BMJ Mental Health

Introduction Functional neurological disorder (FND) is a common cause of neurological disability and is associated with substantial healthcare utilisation and cost. Most available treatments target specific symptom subtypes, and prospective evidence regarding the effect of treatment on health-system costs remains limited. We evaluated the real-world clinical and economic outcomes of a transdiagnostic outpatient intervention, attention-based rehabilitation (ABR). Methods We conducted a pragmatic waitlist-controlled study in 54 consecutively referred patients with neurologist-diagnosed FND attending a specialist outpatient service. Clinical outcomes--including quality of life (Short Form-36), social and occupational participation (Work and Social Adjustment Scale), symptom severity, and mental health (Hospital Anxiety and Depression Scale)--were assessed at waitlist entry, treatment commencement, treatment completion, and 6 and 12 months post-treatment. Healthcare utilisation and costs were obtained prospectively from health-service financial records for the 6 months preceding treatment, the treatment period, and two consecutive 6-month post-treatment periods. Longitudinal clinical outcomes and healthcare costs were analysed using Bayesian mixed-effects and mixture models, respectively. Results All clinical measures remained stable or worsened during the waitlist control period. Across treatment, six of eight SF-36 domains, WSAS, employment status, and both HADS subdomains improved, with maintenance through 12 months. Patient-reported symptom improvement persisted post-treatment. Expected monthly health system costs approximately halved post-treatment, with net cost savings by approximately 50 days. Conclusion A fixed-duration, symptom-agnostic outpatient ABR programme was associated with durable improvements in functioning and quality of life, alongside substantial reductions in healthcare utilisation and cost, supporting scalable symptom-agnostic treatment models for FND.

ObjectivesO_LIDetermine differences in frequency and choice of antidepressant for anxiety and depression between pwHD and controls. C_LIO_LIDetermine if regional variation affects antidepressant prescribing between pwHD and controls. C_LI MethodsWe used data from the observational cohort study ENROLL-HD. Clinical assessments and medication are recorded annually for 19540 pwHD and 6010 controls. We determined an episode of depression and anxiety as >1 for both severity and frequency Problem Behaviours Assessment(PBAs) depressed mood item and anxiety item respectively. We classed antidepressants as SSRI, SNRI, TCA, Unique, TeCA (tetracyclic antidepressant), NDRI (noradrenaline - dopamine reuptake inhibitor), phenylpiperazine. We used logistic models to determine the effect of case status on probability of antidepressant treatment and multinomial models to determine the effect of region and case status on antidepressant class. ResultsWe found that rates of both depression(46.06% vs 32.42%) and anxiety(50.23% vs 37.47%) were higher in pwHD than controls. Even accounting for severity, pwHD were significantly more likely to receive an antidepressant than controls for both depression(OR 3.48,p<2x10-16) and anxiety(OR 4.34,p<2x10-16). Accounting for regional variation, pwHD were more likely than controls to receive a TeCA for depression(OR 2.1,p=1.2x10-7) or anxiety(OR 4.2,p=0.00025); and less likely to receive an NDRI for depression than controls(OR 0.78,p=0.022). There was substantial regional variation in antidepressant class selection for pwHD. ConclusionsAnxiety and Depression are treated differently in pwHD and controls: the lack of an evidence base to justify this underscores the need for a clinical trial of antidepressants for depression and anxiety in pwHD.

Introduction: Parkinson's disease is a neurodegenerative disease affecting motor and cognitive function that has a major impact on society. Epidemiological evidence has suggested that the incidence of PD may be increasing; however, the underlying etiology is unclear. Here, we investigated the role of increasingly used antipsychotics in the diagnosis of PD. Methods: We harnessed Merative Marketscan insurance claims databases to conduct a case-control study of 65,275 new cases of PD and 652,364 age-, sex-, and time-matched controls. We estimated associations between exposure and duration of use for antipsychotics adjusted for important confounders using fixed effects logistic regression. We performed sensitivity analyses stratified by the level of D2 receptor inhibition to assess dose-response relationships; a lagged exposure analysis to address confounding by indication; analysis assessing exposure of other psychiatric medications without significant D2 inhibition (bupropion, trazodone, and Z-drugs); analysis assessing exposure of non-psychiatric medications with significant (metoclopramide) or no D2 inhibition (ondansetron). Results: We found cases with PD had elevated odds of antipsychotic exposure. Longer durations of exposure and greater affinity for the D2 receptor were associated with greater associations with PD. There was a dose-response relationship between D2 inhibition activity and increased odds of PD for a similar duration of exposure. There was a dose response relationship between duration of metoclopramide and the odds of PD; however, there was no such relationship between the non-D2 inhibiting control medications. The association between exposure to an antipsychotic and increased odds of PD was present even when the first exposure was 10 years prior to the PD diagnosis date. Conclusion: If these results are causal, antipsychotic use may explain up to 2.4% of all cases of PD. Given the increasing rate of use of these medications, and the concurrent increasing age-adjusted incidence of PD, there is an urgent need for further investigation into this association and greater awareness of the potential risks of these medications in older adults.

