Epidemiology and Psychiatric Sciences

BackgroundNon-medical use of prescription psychotropic medications (NMUPM) among adolescents and young adults in low- and middle-income countries (LMICs) is an emerging public health concern. Such practices are associated with psychiatric comorbidities, increased risk behaviors, and long-term dependence. Limited access to mental health services, weak regulatory enforcement, and the widespread availability of prescription drugs contribute to NMUPM. Despite anecdotal reports, comprehensive epidemiological synthesis across LMICs is scarce. ObjectiveTo systematically review the prevalence, patterns, psychiatric correlates, and health-system drivers of NMUPM among young people (aged 10-35 years) in LMICs and provide a pooled estimate of prevalence through meta-analysis. MethodsWe conducted a systematic review following the PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus, Web of Science, Embase, PsycInfo, LILACS, AJOL, WHO GIM, Google Scholar, and regional LMIC repositories were searched for studies published between 2000 and 2026 reporting NMUPM among adolescents and young people. Inclusion criteria comprised cross-sectional surveys, community or school-based studies, and national or regional surveillance reports. Data were extracted on sample size, prevalence, commonly misused drugs, sources of medication, and motivations. A random-effects generalized linear mixed model (GLMM) with logit transformation was used to estimate pooled prevalence, and heterogeneity was assessed using I{superscript 2} statistics. Risk of bias was evaluated using the Joanna Briggs Institute (JBI) checklist. ResultsA total of 13 studies were included in the systematic review, with 10 studies (N = 6,728 participants) suitable for quantitative meta-analysis. The pooled prevalence of NMUPM among young people in LMICs was 18.4% (95% CI: 12.1-26.2%), with substantial heterogeneity (I{superscript 2} > 90%). Benzodiazepines and tramadol were the most commonly misused drugs. Primary drivers included prior experience with medications, ease of access through pharmacies or peers, and limited awareness of potential harms. NMUPM was associated with psychiatric symptoms, risky behaviors, and early progression to substance use disorders. ConclusionNon-medical use of psychotropic medications is prevalent among adolescents and young adults in LMICs, posing significant psychiatric and public health challenges. Interventions are urgently needed to strengthen regulatory enforcement, improve public awareness, enhance mental health service accessibility, and promote safe medication practices. Future research should focus on longitudinal studies to clarify causal pathways and test behavioral interventions to reduce NMUPM.

SummaryO_ST_ABSBackgroundC_ST_ABSThe aim of this systematic review was to synthesise evidence on the effectiveness and cost-effectiveness of interventions to support the recovery of people living with psychosis and their families in low-income and middle-income countries (LMICs). MethodsWe searched nine databases for articles published from January 2001 to January 2024 without language restrictions. Studies were eligible if they enrolled people living with psychosis or family members, and tested a psychoeducational, psychological, social, economic or service intervention or delivery or implementation strategy aimed at improving outcomes of people with psychosis. Eligible studies were required to compare outcomes with an alternative condition, using any prospective evaluation study design in a LMIC setting. We extracted summary data from published papers and appraised risk of bias using the Effective Public Health Practice Project tool. We prioritised the reporting of recovery-orientated outcomes including social inclusion, personal recovery, reduced stigma and discrimination and human rights protections. We conceptualised the person living with psychosis in their context (individual, family, organisation and community) based on the socio-ecological model of disability and highlighted studies intervening and measuring outcomes across multiple socio-ecological levels. Protocol registration: PROSPERO (CRD42022330298). FindingsA total of 310 individual studies including data from 34,435 participants in 37 countries were included. Aggregate data from a further five meta-analyses, comprising data from 130 individual studies were also included. The majority of studies (77%) were conducted in upper middle-income countries. There was a dominance of studies evaluating impacts of interventions on individual-level mental health and functioning and a paucity of studies measuring the recovery-orientated outcomes prioritised by people living with psychosis. There were modest effects for comprehensive interventions involving family, psychosocial rehabilitation and care close to home provided by trained specialists however their scalability in resource-limited settings is unclear. Over half the studies were considered to have a high risk of bias. InterpretationThere is a need for studies that evaluate scalable interventions supporting recovery with comprehensive and contextualised outcome measures and for greater investment in strengthening capacity to conduct rigorous psychosis research across LMICs. FundingNone. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSRecent World Health Organization (WHO) guidance on human rights-based, recovery-orientated community mental health care featured markedly few case studies of good practice for people with psychosis in low-income and middle-income countries (LMICs). Systematic reviews of interventions for psychosis in LMICs have been narrow in focus and reporting outcomes, and limited to English language publications. Added value of this studyThis systematic review is the most comprehensive synthesis to date of psychosis interventions in LMICs. Inclusion is not restricted by publication language. We highlight studies reporting recovery-oriented outcomes prioritised by people living with psychosis and impacts of interventions across levels of the socio-ecological model of disability. While being particularly relevant to LMICs, our findings also contribute a useful perspective for high income settings. Implications of all the available evidenceMost interventions were targeted at the individual and focused on mental health and functioning outcomes, with few evaluations of impact on social inclusion and other valued outcomes. There is some evidence in support of specialist-delivered comprehensive interventions involving family, psychosocial rehabilitation and care close to home, but effect sizes were small-to-modest, and many intervention types and delivery agents have not been adequately tested, especially in LICs and rural settings. There is a clear need to develop comprehensive and contextualised measures for recovery-orientated outcomes and to invest in strengthening capacity to conduct rigorous research on interventions for psychosis in LMICs.

