants screened positive more frequently for likely autism (66.3% vs 49.0%; OR 2.05, 95% CI 1.48 to 2.85) and likely ADHD (34.3% vs 26.0%; OR 1.46, 95% CI 1.03 to 2.08) than EET participants, despite identical existing formal diagnosis rates. Physical (OR 2.00, 95% CI 1.38 to 2.90) and mental (OR 2.57, 95% CI 1.80 to 3.68) health conditions were also associated with higher odds of NEET status. In mediation analyses, neurodivergent traits predicted NEET status both directly (OR 1.33, 95% CI 1.13 to 1.68) and indirectly via greater health burden (indirect OR 1.13, 95% CI 1.02 to 1.35) and lower educational attainment (indirect OR 1.08, 95% CI 1.03 to 1.15). Conclusion NEET adults showed a marked excess of autism and ADHD traits, alongside elevated physical and mental health burden and lower educational attainment. Earlier recognition of neurodivergent traits, proactive provision of equitable requirements in education and employment, and integrated physical and mental health support may reduce NEET risk in this population. This has considerable implications for policy and practice in health, education, and wider society.

Background: Autistic people experience substantially higher rates of mental health conditions and are overrepresented in mental health services. However, most interventions and service models have been developed for non-autistic people, and evidence is needed as to whether there are disparities in outcomes. This systematic review aimed to compare outcomes between autistic and non-autistic people receiving the same mental health interventions or services. Methods: We conducted a systematic review following PRISMA guidelines (PROSPERO: CRD420251021068). We searched academic databases (MEDLINE, Embase, PsycINFO, PubMed, CINAHL), a grey literature database (HMIC), a trial registry (ISRCTN), preprint servers (medRxiv and PsyArXiv), Google, and Google Scholar, to identify relevant papers published 01/01/1992-30/04/2026. We conducted backwards and forwards citation searching and contacted experts. Study quality was assessed using a modified Critical Appraisal Skills Programme Cohort Study Checklist and the Autism-Inclusive Research Assessment (AIRA). Data were synthesised narratively, with random effects meta-analyses where appropriate. Results: Thirty-nine studies were included, comprising 4787730 participants, assessing outcomes of psychological therapies (n = 17) and multi-component or service-level approaches (n = 22). Nearly half (46.2%) were UK-based, and under a quarter (23.1%) included people with intellectual disabilities. Ten studies (25.6%) were rated low quality, twenty-two (56.4%) medium quality, and seven (17.9%) high quality. AIRA ratings highlighted concerns about research inclusiveness for autistic people, including limited involvement of autistic people and lack of validated or adapted outcome measures. Findings varied by intervention: for some, multiple large, higher-quality studies showed less favourable outcomes for autistic people (e.g., less improvement in symptoms or functioning, or higher rates of restrictive practices or acute service use). For other interventions, comparable or mixed outcomes were found across studies, with interpretation often limited by small samples. Conclusions: Mental health treatment outcomes for autistic versus non-autistic people varied across interventions and outcome types. Where significant differences were observed, these usually showed poorer outcomes for autistic people, although they generally reflected smaller improvements rather than a lack of benefit. Action is needed to improve the accessibility and appropriateness of mental health care for autistic people, supported by more high-quality, co-produced research across a broader range of countries and service contexts.