BackgroundHealthcare workers experience disproportionately high rates of depression, anxiety, and post-traumatic stress compared with the general population. Within the NHS, work-related stress and mental health-related sickness absence has increased over the past decade, a trend intensified by COVID-19. Mental health support offers are patchy across the UK, and the evidence base around interventions is scarce. The Staff Mental Health Service (SMHS) provides rapid, confidential support for NHS staff across Cambridgeshire and Peterborough. In this study, we report an economic evaluation of this dedicated service. AimsTo assess costs and patient outcomes associated with SMHS treatment, compared with local NHS Talking Therapies (TT) support. MethodA model-based cost-consequence analysis comparing two treatment pathways: SMHS or TT, versus TT only. Routinely collected service data and survey responses informed a decision-tree model estimating costs (2022/23 {pound}GBP), clinical outcomes (PHQ-9 and GAD-7 scores), and quality-adjusted life years (QALYs). Additional analyses examined service waiting times and productivity losses. ResultsCosts per patient were slightly higher for SMHS or TT ({pound}614 versus {pound}553), resulting in an incremental cost-effectiveness ratio of {pound}7,126/QALY. Treatment at either SMHS or TT yielded greater improvements in mental health outcomes than TT alone, with mean score reductions of 4.2 versus 2.8 (PHQ-9), and 4.6 versus 2.7 (GAD-7). Median waiting times were substantially shorter at SMHS versus TT from referral to assessment (14 versus 17 days), referral to treatment (22 versus 51 days), and assessment to first treatment (7 versus 30 days; all p<0.001). Productivity losses during waiting periods were lower for SMHS, with an estimated value of {pound}2,018 per patient. ConclusionsThe SMHS offers a clinically effective and cost-effective model of support for NHS staff, delivering greater improvements in mental health symptoms, substantially shorter waiting times, and reduced productivity losses at only modest additional cost compared with TT. These findings provide early evidence that specialist services for healthcare workers represent good value for money and support continued investment in specialist staff mental health provision within the NHS.

BACKGROUNDDepression is a disabling disorder with variable outcomes. In severe cases treatment is provided by specialist mental health care services, yet there is a lack of real-world evidence demonstrating how depression is managed within these settings, and consequently, a limited understanding of how to improve care for this population. AIMSWe examine the characteristics of patients receiving secondary mental healthcare for depressive disorders within a UK National Health Service (NHS) provider, and the treatments they receive. We investigate when patients receive treatments, and what predicts the use of specific treatments, improvement, and duration with services, with the aim of comparing real-world care to that advised by national guidelines. METHODSA retrospective cohort study was conducted using de-identified electronic patient records of patients with depression referred to Cambridgeshire and Peterborough NHS Foundation Trust (serving a population [~]0{middle dot}86 million), between January 2013 and June 2021. ANOVA models examined predictor variables of improvement and duration of care, while survival analyses explored treatment initiation rates and predictors of which treatments were used. RESULTS9,083 patients met the studys inclusion criteria. Almost half of those with depression had additional psychiatric diagnoses, reflecting the complexity of cases in secondary care. Treatment within secondary care was associated with improvements in both depressive and overall symptoms. Patients with a greater degree of psychiatric co-morbidity and those with lower socio-economic status indicators presented with greater overall illness severity at baseline, were more likely to be admitted into hospital, spent longer with services, and improved less than the average. Treatment patterns differed across age groups, sex/gender, socio-economic status, and psychiatric comorbidities. Some nationally recommended further-line treatments appeared to be under-used. CONCLUSIONSTreatment gaps in further-line treatments for depression exist, highlighting key areas for service improvement. Future work should target patients with complex needs and those who are socio-economically deprived.