BackgroundThe design and delivery of safe and effective mental healthcare requires data on local needs and priorities. The aim of this scoping review is to provide background information on the prevalence of mental health conditions and local stakeholder experiences of mental healthcare in Zambia. MethodsWe searched electronic databases of published (Medline, PsycINFO, Embase, African Index Medicus) and unpublished (University of Zambia repository) literature to retrieve relevant epidemiological and qualitative articles from database inception to January 9th, 2024. Qualitative studies were synthesised using thematic synthesis and key themes were triangulated with experiences of local stakeholders. ResultsEleven epidemiological papers were identified. These reported on the prevalence of mental distress in the general population (16.9%); depressive symptoms in adolescents (29.7%); problematic alcohol consumption in the general population (dependence, 7.4%; binge, 11.6%; and unhealthy consumption, 15.3%) and in adolescents (45.1%); suicidal ideation (7.8%) and behaviour (8.5%) in the general population and in adolescents (31.3% and 39.6%, respectively); suicide attempts in the general population (2.3%). Synthesis of 10 qualitative articles identified interrelated themes relating to barriers to access and provision of mental healthcare. Mental health stigma is perceived to be pervasive across all sectors of society and partly attributed to the language used in the previous Mental Health Act and the national psychiatric hospital. Structural stigma is perceived to drive the low priority of mental health in Zambia in policy, funding, advocacy and research. Reported consequences include low availability of safe and effective mental healthcare, particularly at community level, resulting in a cycle of coercive hospital admission, discharge, relapse and readmission. This is perceived to place significant social, emotional and economic stress on patients and their families. Carer burnout and the lack of visible recovery perpetuates the stigma that people with mental illness have little value to society. ConclusionsFindings from this review indicate the need for a multisectoral approach to tackle structural stigma, increase national advocacy for mental health, and facilitate the provision of safe and effective community-based mental healthcare in Zambia. While epidemiological data is limited, the current evidence indicates that adolescents are a high priority group for early intervention.

BackgroundPeople with mental disorders have an excess chronic disease burden. One mechanism to potentially reduce the public health and economic costs of mental disorders is to reduce preventable hospital admissions. Ambulatory care sensitive conditions (ACSCs) are a defined set of chronic and acute illnesses not considered to require hospital treatment if patients receive adequate primary healthcare. We examined the relationship between both severe and common mental disorders and risk of emergency hospital admissions for ACSCs and factors associated with increased risk. MethodsBaseline data from England (N=445,814) were taken from UK Biobank, which recruited participants aged 37-73 years during 2006 to 2010, and were linked to hospital admission records up to 31st December 2019. Participants were grouped into those who had a history of either schizophrenia, bipolar disorder, depression or anxiety, or no record of mental disorder. Cox proportional hazard models (for the first admission) and Prentice, Williams and Peterson Total Time models (PWP-TT, which account for all admissions) were used to assess the risk (using hazard ratios (HR)) of hospitalisation for ACSCs among those with mental disorders compared to those without, adjusting for factors in different domains, including sociodemographic (e.g. age, sex, ethnicity), socioeconomic (e.g. deprivation, education level), health and biomarkers (e.g. multimorbidity, inflammatory markers), health-related behaviours (e.g. smoking, alcohol consumption), social isolation (e.g. social participation, social contact) and psychological (e.g. depressive symptoms, loneliness). ResultsPeople with schizophrenia had the highest risk of hospital admission for ACSCs compared to those with no mental disorder (HR=4.40, 95% CI: 4.04 - 4.80). People with bipolar disorder (HR=2.48, 95% CI: 2.28 - 2.69) and depression or anxiety (HR=1.76, 95% CI: 1.73 - 1.80) also had higher risk. Associations were more conservative when accounting for all admissions. Although adjusting for a range of factors attenuated the observed associations, they still persisted, with socioeconomic and health-related variables contributing most. ConclusionsPeople with severe mental disorders had highest risk of preventable hospital admissions, with the risk also elevated amongst those with depression and anxiety. Ensuring people with mental disorders receive adequate ambulatory care is essential to reduce the large health inequalities experienced by these groups.

