Epidemiology and Psychiatric Sciences

Objective. To estimate lifetime and 12 month mental health contact gaps among Peruvian adults with survey-defined mental disorders, and to describe inequalities in contact, perceived need for care, and mental health service use. Methods. We analyzed the information for adults of the 2022 Peruvian National Mental Health Survey, a cross-sectional household survey. The primary outcome was the survey-weighted proportion of adults with a 12 month mental disorder who reported no contact with an included source of mental health-related care during that period; the lifetime contact gap was descriptive. Perceived need was assessed using two derived 12 month perceived-need measures based on direct ENSM variables and service contact routing items. Analyses incorporated weights, strata, and clusters. Adjusted prevalence ratios were estimated using survey weighted Poisson models. Results. The dataset contained information on 13,840 individuals; 13,833 had complete survey-design information. Contact gap denominators were 3,927 for lifetime disorders and 1,649 for 12-month disorders. The lifetime and 12-month contact gaps were 61.0% (95% CI 58.4-63.7) and 84.5% (95% CI 81.5-87.6), respectively. Rural estimates exceeded urban estimates in both periods; after adjustment, poverty and rural residence were associated with the lifetime gap, and extreme poverty with the 12-month gap. Among individuals meeting survey-based criteria for one or more 12-month mental disorders, 37.3% (95% CI 33.4-41.4) reported self-perceived need, whereas 25.6% (95% CI 21.8-29.8) reported that need had been identified by others. Annual psychological and psychiatric service use was 3.7% and 1.1%, respectively. Conclusions. Mental health contact gaps were high, particularly for one or more 12-month mental disorders, and were associated with social and territorial variables. These contact measures do not establish adequate, continuous, or effective treatment, which needs to be addressed to understand the impact of the Peruvian mental health reform.

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

One-to-one peer support is widely used in mental health services, but the components associated with better outcomes remain unclear. We systematically reviewed randomised controlled trials and conducted additive component network meta-analyses to identify which components of one-to-one peer support worker interventions were associated with outcomes for adults using mental health services. CINAHL Ultimate, Embase, MEDLINE, PsycINFO, CENTRAL, ClinicalTrials.gov and ISRCTN were searched, supplemented by citation tracking, previous reviews and expert consultation. Interventions were coded for seven components: Training and development, Maintaining peer support worker wellbeing, Relationship-building, Social support, Emotional support, Practical support and Cultural adaptation. The review followed PRISMA-NMA reporting guidance and was registered with PROSPERO (CRD42022355291). Thirty-six trials randomised 6,645 participants across nine countries. Only quality of life and recovery yielded estimable component effects at one or more follow-up points. For quality of life, Practical support had a positive incremental estimate at 3 months (standardised mean difference 0.52, 95% confidence interval 0.17 to 0.87); no component showed clear evidence of benefit at 6 months; and at 12 months Social support had a positive estimate (1.57, 0.12 to 3.01), whereas Maintaining peer support worker wellbeing had a negative estimate (-1.66, -3.05 to -0.28). These estimates were not consistent across follow-up points. For recovery, Relationship-building had positive estimates at 6 months (0.90, 0.03 to 1.78) and 12 months (0.50, 0.29 to 0.72). Networks were sparse and often disconnected, and additivity could not be tested in disconnected networks. Current trials do not permit definitive prioritisation of peer-support components. Relationship-building was the most consistent candidate component, but all findings remain provisional. Future trials should prospectively specify, manipulate and measure component delivery.

Violence against women is a key contributor to mental health gender disparities, with greater gender gaps observed in low-and middle-income countries. This study examines state-level associations between gender-based violence against women and mental health burden in India over time. We linked 1) annual state-level age-standardised disability-adjusted life year rates (ASDR) from the Global Burden of Disease study for overall mental health disorders, depressive disorders, anxiety disorders, bipolar disorder, schizophrenia and self-harm, with 2) annual state-level gender-based violence rates from the Open Government Data Platform, India. We used descriptive ecological analyses and multilevel modelling to estimate the state-level association between gender-based violence and sex-stratified mental health outcomes over time (2001 - 2021). Results showed higher state-level gender-based violence (GBV) rates were associated with higher state-level ASDR of schizophrenia ({beta}women = 0.39 [95%CI 0.25 - 0.52]; {beta}men = 0.42 [0.29 - 0.55]) and bipolar disorder ({beta}women = 0.02 [0.01- 0.03]; {beta}men = 0.04 [0.03 - 0.05]), after adjustment for state-level social development, but not with other outcomes. Higher GBV rates were associated with a lower gender disparity in depressive disorders. Longitudinal findings revealed that the state-level association between GBV rates and ASDR of overall mental health disorders strengthened over time ({beta}women = 5.08 [3.96 - 6.20]; {beta}men = 3.38 [2.60 - 4.15]), whereas the association weakened for self-harm and schizophrenia. Lagged findings suggested that with an increase in GBV rate, ASDR of overall mental health disorders increased for men over two years and for both sexes over five years. Our findings highlight the importance of considering state-level trends in GBV and related policies, and considering impacts of GBV on both men and women's mental health.