BackgroundIntensive Support Teams (ISTs) are recommended for individuals with intellectual disabilities who display behaviours that challenge. However, there is currently little evidence about the clinical and cost effectiveness of IST models operating in England. AimsTo investigate the clinical and cost effectiveness of IST models. MethodsWe carried out a cohort study to evaluate the clinical and cost-effectiveness of two previously identified IST models (independent and enhanced) in England. Adult participants (n=226) from 21 ISTs (10 independent and 11 enhanced) were enrolled. The primary outcome was change in challenging behaviour between baseline and 9 months measured by the Aberrant Behaviour Checklist-Community 2. ResultsWe found no statistically significant differences between models for the primary outcome (adjusted {beta}: 4.27; 95% CI: -6.34 to 14.87; p=0.430) or any secondary outcomes. Quality Adjusted Life Years (0.0158; 95% CI: -0.0088 to 0.0508) and costs ({pound}3409.95; 95% CI: -{pound}9957.92 to {pound}4039.89) of the two models were comparable. ConclusionsThe study provides evidence that both models were associated with clinical improvement for similar costs at follow-up. We recommend that the choice of service model should rest with local services. Further research should investigate the critical components of IST care to inform the development of fidelity criteria, and policy makers should consider whether roll out of such teams should be mandated. Study registration numberClinicalTrials.gov NCT03586375; IRAS 239820; National Institute for Health Research (NIHR) Central Portfolio Management System (CPMS) 38554.

Living at risk of a neurodegenerative condition such as inherited prion disease (IPD) is associated with substantial psychological burden, yet evidence-based supportive interventions are lacking. This unmet need is likely to grow as advances in biomarkers and predictive testing lead to increasing identification of individuals in pre-symptomatic stages of neurodegenerative disease. Acceptance and Commitment Therapy (ACT), a transdiagnostic intervention targeting psychological flexibility, has shown promise in chronic health contexts but has not been evaluated in individuals at genetic risk. We conducted a feasibility and acceptability study of a brief, group-based ACT intervention in adults at risk of IPD recruited through the UK National Prion Clinic. The intervention comprised a single 5-hour, face-to-face workshop followed by an individual booster session. Prespecified feasibility and acceptability criteria were assessed alongside secondary psychological outcomes at baseline, 1 month, and 3 months post-intervention, complemented by semi-structured qualitative interviews. Twenty-three participants completed the intervention. All predefined feasibility criteria were met, including recruitment (58%), intervention completion (80%), retention at 3 months (79%), and low missing data (10%). Acceptability was high, with all participants reporting the intervention as useful and appropriate. Quantitative analyses demonstrated improvements in psychological quality of life and behavioural awareness at 3 months, with larger effects observed in participants with elevated baseline depressive symptoms. Qualitative findings highlighted the importance of peer connection, experiential learning, and practical strategies for managing uncertainty. These findings demonstrate that a brief, hybrid ACT intervention is feasible and acceptable for individuals living at risk of IPD and provide preliminary evidence for improving psychological well-being. As the population of individuals identified as at risk for neurodegenerative disease continues to expand, scalable psychological interventions that address cost and time barriers may represent an important component of future clinical care.

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

BackgroundPsychosis affects over half of people with Parkinsons disease (PD) over the disease course and severely worsens quality of life. Clinicians often face a trade-off between reducing dopaminergic therapies to control hallucinations/delusions and maintaining motor function. Multiple atypical antipsychotics are used, but their comparative efficacy and safety remain uncertain. MethodsWe conducted a prespecified systematic review and network meta-analysis (NMA) following PRISMA 2020 and registered in PROSPERO (CRD420251143957). PubMed, Embase, Scopus, and CENTRAL were searched to August 2025 without language restrictions. Randomized controlled trials evaluating atypical antipsychotics for PD psychosis were eligible. Two reviewers independently screened studies, extracted data, and assessed risk of bias (RoB 2); certainty was appraised with GRADE. Continuous outcomes (BPRS, CGI-S, UPDRS-II) were synthesized as mean differences; binary outcomes (adverse events, discontinuation, mortality, cardiovascular events) as risk ratios in a random-effects NMA, with placebo as the common comparator. ResultsA total of 22 trials with 2,047 participants (mean age 70.6 {+/-} 12 years; 1,038 males and 997 females) were included, with a mean follow-up of 2.73 {+/-} 1.0 months. Across treatment arms, 1,091 patients received active interventions and 1,036 placebo. The active groups included clozapine (n=139), olanzapine (n=111), pimavanserin (n=746), quetiapine (n=126), risperidone (n=5), and ziprasidone (n=8). None of the drugs demonstrated consistent or statistically significant superiority over placebo in reducing psychosis severity as measured by BPRS or CGI-S, although clozapine and quetiapine showed trends toward improvement and risperidone suggested possible benefit with very wide intervals due to small samples. Motor and daily living outcomes assessed with UPDRS-II revealed no significant changes across treatments, with pooled effects for clozapine, olanzapine, quetiapine, pimavanserin, risperidone, and ziprasidone all overlapping the null. Safety analyses indicated no meaningful increase in risk of PD worsening, insomnia, cardiovascular events, or mortality compared with placebo, with overall pooled risk ratios approximating unity and showing no heterogeneity. SUCRA rankings suggested risperidone and clozapine as potentially more efficacious on BPRS, olanzapine as higher on CGI-S, and ziprasidone on UPDRS-II, though none achieved robust statistical significance. ConclusionsNo antipsychotic showed clear superiority over placebo; clozapine and pimavanserin remain the most relevant options, but stronger evidence is needed.