BackgroundPsychiatric hospital admissions in the Western Cape are increasing, driven by poverty and substance use. AimTo assess the trend of psychiatric admissions from 2015-2022 and factors associated with repeat psychiatric admissions and linkage to ambulatory services post-discharge. SettingPublic hospitals in the Western Cape, South Africa MethodsUsing electronic data from the Provincial Health Data Centre, a consolidated routine service database, all psychiatric hospital admissions in the Western Cape were analyzed, stratified by hospital level. Mixed effects logistic regression was used to determine factors associated with successful linkage to ambulatory services within 30 days following hospital discharge, and repeat psychiatric admission within 30 and 90 days. ResultsPsychiatric hospital admissions, particularly at the district/acute level, were increasing prior to 2020 and an increasing proportion were substance related. 40% of admissions at the district level had not been seen at a primary health care facility in the year prior to admission. Males and those with substance use disorders were less likely to be successfully linked to outpatient services post-discharge. Successful linkage was most protective against readmission within 90 days with an adjusted odds ratio of 0.76 (95%CI 0.73-0.79) and 0.45 (95%CI 0.42-0.49) at district/acute and specialized hospitals respectively. ConclusionImproving linkage to ambulatory services for mental health patients post-discharge is likely to avert hospital readmissions. ContributionThis research highlights how often mental health patients requiring admissions are not seen at the primary health care level and quantifies the risk for readmission of not following up psychiatric admissions post-discharge.

The COVID-19 pandemic in the UK was accompanied by excess all-cause mortality at a national level, only part of which was accounted for by known infections. Excess mortality has previously been described in people who had received care from the South London and Maudsley NHS Foundation Trust (SLaM), a large mental health service provider for 1.2m residents in south London. SLaMs Clinical Record Interactive Search (CRIS) data resource receives 24-hourly updates from its full electronic health record, including regularly sourced national mortality on all past and present SLaM service users. SLaMs urban catchment has high levels of deprivation and is ethnically diverse, so the objective of the descriptive analyses reported in this manuscript was to compare mortality in SLaM service users from 16th March to 15th May 2020 to that for the same period in 2019 within specific ethnic groups: i) White British, ii) Other White, iii) Black African/Caribbean, iv) South Asian, v) Other, and vi) missing/not stated. For Black African/Caribbean patients (the largest minority ethnic group) this ratio was 3.33, compared to 2.47 for White British patients. Considering premature mortality (restricting to deaths below age 70), these ratios were 2.74 and 1.96 respectively. Ratios were also high for those from Other ethnic groups (2.63 for all mortality, 3.07 for premature mortality).

The COVID-19 pandemic had substantial impact on healthcare systems across the globe, including psychiatric services. Use of electroconvulsive therapy (ECT), a lifesaving intervention for severe mental illness, was reported to have declined during the pandemic in several countries, but nationwide data remain scarce. Using nationwide data from the Danish National Patient Register, we examined all ECT treatments administered in Denmark from September 2019 to May 2025. Weekly treatment numbers were visualized across the three national COVID-19 lockdowns to descriptively assess changes in ECT use. A notable reduction in ECT treatments was observed in the weeks preceding and during the first lockdown (March 11 to May 18, 2020). A post-hoc estimation indicated approximately 1,366 "missed" treatments during the initial pandemic phase in 2020. When these were added to the 27,033 treatments delivered in 2020, the adjusted total approximated annual treatment volumes in 2019 and 2022, suggesting a temporary disruption rather than sustained decline. In contrast, ECT activity during the second and third lockdowns appeared largely unaffected. These findings suggest that ECT provision in Denmark was temporarily reduced during the initial phase of the pandemic but remained resilient thereafter. In the case of a future pandemic, safeguarding timely access to ECT--particularly in early phases-- should be prioritized given its critical role in the treatment of severe mental illness.