Importance: Clozapine is the only evidence-based treatment for treatment-resistant schizophrenia (TRS), yet substantial international variation in its use has been reported. Objective: To provide a comprehensive and updated assessment of international clozapine utilisation by estimating prevalence across countries using a standardised methodology and examining factors associated with variation in use. Design, Setting, and Participants: Repeated cross-sectional study using population-based data from 2015 to 2024. Individual-level data were obtained from 36 countries and 1 special administrative region, supplemented by national clozapine consumption data from 5 additional countries. Analyses were conducted separately for adults (20-64 years; primary analysis), adolescents (10-19 years), and older adults ([≥]65 years). Main Outcomes and Measures: Annual outpatient clozapine utilisation prevalence per 100,000 population by age group, sex, country and calendar year. Associations between clozapine utilisation prevalence and country-level health system, demographic, and socioeconomic indicators were also examined. Results: We analysed data from more than 1.1 billion people across all inhabited continents. In 2024, crude adult clozapine use prevalence was highest in Croatia (415.3 per 100,000 population) and Finland (302.0 per 100,000), and lowest in Oman (0.5 per 100,000) and Ethiopia (0.3 per 100,000), representing a 1,384-fold difference. Across most countries, utilisation peaked among individuals aged 50 to 59 years. The male-to-female prevalence ratio ranged from 0.4 in the United Arab Emirates to 2.8 in Colombia. Among adolescents, prevalence was highest in Colombia (42.7 per 100,000) and Croatia (24.4 per 100,000), while among older adults it was highest in Croatia (406.9 per 100,000) and Iceland (339.7 per 100,000). Across all countries, adult clozapine utilisation increased by 17% (95% CI, 16%-18%), from 44.7 per 100,000 population (95% CI, 44.5-44.9) to 52.2 per 100,000 population (95% CI, 51.1-52.4). Country-specific trends ranged from a 71% decrease to a 342% increase. None of the examined indicators explained variation in clozapine utilisation across countries. Conclusion and relevance: Clozapine use increased modestly over the past decade but remained highly variable between countries. This variation was not explained by national socioeconomic, healthcare-system, or monitoring-related factors, suggesting an important role for clinical and service-level barriers. The concentration of clozapine use in later adulthood is consistent with delayed initiation and highlights opportunities to improve timely access to evidence-based treatment for TRS.

Background The prevalence and pattern of secondary causes of first-onset psychosis (FEP) in Asian populations are understudied. Our objectives are to investigate the prevalence and pattern of secondary causes of FEP presenting in an acute medical setting in a metropolitan, Chinese-predominant population, and to investigate the prevalence and pattern of undiagnosed conditions presenting as psychosis. Method This is a retrospective observational study. We reviewed medical records of patients referred to the consultation psychiatry team at a tertiary acute teaching hospital in Hong Kong from January 2015 to Apr 2025. The inclusion criteria of the study are 1) age 18-64 at the time of the assessment, and 2) FEP confirmed by the consultation liaison team. Patients diagnosed with delirium were excluded. Result Among the 384 patients included in the study (mean age = 40.0 {+/-}13.7 years, 69% female), secondary causes of psychosis were found in 9.6% (n=37) of the cohort. Substance use is the most common secondary cause found (n=11, 2.9% of all FEPs) overall. Among those with secondary psychoses, patients' underlying conditions were revealed only by the workup in relation to the FEP in 16 of them, of which definitive or probable autoimmune encephalitis (n=5) and early-onset dementia (n=4) were the most common conditions uncovered. Conclusion The prevalence of secondary psychoses in our FEP cohort is lower than published international figures. Clinicians need to be aware of the suspicious clinical features suggestive of autoimmune encephalitis and early-onset dementia in FEP patients with otherwise unremarkable past history and toxicology test.

Objective: To compare appointment completion and offered-slot utilization between virtual and in-person outpatient psychiatric care in Peru. Methods: We conducted a retrospective ecological longitudinal study using routinely collected monthly aggregate administrative indicators from January 2022 through June 2026, with modality-month as the unit. Virtual-minus-in-person differences and 95% confidence intervals used Newey-West standard errors with 12 lags. June 2026 was partial; slot utilization was restricted to 2024-2026. Results: Across 54 paired months, mean completion was 90.9% (SD=3.9) for virtual and 83.8% (SD=2.7) for in-person care; difference +7.2 points (95% CI=4.4-9.9). Across 30 paired months, slot utilization was 73.0% (SD=8.3) and 90.5% (SD=3.8), respectively; difference -17.5 points (95% CI=-24.5 to -10.4). Sensitivity analyses were similar. Conclusions: Virtual care had higher completion but lower slot utilization. Attendance and capacity use should be evaluated separately when planning hybrid psychiatric services. Outpatient psychiatric services increasingly operate as hybrid systems in which virtual and in-person visits coexist.