BackgroundAdults with intellectual disabilities who display behaviours that challenge (BtC) are more prone to poor health. This study seeks to evidence the long-term health outcomes for this population. MethodsWe conducted a longitudinal cohort study of adults with intellectual disabilities aged 18+ years in England using data from Clinical Practice Research Datalink Aurum (01/2003-12/2023) linked to Hospital Episode Statistics and Office for National Statistics. Main outcome measures were Annual Health Checks (AHCs), GP referrals, emergency visits, outpatient attendance, inpatient admissions, and mortality. ResultsAmong 83,166 adults with intellectual disabilities (mean age 38.6 years), 18.5% had a record of BtC with similar sociodemographic distributions to those without BtC but higher rates of physical and mental health comorbidities and uptake of AHCs. 72.5% of participants with BtC were receiving psychotropic medication(s). Adults with BtC had higher rates of mental health outpatient attendance (OR: 1.42, 95% CI: 1.33 to 1.52) and inpatient admissions (IRR: 1.19, 95% CI: 1.09 to 1.29) but consistently lower rates of physical health outpatient attendance (IRR: 0.81, 95% CI: 0.78 to 0.84) and inpatient admissions (IRR: 0.77, 95% CI: 0.74 to 0.79), after adjusting for demographic and clinical characteristics. BtC was not associated with mortality after adjustment for comorbidities (HR: 0.97, 95% CI: 0.93 to 1.00). ConclusionThis longitudinal study not only corroborated the markedly elevated burden of physical and mental health comorbidities among individuals displaying BtC but also indicated that repeated efforts to improve health outcomes have yielded minimal measurable benefit over time. The apparent absence of progress is likely underpinned by a combination of insufficiently effective or poorly tailored interventions and wider systemic constraints that limit the capacity of services to respond to the complex needs of this population.

BackgroundThe COVID-19 pandemic significantly affected health and social care services. We aimed to explore whether this impacted the prescribing rates of antipsychotics within at-risk populations. MethodsWith the approval of NHS England, we completed a retrospective cohort study, using the OpenSAFELY platform to explore primary care data of 59 million patients. We identified patients in five at-risk groups: autism, dementia, learning disability, serious mental illness and care home residents. We then calculated the monthly prevalence of antipsychotic prescribing in the population, as well as the incidence of new prescriptions in each month over the study period (Jan 2019-Dec 2021). ResultsThe average monthly rate of antipsychotic prescribing increased in dementia from 82.75 patients prescribed an antipsychotic per 1000 patients (95% CI 82.30-83.19) in Q1 2019 to 90.1 (95% CI 89.68-90.60) in Q4 2021 and from 154.61 (95% CI 153.79-155.43) in Q1 2019 to 166.95 (95% CI 166.23-167.67) in Q4 2021 in care homes. There were notable spikes in the rate of new prescriptions issued to patients with dementia and in care homes. In learning disability and autism groups, the average monthly rate of prescribing per 1000 decreased from 122.97 (95% CI 122.29-123.66) in Q1 2019 to 119.29 (95% CI 118.68-119.91) in Q4 2021, and from 54.91 (95% CI 54.52-55.29) in Q1 2019 to 51.04 (95% CI 50.74-51.35) in Q4 2021 respectively. ConclusionsDuring each of the lockdowns in 2020, we observed a significant spike in antipsychotic prescribing in the dementia and care home groups. We have shown that these peaks are likely due to prescribing of antipsychotics for palliative care purposes and may have been linked to pre-emptive prescribing, when on-site medical visits would have been restricted. Over the study period, we observed gradual increases in antipsychotic use in patients with dementia and in care homes and a decrease in their use in patients with learning disability or autism.

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.