BackgroundBrain disorders are leading contributors to increasing disability and spending worldwide. In 2022 the Swiss Brain Health Plan (SBHP) was launched to promote brain health and prevent brain disorders. To guide the implementation of the SBHP, we performed a detailed analysis of the health and economic burden of brain disorders in Switzerland. MethodsWe analyzed Global Burden of Disease 2023 disability-adjusted life years (DALYs) and Institute for Health Metrics and Evaluation (IHME) cause-specific health-care spending estimates for Switzerland. DALYs were quantified for 1990 - 2023. Spending was analyzed for 2000 - 2019 across six types of care. We examined age and sex patterns, spending distribution, and international comparisons with six other countries (Germany, France, Denmark, Norway, Italy, Singapore). To assess short- and longer-term association between burden and spending estimates, we fitted panel regression models with disorder and year fixed effects under one-year and five-year lag specifications. FindingsBoth disease burden and spending were highly concentrated in a small number of conditions in Switzerland. In 2023, ten brain disorders accounted for 82{middle dot}9% of Switzerlands total DALY burden. In 2019, ten brain disorders accounted for 86{middle dot}0% of all direct brain-health spending, with dementia alone comprising 29{middle dot}5% of total expenditures. Among seven analyzed comparator countries, Switzerland had the highest per-capita brain-health spending and the highest spending per DALY. In fixed-effects panel models that accounted for spending persistence, lagged DALYs were not statistically associated with subsequent spending. Suicide prevention and addiction showed significant lower-than-expected health-sector spending (self-harm: {beta} = -0{middle dot}23; drug use disorders: {beta} = -0{middle dot}08 to -0{middle dot}18 across lag models). InterpretationBrain disorders generate a large burden in Switzerland. Within the IHME estimates, the burden-spending relationship over time appears limited. The implementation of the SBHP will refer to the current data and call for a burden-informed financing to guide strategic cross-sectorial allocation and prevention investments. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe drew on evidence from the Global Burden of Disease (GBD) 2023 estimates on neurological and mental health conditions, and on cause-specific health-care spending data from the Institute for Health Metrics and Evaluation for Switzerland and selected high-income countries. These sources show that brain disorders are major contributors to disability and premature mortality, and that Switzerland is among the worlds highest spenders per capita on health care. Prior work has described the costs of individual brain disorders and drivers of health expenditure growth; however, it has often treated burden and spending as partly separate domains, leaving the country-level link between cause-specific disability-adjusted life-years (DALYs) and cause-specific spending, over time and in either direction, poorly characterized. Added value of this studyTo our knowledge, this is the first study in a single country to systematically link cause-specific DALYs and cause-specific direct health-care spending for brain disorders and to examine their longitudinal and bi-directional associations. Using harmonized GBD 2023 estimates and IHME 2019 cause-specific health spending data, we quantify the health and economic burden of 23 brain disorders in Switzerland across age, sex, care setting, and time, and benchmark patterns against six other high-income countries. By applying panel regression models with disorder and year fixed effects, we assess whether modeled spending shows any association with prior modeled burden once spending persistence is accounted for, and identify conditions with higher or lower spending relative to burden. Implications of all the available evidenceSwitzerland bears a major burden of brain disorders and devotes substantial resources to their care, yet within the modeled estimates, spending does not consistently correspond to burden over time. Disorders with long-standing multisectoral programs tended to show lower spending-to-burden ratios, suggesting that coordinated action beyond the health sector may reduce downstream health-sector demand. For Switzerland and similar health systems, these findings support national brain-health strategies that strengthen life-course prevention and early intervention, and that integrate financing with burden data to inform priority setting and periodic reassessment of resource allocation.

BackgroundPeople who inject drugs (PWID) have high risk for overdose, but there are no current estimates of overdose rates in this population. We estimated the rates of non-fatal and fatal overdose among PWID living in the U.S. and comparator countries (Canada, Mexico, United Kingdom, Australia), and ratios of non-fatal to fatal overdose, using literature published 01/01/2010 - 09/29/2023. MethodsPubMed, PsychInfo, Embase, and ProQuest databases were systematically searched to identify publications reporting prevalence or rates of recent (past 12 months) non- fatal and fatal overdose among PWID. Non-fatal and fatal overdose rates were meta-analyzed using random effects models. Risk of bias was assessed using an adapted quality assessment tool, and heterogeneity was explored using sensitivity analyses. ResultsOur review included 143 records, with 58 contributing unique data to the meta- analysis. Non-fatal and fatal overdose rates among PWID in the U.S. were 32.9 per 100 person- years (PY) (95% CI: 26.4 - 40.9; n=28) and 1.7 per 100 PY (95% CI: 0.9 - 3.2; n=4), respectively. Limiting the analysis to data collected after 2016 yielded a non-fatal rate of 41.0 per 100 PY (95% CI: 32.1 - 52.5; n=16) and a fatal rate of 2.5 per 100 PY (95% CI: 1.4 - 4.3; n=2) in the U.S. An estimated 5% of overdoses among PWID in the U.S. result in death. Among the analyzed countries, Australia had the lowest non-fatal and fatal overdose rates and the largest ratio of non-fatal to fatal overdose. ConclusionFindings demonstrate substantial burden of non-fatal and fatal overdose among PWID in the U.S. and comparator countries. Scale-up of interventions that prevent overdose mortality and investments in PWID health research are urgently needed.