While Artificial intelligence (AI) is increasingly being integrated into psychotherapy, little is known about how prospective patients evaluate different levels of AI involvement. Participants (n = 1,003) with depression evaluated vignettes describing psychotherapy options, from treatment delivered without AI integration (Human therapist) to treatments involving different degrees of AI integration (Assistive, Collaborative, Fully Autonomous AI). Participants consistently evaluated Human therapists more favorably, reporting a greater likelihood of seeking treatment, less hesitancy, and greater treatment acceptability. Economically, compared with a Human therapist, participants were willing to pay 31.6% less for therapists using Assistive or Collaborative AI and 57.2% less for Fully Autonomous AI. 18-19% of participants indicated that they would refuse treatment involving Assistive or Collaborative AI, compared with 31% for Fully Autonomous AI. Preference for Human over AI therapists was particularly pronounced at higher levels of therapist experience (doctoral/masters vs. peer/trainee). Overall, participants valued psychotherapy delivered by Human therapists more highly than AI integrated psychotherapy. These findings suggest that, despite increasing AI integration in mental health care, prospective patients continue to view psychotherapy as a distinctly human endeavor.

Autistic individuals may be at an increased risk of hazardous drinking compared to non-autistic counterparts: potential motivations include facilitated social interactions and self-medication of co-occurring difficulties, and possible risk factors include being older and female. However, research remains limited and centred around clinical samples. Given the diversity of the autistic community, it is important to understand the intricacies of alcohol use to inform appropriate support. Eighteen autistic adults took part in semi-structured interviews about their drinking experiences. Data were analysed using reflexive thematic analysis. Three main themes were created (Autistic experiences, Managing expectations and coping by drinking and Recommendations for support). Autistic experiences was used to denote the ways in which participants described their own autistic features influenced their relationship with alcohol. Managing expectations and coping by drinking was chosen to reflect the pressures felt by participants to show up in social relationships and the co-occurring difficulties many of them managed using alcohol. Therapeutic preferences for alcohol services were captured under Recommendations for support. As expected, participants used alcohol to facilitate social interactions and self-medicate. However, additional nuances uncovered may provide clinical utility and highlight the need for further research in other demographics within the community.

Objectives: This research aimed to characterize longitudinal changes in dose-normalized psychotropic exposure around transfer to a specialized older adult mental health service in Peru, with the primary contrast comparing the last eligible pre-transfer consultation (T0) with six months after transfer. We additionally explored characteristics associated with average medication-score levels and potential modification of the T0-to-6-month change. Methods: A retrospective longitudinal single-cohort study was conducted using routine clinical records from the Instituto Nacional de Salud Mental Honorio Delgado-Hideyo Noguchi in Lima, Peru. The primary analytic cohort comprised patients transferred to the older adult service who had valid longitudinal medication data at or before transfer and after transfer. A dose-normalized psychotropic medication score was calculated at approximately -6 months, -3 months, T0 (the last eligible consultation before transfer), +3 months, and +6 months. Longitudinal change was estimated using linear mixed-effects models with categorical time and participant-specific random intercepts; the prespecified primary contrast compared +6 months with T0. Sensitivity analyses evaluated alternative score definitions, age restrictions, influential observations, and participant-level cluster bootstrap resampling. Results: The primary analytic cohort included 213 participants; mean age at T0 was 65.5 years (SD 7.2), 59.2% were female, and the most frequent diagnostic categories were psychotic disorders (52.1%) and depressive disorders (29.1%). The medication score was 17.87 points higher at +6 months than at T0 (95% CI 12.18 to 23.57; p < 0.001), and the exploratory adjusted estimate was similar (17.82 points; 95% CI 12.10 to 23.54; p < 0.001). The primary contrast remained positive across alternative score definitions, age-restricted analyses, influence analyses, and participant-level bootstrap resampling. In exploratory effect-modification analyses, each 10-year increase in age was associated with a 10.94-point greater T0-to-+6-month change (95% CI 2.33 to 19.55; p = 0.013), although this association did not remain statistically significant after false-discovery-rate correction (FDR-adjusted p = 0.091); no other tested modifier showed evidence of interaction after FDR correction. Conclusions: Dose-normalized prescribed psychotropic exposure increased from a relative pre-transfer low point at T0 to 6 months after transfer, with similar estimates across sensitivity analyses. In the absence of a contemporaneous comparison group, this finding should be interpreted as a temporal association around service transfer rather than evidence that transfer itself caused the increase or that the resulting prescribing was clinically beneficial, harmful, or inappropriate.