BackgroundPreliminary evidence indicates that social prescribing (SP) can improve children and young peoples (CYP) wellbeing but is limited by small non-representative samples and often relies on descriptives statistics. Given the wide implementation of SP in the UK, administrative records provide a unique opportunity to understand current practice and assess impacts on wellbeing. ObjectivesO_LITo understand the quality of data captured in SP administrative records C_LIO_LITo explore which CYP are currently receiving SP and what SP entails in practice C_LIO_LITo assess the impact of SP on wellbeing C_LI MethodsWe used administrative records from one CYP SP service in England. Records were extracted from Joy, an online platform for managing SP. Over 18 months, 770 age-eligible CYP were referred to SP, 203 of whom were successfully discharged and completed two measures of wellbeing (the short Warwick-Edinburgh Mental Wellbeing Scale; SWEMWBS) at least seven days apart. We used descriptive statistics, a paired t-test to assess changes in wellbeing, and linear regressions with interactions to test effect modification. FindingsMissing data was the largest issue, with ethnicity missing for 94% of CYP. A lack of detail and inconsistent recording also presented challenges. Despite this, we identified that most CYP were referred by their GP, followed by their school, with 97% referred because of their mental health. The most common pathway was to receive SP for less than 100 days, with 10-15 link worker contacts, and six contact hours. Following SP, SWEMWBS scores improved by 3.72 points (t(202)=17.50, 95% CI=3.30 to 4.14, p<0.001), a 20% relative increase. Exploratory analyses suggested that this increase was greater for those with fewer link worker contacts, no interventions recorded, and lower baseline wellbeing. ConclusionsDespite numerous challenges with missing data and data quality, we found that CYP wellbeing increases following SP (as it is currently implemented). Effect sizes were consistent with larger studies of adults. Clinical implicationsFurther development of online platforms is needed to monitor access to, nature of, and efficacy of SP. For those working in SP, we recommend more training, implementation of standardised guidelines, and designated time to update records. Key messages What is already known on this topicO_LISocial prescribing has been widely implemented in the UK, but there is very little evidence on what it looks like or whether it works for children and young people C_LI What this study addsO_LIWe show that it is feasible to evaluate social prescribing for children and young people using administrative records and identify several priorities for improving data quality C_LIO_LIWe describe the typical social prescribing pathway in one children and young peoples service in England, which includes receiving SP for less than 100 days, with 10-15 link worker contacts, and 6 contact hours C_LIO_LIWe found evidence for clinically significant improvements in children and young peoples wellbeing from their first to their last social prescribing session C_LI How this study might affect research, practice or policyO_LITo meet best practice guidelines for recording and evaluating social prescribing, we need further collaboration between online platform providers and social prescribing services, more training and time for link workers, and for research and policy to emphasize the importance of measuring outcomes C_LI

BackgroundRecovery Colleges (RCs) support recovery through adult education, with preliminary evidence of positive effects on a range of outcomes. This study examined associations between RC enrolment and mental health service use at an index mental health provider, use of other National Health Service (NHS) hospital services for all causes, associated costs, and service user outcomes. MethodsOur retrospective matched cohort study used a controlled before-and-after design. We used linkage with electronic health records to identify all mental health service user students enrolled at one RC. Students were matched with non-student service user controls on sociodemographic and clinical variables using caliper matching. Impacts of RC enrolment on service use were assessed using negative binomial regression models at six-month, 12-month, and five-year post-enrolment. People with lived experience were involved in the design, conduct, and reporting of this study. OutcomesOur sample comprised 1 435 students and 4 665 controls. We observed decreases in several types of mental health service use in students relative to controls at six months (e.g. adjusted Incidence Rate Ratios [aIRRs] for inpatient admissions 0{middle dot}56, 95%CI 0{middle dot}30 to 0{middle dot}64) and 12 months (aIRR 0{middle dot}60, 95%CI 0{middle dot}44 to 0{middle dot}81). At 12 months, students showed a {pound}5 028 (95%CI -{pound}8 223 to -{pound}1 834) greater reduction in total costs per student compared with controls. This indicates that RCs offer an 8{middle dot}4:1 financial return on investment. Students also showed relative reductions in all-cause hospital bed days at six months (aIRR 0{middle dot}53, 95%CI 0{middle dot}35 to 0{middle dot}81) and 12 months (aIRR 0{middle dot}66, 95%CI 0{middle dot}46 to 0{middle dot}96), with a {pound}412 (95%CI -{pound}1 085 to -{pound}260) greater reduction in associated total costs at 12 months. Among students, reductions in Health of the Nation Outcome Scale (HoNOS) scores indicated consistent improvement in functioning over time. InterpretationMental health service users who enrol in a RC have reduced subsequent mental and all-cause healthcare use, and reduced service-related costs compared with matched service users not using a RC. Service user outcomes are also improved. FundingNational Institute for Health and Care Research. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSSince the first one opened in England in 2009, Recovery Colleges (RCs) have spread globally. A 2025 review collating 2013-2024 evidence (64 papers) identified 11 studies investigating outcomes and four investigating service use. Quantitative evaluation of outcomes has used pre-post designs to investigate the impact of RCs on components of recovery, finding consistent evidence of benefit in relation to a number of outcomes including wellbeing, empowerment, hope, and social inclusion. Service use studies have indicated benefits from RC attendance, including increased employment and reduced hospital admissions and bed days, with preliminary evidence of associated cost savings. However, across all studies the evidence quality is low, with most outcome studies using small samples (mostly <100 students) and none using a separate control group. Consequently, change due to other factors such as measurement error or time cannot be discounted, so causation cannot be established. Added value of this studyThis is the largest study of its kind which utilises a methodologically rigorous approach to investigate the impact of RCs on service use, costs and outcomes. In 6 100 people, we identified a consistent positive impact for service user students, compared with optimally matched service user non-students, in relation to mental health service use at an index mental health provider (especially in-patient admissions) and wider all-cause hospital service use (especially bed days) at 12 months post-enrolment, resulting in relative cost savings for service users who are students compared with those who are not. Furthermore, we showed a relative beneficial impact for students on functioning consistently up to five years after RC enrolment. Implications of all the available evidenceThe evidence base for supporting RCs is significantly strengthened. Mental health service users who are students at RCs are likely to benefit, both in terms of clinical outcomes and reduced service use, compared to similar people not using the RC. Significant cost savings also arise, which we estimate as an 8{middle dot}4:1 financial return on investment. Our study evidence supports ongoing investment in RCs with significant return on investment, especially in England.