BackgroundThe identification of geographic variation in incidence can be an important step in the delineation of disease risk factors, but has mostly been undertaken in upper-income countries. Here, we use Electronic Health Records (EHR) from a middle-income country, Colombia, to characterize geographic variation in major mental disorders. MethodWe leveraged geolocated EHRs of 16,295 patients at a psychiatric hospital serving the entire state of Caldas, all of whom received a primary diagnosis of bipolar disorder, schizophrenia, or major depressive disorder at their first visit. To identify the relationship between travel time and incidence of mental illness we used a zero-inflated negative binomial regression model. We used spatial scan statistics to identify clusters of patients, stratified by diagnosis and severity: mild (outpatients) or severe (inpatients). ResultsWe observed a significant association between incidence and travel time for outpatients (N = 11,077, relative risk (RR) = 0.80, 95% confidence interval (0.71, 0.89)), but not inpatients (N = 5,218). We found seven clusters of severe mental illness: the cluster with the most extreme overrepresentation of bipolar disorder (RR = 5.83, p < 0.001) has an average annual incidence of 8.7 inpatients per 10,000 residents, among the highest frequencies worldwide. ConclusionsThe hospital database reflects the geographic distribution of severe, but not mild, mental illness within Caldas. Each hotspot is a candidate location for further research to identify genetic or environmental risk factors for severe mental illness. Our analyses highlight how existing infrastructure from middle-income countries can be extraordinary resources for population studies.

The COVID-19 pandemic is likely to have had a particularly high impact on the health and wellbeing of people with pre-existing mental disorders. This may include higher than expected mortality rates due to severe infections themselves, due to other comorbidities, or through increased suicide rates during lockdown. However, there has been very little published information to date on causes of death in mental health service users. Taking advantage of a large mental healthcare database linked to death registrations, we describe numbers of deaths within specific underlying-cause-of-death groups for the period from 1st March to 30th June in 2020 and compare these with the same four-month periods in 2015-2019. In past and current service users, there were 2561 deaths in March-June 2020, compared to an average of 1452 for the same months in 2015-19: an excess of 1109. The 708 deaths with COVID-19 as the underlying cause in 2020 accounted for 63.8% of that excess. The remaining excess was accounted for by unnatural/unexplained deaths and by deaths recorded as due to neurodegenerative conditions, with no excess in those attributed to cancer, circulatory disorders, digestive disorders, respiratory disorders, or other disease codes. Of 295 unexplained deaths in 2020 with missing data on cause, 162 (54.9%) were awaiting a formal death notice (i.e. the group that included deaths awaiting a coroners inquest) - an excess of 129 compared to the average of previous years, accounting for 11.6% of the excess in total deaths.

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

IntroductionReliable epidemiological data are crucial to make evidence-based decisions about youth mental health. Yet little is known about the epidemiology of child and adolescent mental health in sub-Saharan Africa. We conducted a systematic review and meta-analysis on the prevalence of mental disorders, suicidal behaviors, mental well-being and mental health awareness/literacy among children and adolescents in South Africa (SA). MethodsWe searched PubMed, PsycINFO, Web of Science, Scielo.org, and Google Scholar from their inception to 19th February 2025. We performed random effects meta-analysis for all disorders that had 5 or more prevalence estimates. Meta-regressions were used to investigate factors associated with prevalence estimates. ResultsWe screened 12,768 records and identified 40 studies with 56 prevalence estimates for mental disorders and 30 prevalence estimates for suicidality. Across all studies on mental disorders, the pooled prevalence for all disorders was 8.53% [6.1; 11.9] (k=56, N=39,962), with significant heterogeneity (I{superscript 2}=99.0%, Q (55) = 5467.0, p<.001). Pooled prevalence estimates for depressive disorders, anxiety disorders, PTSD and behavioural disorders were 10.1% [4.9; 19.9], 6.7% [3.4; 12.8], 17.6% [8.5; 33.1], 3.9% [1.8; 8.5], respectively. All other disorders had 5 or fewer prevalence estimates. Pooled prevalence estimates for suicidal ideation, plan and attempt were 12.0% [7.8; 18.0] (k=10, N=41489), 11.8% [7.7; 17.6] (k=8, N=39,928), and 10.3% [6.2; 16.6] (k=9, N=40,294), respectively. No papers reported mental well-being, quality of life, mental health literacy, mental health awareness, or cognitive impairment. It is not possible to reliably assess the mental health of SAs youth due to the small number of studies, narrow focus on few disorders and heterogeneity. ConclusionThere is clear need for a reliable national survey of child and adolescent mental health in SA, using well validated instruments that can assess a wide range of disorders and mental well-being among a representative sample of young people.