BackgroundPsychotic-like experiences (PLEs) have been shown to increase the risk for mental health problems in later life, especially psychosis. Following previously raised methodological concerns about the assessment of PLEs in adolescents, this study sought to differentiate subtypes of PLEs and to explore their trajectories. MethodsLongitudinally matched data of 671 German adolescents from three surveys over the time span of one year were analysed. Four trajectories were identified, including persisting, subsiding, and emerging highly indicative PLEs (HIPs), and non-highly indicative PLEs (non-HIPs), and longitudinally compared in terms of associated distress, psychopathology, and substance use. A differentiated never PLEs group was considered as a control. ResultsThe persisting HIPs group reported greater distress than the non-HIP group over time and was consistently associated with higher rates of internalising symptoms. The subsiding HIP group showed significant reductions in distress and internalising symptoms over time, but no significant changes regarding externalising symptoms and substance use. There was no difference in the extent of substance use between the groups. ConclusionsScreenings of PLEs should be mindful of different subtypes of PLEs that indicate a greater associated risk of poor mental health. PLE screening should not stop at whether PLEs are present but ask which ones.

Background: Mental health conditions represent a significant public health burden in sub-Saharan Africa, where access to specialist services remains limited. Sokoto State, Nigeria, has an estimated population exceeding 5.4 million with fewer than five psychiatrists, leaving frontline health workers to provide much of the mental health care. LUMANA is a human-centred artificial intelligence (AI) system developed to support mental health screening in resource-constrained settings. Methods: We conducted a field validation of LUMANA in Sokoto State, Nigeria, on 28-29 January 2026 following ethical approval (SKHREC/014/2026). Twenty stakeholders were enrolled, of whom 17 completed structured evaluations across eight standardized clinical scenarios using five assessment tools. The evaluation examined AI output safety, Hausa language performance, human-AI workflow integration, trust and cultural appropriateness, and implementation readiness. Results: A total of 136 AI output safety assessments were completed. Overall, 113/136 (83%) AI outputs were rated acceptable as shown, while 23/136 (17%) were considered acceptable only with human review; no AI output was rated unacceptable. Religion and culture were identified as important determinants of trust by 14/17 (82%) participants, while 17/17 (100%) agreed that disclosures of self-harm or suicide should always involve a human clinician. Mean language quality scores were 9.9/10 for Hausa transcription, 9.9/10 for Hausa-to-English translation, and 9.2/10 for English-to-Hausa summary generation. Clinicians considered 7/8 (88%) human-AI workflow scenarios comfortable for routine practice. Three operational improvements were identified before pilot implementation: clearer protocols for interpreting distress, refinement of language to minimise potentially stigmatizing expressions, and automatic escalation of suspected psychotic symptoms. Conclusions: This scenario-based field validation provides preliminary evidence that LUMANA is perceived as culturally appropriate, acceptable and capable of supporting human-supervised mental health screening in a low-resource setting. However, the findings are based on a small convenience sample using standardized scenarios rather than live clinical use. Accordingly, the results support progression to a carefully monitored pilot implementation following completion of the identified system improvements, with prospective evaluation of safety, workflow integration and implementation outcomes before consideration of wider deployment.