BackgroundPopulation-based studies have observed sex biases in the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). Females are less likely to be diagnosed or prescribed ADHD medication. This study uses national healthcare records, to investigate sex differences in diagnosis and clinical care in young people with ADHD, particularly regarding recognition and treatment of other mental health conditions. MethodThe cohort included individuals diagnosed with ADHD, born between 1989 and 2013 and living in Wales between 2000 and 2019. Routine primary and secondary healthcare record data were used to derive diagnoses of ADHD and other neurodevelopmental and mental health conditions, as well as ADHD and antidepressant medications. Demographic variables included ethnicity, socioeconomic deprivation, and contact with social services. ResultsThere were 16,458 individuals diagnosed with ADHD (20.3% females, ages 3-30 years), with a male-to-female ratio of 3.9:1. Higher ratios (4.8:1) were seen in individuals diagnosed younger (<12 years), with the lowest ratio (1.9:1) in those diagnosed as adults (>18). Males were younger at first recorded ADHD diagnosis (mean=10.9 vs 12.6 years), more likely to be prescribed ADHD medication, and younger at diagnosis of co-occurring neurodevelopmental conditions. In contrast, females were more likely to receive a diagnosis of anxiety, depression, or another mental health condition and to be prescribed antidepressant medications, prior to ADHD diagnosis. These sex differences were largely stable across demographic groups. ConclusionThis study adds to the evidence base that females with ADHD are experiencing later recognition and treatment of ADHD. The results indicate that this may be partly because of diagnostic over-shadowing from other mental health conditions, such as anxiety and depression, or initial misdiagnosis. Further research and dissemination of findings to the public are needed to improve awareness, timely diagnosis, and treatment of ADHD in females.

BackgroundAntidopaminergic medications (ADMs), including vesicular monoamine transporter-2 (VMAT2) inhibitors and antipsychotics, are frequently-used to manage Huntington disease (HD) symptoms. Prior studies suggest that ADMs may be associated with worsening on measures of outcome in HD clinical trials. The PROOF-HD placebo arm (NCT04556656) provided a controlled, double-blind setting to evaluate ADM impacts on measures of HD progression. ObjectiveAssess the association between ADM exposure and change in clinical outcomes in the placebo arm of PROOF-HD. MethodsPlacebo-arm participants (n=247) were categorized as on- vs off-ADMs. Overall main analyses were corroborated by propensity-score weighting (PSW)-adjusted analyses. Unadjusted analyses examined exposure by ADM class and dose. Outcomes included Total Functional Capacity (TFC), composite Unified Huntingtons Disease Rating Scale (cUHDRS), Stroop Word Reading (SWR), Symbol Digit Modalities Test (SDMT), and Total Motor Score (TMS). ResultsGroup differences ({Delta}) favored off-ADMs in cUHDRS (Weeks 39-78) and TFC (Weeks 26-78); at Week 52, cUHDRS had {Delta}=0.66 (95% CI 0.31-1.01; p=0.0002) and TFC with {Delta}=0.85 (95% CI 0.47-1.22; p<0.0001) as compared with on-ADMs. Other outcomes were significant or directionally-favored off-ADM participants beyond Week 39. All TMS-subdomain scores, except for chorea, directionally-favored off-ADMs at all visits. Antipsychotic-only and higher-dose ADMs were associated with worse cUHDRS and TFC vs off-ADMs. ConclusionsIn this post hoc study, ADM use was associated with greater worsening of measures of global, functional, cognitive, and motor outcomes, versus off-ADMs. Accounting for ADM exposure and dose is essential for the interpretation of results from HD trials.