ObjectiveTo standardize the implementation dates of various cannabis liberalization policies and determine whether previous research by Anderson et al. [D.M. Anderson, D.I. Rees, J.J. Sabia, American Journal of Public Health 104, 2369-2376] on medical marijuana access and population-level suicidality is robust to additional years of data and further cannabis liberalization in the form of recreational marijuana access. DesignA state-level longitudinal (panel) analysis. Suicide mortality rates from the National Center for Health Statistics and mental health morbidity rates from the National Survey on Drug Use and Health were employed with the procedures outlined by Anderson et al., using weighted ordinary least squares for three different specifications with various combinations of control variables as a sensitivity analysis to test for robustness. SettingAll 50 states and Washington, DC for the period 1990-2020. ParticipantsUSA population. InterventionsCannabis liberalization policies in the form of recreational and medical access. Primary and Secondary Outcome MeasuresState-level population mental health outcomes in the form of suicide mortality among various age groups for males and females defined by the International Classification of Diseases, Ninth and Tenth Revisions; past-month and -year marijuana use, mental illness, serious mental illness, major depression, and suicidal ideation defined by the Substance Abuse and Mental Health Services Administration. ResultsMedical marijuana access was associated with a 3.3% reduction (95% CI -5.0% to -1.7%) in suicide rates for males, which was mediated by a 5.4% reduction (95% CI -8.0% to -2.7%) among males in the 30 to 39 age group. No other mental health outcomes were consistently affected by cannabis liberalization. ConclusionsAdverse mental health outcomes do not follow cannabis liberalization at the state level, confirming the findings of Anderson et al. In addition, there is evidence that medical marijuana access reduces suicide rates for young-adult males. Strengths and limitations of this studyO_LICannabis liberalization policies, which vary greatly throughout the literature, are explicitly defined and corrected from previous studies. C_LIO_LISAMHSA suppresses state-level geographical information for individual-level responses in the NSDUH, so the analysis relied on population averages for a small number of age groups published in the NSDUH State Prevalence Estimates, which did not allow us to evaluate gender differences for mental health outcomes. C_LIO_LIThe reliability of suicide and NSDUH data to estimate true population rates is highly debated. C_LIO_LIPopulation-level analyses of longitudinal data can be evaluated with multiple accepted methods from the medical literature and it is not clear whether weighted ordinary least squares is the most appropriate approach for this type of analysis. C_LI Funding statementThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing interests statementReason Foundation is a 501(c)(3) nonprofit organization completely supported by voluntary contributions from individuals, foundations, corporations, and the sale of its publications. Reason Foundations general support includes contributions from marijuana manufacturers, which account for less than one percent of its annual budget. Data sharing statementMost data relevant to the study are publicly available and included as supplementary information. Mortality rates calculated from death counts of less than 10 deaths for any region are suppressed and may require special permissions for access.

BackgroundOpioid dependence poses a growing public health challenge in low- and middle-income countries (LMICs), yet data from sub-Saharan Africa remain scarce. This study examines sociodemographic, clinical, and substance use correlates of opioid dependence among adolescents and young adults in Zambia. MethodsA cross-sectional analysis of 427 medical records (aged 10-27 years) from a tertiary hospital in Southern Zambia (2022-2024) was conducted. Univariable and multivariable logistic regression models assessed associations between opioid use, sociodemographic factors, psychiatric comorbidities, and physiological markers. ResultsThe median age was 21 years (IQR: 18-23), with 77.5% male participants. Opioid use prevalence was 15.5%, strongly associated with cannabis use (76.7% vs. 7.8%, p < 0.0001) and alcohol abuse (15.5% vs. 10.3%, p = 0.0002). Psychosis was less prevalent among opioid users (12.1% vs. 19.7%, p = 0.032). In adjusted models, systolic blood pressure (SBP) inversely correlated with opioid use (AOR = 0.80, 95% CI: 0.65-0.99; p = 0.040), while diastolic blood pressure (DBP) showed a positive association (AOR = 1.37, 95% CI: 1.03-1.81; p = 0.027). Alcohol abuse retained significance (AOR = 3.76, 95% CI: 1.47-95,874.35; p = 0.036), though wide confidence intervals indicated instability. ConclusionOpioid dependence in this Zambian cohort is closely linked to polysubstance use, particularly cannabis and alcohol. The paradoxical inverse relationship between SBP and opioid use may reflect confounding by comorbidities or antihypertensive treatment, while elevated DBP aligns with regional studies on opioid-related cardiovascular risk. Despite limitations, including sparse data and cross-sectional design, these findings underscore the need for integrated substance use and mental health interventions in LMICs. Future research should prioritize longitudinal designs and community-based sampling to address methodological gaps and inform context-specific policies.