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 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.

Objective: Parent-adolescent disagreement in ratings of attention-deficit/hyperactivity disorder (ADHD) symptoms can complicate clinical assessment. This study examined parent - adolescent agreement in ADHD symptom ratings and characteristics associated with disagreement. Method: Participants were 1,008 parent-adolescent dyads recruited from a nationally stratified U.S. community sample. Adolescents were 12--18 years old (49.6% female) and along with their parents completed measures of ADHD and depressive symptoms. Agreement on Inattention (IN), Hyperactivity/Impulsivity (HI), and Total ADHD scores was examined. Item-level agreement was assessed using weighted kappa, Gwet 's AC2, percent agreement, and polychoric correlations. Associations between age, sex, and severity of ADHD and depression with levels of agreement were analyzed. Results: Agreement for ADHD factor and total symptom scores was moderate (intraclass correlations = 0.67--0.71), with moderate-to-strong rank-order correspondence. Adolescents reported slightly higher ADHD symptom levels than parents, although the mean difference was small. Item-level agreement was moderate to high (Gwet 's AC2 = 0.79--0.95). Several HI items demonstrated the kappa's paradox, with relatively low kappa values despite high Gwet's AC2 and percent agreement. Q-correlations revealed low agreement on relative strengths and weaknesses. Age and sex were not associated with disagreement and parent-reported ADHD severity and adolescent-reported depressive symptoms were associated with disagreement. Conclusions: Parent and adolescent ratings showed moderate agreement across boys and girls ages 12-- 18; however, disagreement related to relative strengths and weaknesses. Disagreement was associated with ADHD and depressive symptom severity. Findings suggest that ratings from parents and adolescents offer unique perspectives on the assessment of ADHD symptoms.

Background Children of parents with schizophrenia (SZ) or bipolar disorder (BP) show elevated rates of mental disorders. Longitudinal studies comparing offspring at familial risk with the background population are lacking. Method This study is an eight-year follow-up of the Danish High Risk and Resilience study. We examined four-year prevalence from age 11 to age15 (n=416), cumulative incidence by age 15 (n=516), persistency of mental disorders from age 11to age 15 (n=396) and global functioning in 15-year-old adolescents with familial high risk of SZ (FHR-SZ) or BP (FHR-BP) compared to population-based controls (PBC). We assessed mental disorders and global functioning with the Kiddie Schedule for Affective Disorders and Schizophrenia - Present and Lifetime Version (K-SADS-PL) and the Childrens Global Assessment Scale (CGAS). Results Four-year prevalence of any mental disorder was higher in FHR-SZ (51.3%, OR=2.39, 95% CI 1.49-3.83) and FHR-BP (45.9%, OR=1.98, 95% CI 1.16-3.37) compared with PBC (30.5%). Cumulative incidence of mental disorders by age 15 was higher in FHR-SZ (67.2%, OR=3.19, 95% CI 2.11-4.82) and FHR-BP (64.4%, OR=2.82, 95% CI 1.75-4.54) than in PBC (39.1%). Adolescents with FHR-SZ showed the highest rate of persistent mental disorders (33.3%), followed by FHR-BP (24.5%), and PBC the lowest (12.9%). Global functioning at age 15 was lower in FHR-SZ than in both FHR-BP and PBC, and FHR-BP showed lower scores compared with PBC. Between-group differences in cumulative incidences of mental disorders and in global functioning scores remained stable across ages 7,11 and 15. Conclusion Adolescents at FHR-SZ or FHR-BP show elevated risks of a range of mental disorders, psychiatric comorbidity, and lower global functioning from childhood to mid-adolescence, not confined to the disorders for which they carry familial risk. This vulnerability underscores the need for early detection and support for FHR offspring and their families.