IntroductionAttention-deficit/hyperactivity disorder (ADHD) treatment and diagnoses show marked international and regional variation, not fully explained by underlying morbidity. In Denmark, earlier studies reported substantial regional differences, raising concerns about inequities in access to care. We examined nationwide patterns of ADHD medication use and diagnosis in 2024 and assessed system-level factors potentially contributing to geographic variation. MethodsWe conducted a register-based cross-sectional study of all Danish residents aged 4-17 years in 2024, using data from the National Patient Register, National Prescription Registry, Civil Registration System, and administrative sources. Pharmacological treatment of ADHD was defined as at least one redeemed prescription for ADHD drugs, while ADHD diagnoses were defined as at least one hospital contact with International Classification of Diseases, 10th revision codes F90.x/F98.8. Prevalence estimates were calculated overall and stratified by subgroups of sex and age. Associations with municipal socioeconomic index, regional hospital waiting times, and private child psychiatrist capacity were evaluated using Spearmans rank correlations and regression analyses. ResultsAmong 4-17-year-olds, ADHD medication prevalence ranged sixfold across municipalities (9.6-58 per 1,000). ADHD diagnoses showed parallel patterns (15-74 per 1,000). Variation was largest among adolescents (more than sevenfold). Municipal socioeconomic status was weakly and inversely correlated with medication use ({rho} = -0.20, p = 0.049), but not diagnoses. Regional waiting times and specialist capacity varied but showed no significant associations with the prevalence of either medication use or diagnoses. ConclusionMarked geographic variation in ADHD medication use and diagnoses persists in Denmark despite a uniform healthcare framework. Observed differences were only weakly related to socioeconomic context, specialist capacity, or waiting times, suggesting that the unwarranted variation is driven by other factors. Ensuring equitable access will require addressing both structural resources and local practice variation. Significant OutcomesADHD medication and diagnosis prevalence among Danish children and adolescents in 2024 varied more than sixfold across municipalities. Socioeconomic context, specialist capacity, and waiting times explained little of the observed geographic variation. LimitationsWaiting time data were available only for hospital-based services, excluding the referral phase and private practices. Specialist capacity was measured only for private psychiatrists under agreements with the public health insurance system, limiting coverage of capacity for public hospitals and private non-contracted services. Regional-level analyses were constrained by the small number of regions (n=5), reducing statistical power and precision.

PurposePeople living with mental ill-health experience social and economic disadvantages, which contribute to poor outcomes and limit effectiveness of treatments. Interventions to improve social and economic circumstances have been developed, however, little is known about whether these interventions are effective for the most marginalised and disadvantaged groups, and those most in need of support. MethodWe conducted a systematic review in line with a pre-defined protocol to identify interventions to improve the social and economic circumstances of people experiencing mental ill-health. We included relevant records from two previous systematic reviews and updated their searches across four databases. We synthesised the intervention domains and locations of research, participant characteristics, and if effectiveness varied by participant gender, socioeconomic position, and race or ethnicity, and related indicators. ResultsWe identified 266 relevant studies across 34 countries. Certain intervention domains were better researched than others (e.g. housing and employment vs. debt and social security advice). Participant characteristics were poorly reported and so understanding related to inclusiveness and generalisability of research is limited. Only 8% of papers reported any stratified results and statistical reporting standards were poor, limiting our ability to determine what works for whom. There was some indication that interventions are less effective for those in lower socioeconomic groups. ConclusionImproved reporting and representation of marginalised groups, stratified analyses of intervention data, and replication of results is needed to confidently draw conclusions about what works for whom in this field.