BackgroundEvidence-based information is essential to delivering effective mental health care, yet the extent and accessibility of the scientific literature are critical barriers for professionals and policymakers. To map the necessities and make validated resources accessible, we undertook a comprehensive analysis of scientific evidence on child and adolescent mental health in Greece. MethodsThis systematic review encompasses three research topics related to the mental health of children and adolescents in Greece: prevalence estimates, assessment instruments, and interventions. We searched Pubmed, Web of Science, PsycINFO, Google Scholar, and IATPOTEK from inception to December 16th, 2021. We included studies assessing the prevalence of conditions, reporting data on assessment tools, and experimental interventions. For each area, manuals informed data extraction and the methodological quality was ascertained using validated tools. This review was registered in protocols.io [68583]. OutcomesWe included 104 studies reporting 533 prevalence estimates, 223 studies informing data on 261 assessment instruments, and 34 intervention studies. We report the prevalence of conditions according to regions within the country. A repository of locally validated instruments and their psychometrics were compiled. An overview of interventions provided data on their effectiveness. The outcomes are made available in an interactive resource on-line [https://camhi.gr/en/systematic-review-tables/]. InterpretationScientific evidence on child and adolescent mental health in Greece has been cataloged and appraised. This timely and accessible compendium of up-to-date evidence offers valuable resources for clinical practice and policy making in Greece and may encourage similar assessments in other countries. FundingThe Stavros Niarchos Foundation.

BackgroundEarly Intervention for Psychosis Services (EIPS) enhance outcomes for individuals experiencing their first episode of psychosis (FEP). However, in low-resource settings, there is limited knowledge about i) the pathways patients take to access EIPS, ii) the proportion and factors associated with acceptance of referral to EIPS, and iii) if different pathways to EIPS services affect clinical outcomes. Ugandas first EIPS, the Specialised Treatment Early in Psychosis Service at Makerere University Hospital (STEP_MaKH), presents a unique opportunity to explore these important questions. AimsWe aimed to examine the pathways to EIPS, the factors associated with referral to specialised psychosis care and the impact of initial treatment-seeking behaviour on long-term symptom remission and quality of life. MethodsWe conducted a multiple-method study. Pathways to care were assessed retrospectively using the WHO Encounter Form among adults with FEP eligible for referral to STEP_MaKH. Among those who completed referral and enrolled in STEP_MaKH. Symptom severity and quality of life were followed prospectively for 12 months. Modified Poisson regression identified predictors of referral completion. Kaplan-Meier methods and Cox proportional hazards models examined time to symptom remission and time to achieving a good quality of life. ResultsOf the 187 adults with first-episode psychosis eligible for referral to STEP_MaKH, Native/religious healers (n = 86) were the predominant first point of contact. Only 56 (29.9%) accepted referral to STEP_MaKH. Participants referred from Mulago National Referral Hospital more likely to enrol than those referred from Butabika (RR = 4.7; 95% CI: 2.90-7.87). Longer delays from first treatment contact were associated with reduced likelihood of reaching STEP_MaKH (RR = 0.99 per month; p = 0.041). After enrolment, symptoms improved rapidly with 60% achieving PANSS remission by Month 1, and fewer than 10% remained non-remitted by Months 2-3. In adjusted Cox models, participants initially seen by mental health workers achieved remission more quickly than those initially seen by non-medical personnel (HR = 1.48; 95% CI: 1.05-2.10). Older age was associated with slower remission (HR = 0.94; p = 0.023). Quality of life improved over the follow-up period, with earlier attainment of good quality of life among those initially managed by mental health workers. ConclusionsPathways to care for FEP in Uganda are complex and culturally mediated, with substantial attrition before specialised early psychosis care is reached. Referral completion is strongly shaped by referral site and by delays in the care pathway. Once in specialised care, clinical outcomes improve rapidly, and initial contact with mental health workers is associated with faster symptom remission and earlier gains in quality of life. Strengthening referral systems, reducing pathway delays, and developing collaborative detection-and-referral links with community and frontline providers are key priorities for optimising early psychosis outcomes in low-resource settings.