BackgroundAntipsychotic drugs have been associated with increased mortality, stroke and myocardial infarction in people with dementia. Concerns have been raised that antipsychotic prescribing may have increased during the COVID-19 pandemic due to social restrictions imposed to limit the spread of the virus. We used multisource, routinely-collected healthcare data from Wales, UK, to investigate prescribing and mortality trends in people with dementia before and during the COVID-19 pandemic. MethodsWe used individual-level, anonymised, population-scale linked health data to identify adults aged [&ge;]60 years with a diagnosis of dementia in Wales, UK. We explored antipsychotic prescribing trends over 67 months between 1st January 2016 and 1st August 2021, overall and stratified by age and dementia subtype. We used time series analyses to examine all-cause, myocardial infarction (MI) and stroke mortality over the study period and identified the leading causes of death in people with dementia. FindingsOf 57,396 people with dementia, 11,929 (21%) were prescribed an antipsychotic at any point during follow-up. Accounting for seasonality, antipsychotic prescribing increased during the second half of 2019 and throughout 2020. However, the absolute difference in prescribing rates was small, ranging from 1253 to 1305 per 10,000 person-months. Prescribing in the 60-64 age group and those with Alzheimers disease increased throughout the 5-year period. All-cause and stroke mortality increased in the second half of 2019 and throughout 2020 but MI mortality declined. From January 2020, COVID-19 was the second commonest underlying cause of death in people with dementia. InterpretationDuring the COVID-19 pandemic there was a small increase in antipsychotic prescribing in people with dementia. The long-term increase in antipsychotic prescribing in younger people and in those with Alzheimers disease warrants further investigation. FundingBritish Heart Foundation (BHF) (SP/19/3/34678) via the BHF Data Science Centre led by HDR UK, and the Scottish Neurological Research Fund. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Ovid MEDLINE for studies describing antipsychotic prescribing trends in people with dementia during the COVID-19 pandemic, published between 1st January 2020 and 22nd March 2022. The following search terms were used: (exp Antipsychotic Agents/ OR antipsychotic.mp OR neuroleptic.mp OR risperidone.mp OR exp Risperidone/ OR quetiapine.mp OR exp Quetiapine Fumarate/ OR olanzapine.mp OR exp Olanzapine/ OR exp Psychotropic Drugs/ or psychotropic.mp) AND (exp Dementia/ OR exp Alzheimer Disease/ or alzheimer.mp) AND (prescri*.mp OR exp Prescriptions/ OR exp Electronic Prescribing/ OR trend*.mp OR time series.mp). The search identified 128 published studies, of which three were eligible for inclusion. Two studies, based on data from England and the USA, compared antipsychotic prescribing in people with dementia before and during the COVID-19 pandemic. Both reported an increase in the proportion of patients prescribed an antipsychotic after the onset of the pandemic. A third study, based in the Netherlands, reported antipsychotic prescription trends in nursing home residents with dementia during the first four months of the pandemic, comparing prescribing rates to the timings of lifting of social restrictions, showing that antipsychotic prescribing rates remained constant throughout this period. Added value of this studyWe conducted age-standardised time series analyses using comprehensive, linked, anonymised, individual-level routinely-collected, population-scale health data for the population of Wales, UK. By accounting for seasonal variations in prescribing and mortality, we demonstrated that the absolute increase in antipsychotic prescribing in people with dementia of any cause during the COVID-19 pandemic was small. In contrast, antipsychotic prescribing in the youngest age group (60-64 years) and in people with a subtype diagnosis of Alzheimers disease increased throughout the five-year study period. Accounting for seasonal variation, all-cause mortality rates in people with dementia began to increase in late 2019 and increased sharply during the first few months of the pandemic. COVID-19 became the leading non-dementia cause of death in people with dementia from 2020 to 2021. Stroke mortality increased during the pandemic, following a similar pattern to that of all-cause mortality, whereas myocardial infarction rates decreased. Implications of all the available evidenceDuring COVID-19 we observed a large increase in all-cause and stroke mortality in people with dementia. When seasonal variations are accounted for, antipsychotic prescribing rates in all-cause dementia increased by a small amount before and during the pandemic in the UK. The increased prescribing rates in younger age groups and in people with Alzheimers disease warrants further investigation.

Even before the pandemic, the treatment gaps in depression care were substantial, with issues ranging from rates of depression detection and intervention to a lack of follow-up after treatment initiation and access to secondary care services. The COVID-19 pandemic, which has had major effects on global healthcare systems, is almost certain to have impacted the MDD care pathway, though it is unclear what changes have manifested and what opportunities have arisen in response to COVID-19. The extent to which patients receive best-practice care is likely closely linked to clinical outcomes (and therefore disability burden) and as such, it is important to examine treatment gaps on the MDD care pathway during the pandemic. Here, we outline a protocol for a scoping review that investigates this broad topic, focusing on continuity of care and novel methods (e.g. digital approaches) used to mitigate care disruption. This scoping review protocol was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) standards and will culminate in a narrative synthesis of evidence.