BackgroundPsychosis poses a significant burden in sub-Saharan Africa, yet data on risk factors in Zambia remains scarce. Understanding the factors associated with psychosis among adolescents and young adults is critical for effective intervention strategies. MethodsWe conducted a cross-sectional study to determine the correlates of psychosis at Livingstone university teaching hospital (LUTH). We collected sociodemographic and clinical variables. Psychosis was the outcome variable, while independent variables included age, sex, residence, employment, marital status, developmental milestones, depression, anxiety, substance use (cannabis, alcohol, and opioids), criminal history, and hematologic and liver biochemical markers. We conducted both descriptive and inferential analyses using statcrunch. ResultsThe median age (with interquartile range) was comparable between participants diagnosed with psychosis (21 (19-23) and those without psychosis (20 (17-23). Of the study population (n=427), 84% (n=199) of participants with psychosis were male and 16% (n=38) were female. On multivariable analysis, the following variables were significantly associated with psychosis; Poor insight into mental illness was strongly associated with reduced odds of psychosis (AOR: 0.34, 95% CI 0.18, 0.64, p=0.0007), and opioid use was inversely associated (AOR: 0.43, 95%CI 0.19, 0.98, p=0.045). ConclusionThis study highlights Zambias high burden of psychosis among young males and underscores cannabis as a modifiable risk factor. The paradoxical protective role of opioids warrants further investigation. Our findings emphasize the need for context-specific interventions, such as mental health literacy programs and harm-reduction strategies targeting substance use. Addressing systemic gaps in Zambias mental health infrastructure and integrating culturally sensitive diagnostic tools are critical to mitigating psychosis-related outcomes.

Previous research has highlighted the role of social determinants of health on mental health outcomes, but their impact on suicide mortality is less understood. The aim of this umbrella review was to systematically examine the association between 10 social determinants of health, as defined by the World Health Organization, and suicide mortality. A keyword search of titles and abstracts was conducted in six digital databases for studies published to 24 August 2023. Inclusion criteria were peer-reviewed systematic reviews and meta-analyses in English examining the association between these determinants and suicide. Methodological quality was assessed using an adapted AMSTAR-2 tool. Due to significant heterogeneity in the included studies, a meta-analysis was not undertaken. A narrative synthesis, structured by social determinant, was conducted. 49 records (25 meta-analyses and 24 systematic reviews) were eligible for inclusion in this review. The social determinants with the most available evidence were housing, basic amenities and the environment (n=21), income and social protection (n=13), unemployment (n=8) and early childhood development (n=6). Limited evidence was identified for education (n=3), social inclusion and non-discrimination (n=3) and working life conditions (n=3). No reviews examined the relationship between affordable healthcare services, structural conflict or food insecurity and suicide mortality. There was evidence of a modest effect of social determinants on suicide mortality. Most evidence related to unemployment, job insecurity, income and social protection and childhood adversity. The methodological quality of the included reviews varied considerably. High-quality research fully exploring the relationship between social and environmental factors and suicide risk is needed.

BackgroundExposures to stress and traumatic events plays a significant role in triggering or precipitating anxiety. Nonetheless, these are often examined at the individual level, while societal-environmental exposures and their association with anxiety disorders are under-researched, especially in the Israeli context. This study leverages 19 years of longitudinal data from a large healthcare organization to examine the impact of national security instability on short-term anxiolytic purchases in Israel. MethodsWe conducted a retrospective cohort study using electronic medical records of over 1.1 million individuals from 2006 to 2024, examining rates of first-time and renewed use of anxiolytic medications of the benzodiazepines group during periods of armed conflict, including military operations and wars. Cox proportional hazards models were used to assess associations, adjusting for confounders such as age, sex, socioeconomic status, socioreligious sector, residence and previous psychiatric treatment. ResultsThe risk for first purchase of an anxiety-relief short terms medication during military operations was 28% higher (HR 1.28, 95% CI: 1.21-1.34) compared to periods of relative national stability, after adjustments, and 44% higher during the Second Lebanon War (HR 1.44, 95% CI 1.27-1.62). The events of October 7th were the most significant armed conflict increasing the risk for anxiety-related reaction necessitating treatment throughout the 19-years follow-up, with individuals at 317% increased risk for treatment initiation compared to periods of relative national stability (HR 4.17, 95% CI 3.97-4.38). Alongside a baseline increased risk for initiating anti-anxiety treatment, women experienced an additional elevated risk for anxiolytic therapy during times of national security threats, with 26% additional increased risk during military operations and an 81% increased risk following the events of October 7th. Residents of northern Israel had an increased risk of purchasing anxiolytics during the Second Lebanon War (HR 1.39, 95% CI: 1.12-1.72), while during military operations it was the residents of southern Israel who faced an increased risk for anxiolytic usage, with an HR of 1.18 (95% CI: 1.05-1.33). Conversely, the residential region did not significantly influence anti-anxiety treatment patterns following October 7th among residents of southern or northern Israel, compared to individuals living in central Israel, indicating a broader national impact beyond regional differences. ConclusionsNational armed conflicts significantly influence anxiolytic medication use in Israel, with the October 7th war showing the most pronounced effect. These findings highlight the need for comprehensive mental health interventions during times of national crisis, focusing on both short-term relief and long-term mental health support to prevent dependency and improve mental health outcomes in the wake of national crises.