Oregon (OR) and Colorado (CO) were the first states to enact regulations for provision of psilocybin with support of licensed "facilitators." As more states and countries adopt similar policies, informed public policy decisions require that client characteristics and rationale for using psilocybin, psilocybin dosing practices, mental health outcomes, and adverse events are understood. We performed a retrospective observational study of responses for 2363 individuals receiving psilocybin at OR and CO regulated service centers. Clients and facilitators entered data before and after receiving psilocybin, including the Mystical Experience Questionnaire-30 (MEQ-30), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and World Health Organization Well-Being Index-5 (WHO-5). Preexisting mental health issues were common (66%) in participants. Psilocybin doses ranged from 1-95 mg, with a mean total of 28*8 mg. We observed improvements of 49% in PHQ-9 scores, 51% in GAD-7 scores, and 22% in WHO-5 scores at two-weeks after dosing. MEQ-30 scores were dose-dependent. Changes in PHQ-9 and GAD-7 scores were not different for psilocybin doses [≤]30 mg and >30 mg, and only weakly correlated with MEQ-30 scores. There were 94 mild adverse events during and after dosing, five more serious events not clearly related to treatment, and evidence of possible risk of increased suicidality. Study limitations include open label administration, self-reporting, loss of participants for follow-up, and a short 2-week post-dosing end-point. We conclude that psilocybin services, delivered within these regulated frameworks, is associated with improvements in mental health in real world populations, however, more robust monitoring is needed to ensure safety.

Reddit has emerged as an accessible, anonymous platform for public discourse surrounding mental illness, yet little research has examined how users perceive and evaluate existing anti-stigma initiatives. This study addresses this gap by analyzing public discourse around destigmatization efforts, including both corporate-led campaigns (i.e., Bell Lets Talk) and broader community-based discussions. We conducted an interpretive content analysis of Reddit posts and comments identified through an a priori search protocol registered on the Only Science Framework. We drew a criterion-based purposive sample from r/mentalhealth and general Reddit using keywords related to anti-stigma discourse (e.g., anti-stigma, destigmatizing, and #BellLetsTalk). Fifty posts met inclusion criteria, yielding 581 coded references. Posts predominantly addressed mental health in general terms rather than specific diagnoses, with public stigma (n=28 posts) and structural stigma (n=16 posts) most discussed; internalized stigma was rarely a primary focus. #BellLetsTalk posts located outside the mental health community generated substantially greater engagement than posts within r/mentalhealth, with several threads exceeding 300 comments. Four themes emerged during the qualitative analysis: (1) anti-stigma efforts are unhelpful (n=381), (2) hopeful sentiments about anti-stigma efforts, (3) the mixed role of media, and (4) future directions for anti-stigma efforts.

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

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

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

Background: A comprehensive overview of how premature mortality in severe mental illness varies by socioeconomic position and healthcare utilization is lacking. Methods: We followed all Norwegian residents aged 30-79 years on January 1, 2008, through December 31, 2023. Nationwide registry linkage provided data on mental illness in primary and specialist care, educational attainment, and cause of death. We estimated the mortality gap as excess life-years lost from age 30 for depression, bipolar disorder, and schizophrenia compared with the general population, stratified by sex, healthcare utilization, and educational attainment. All-cause, external-cause, and natural cause mortality were assessed using competing risks. Results: The cohort comprised 2,486,836 individuals, including 483,933 with depression, 40,125 with bipolar disorder, and 21,963 with schizophrenia. Among men, the mortality gap ranged from 1.50 year (95% CI 0.36-3.34) among those with depression, non-inpatient care utilization, and university education to 19.86 years (18.34-21.36) among those with schizophrenia, inpatient care utilization, and less than high school education. Among women, the corresponding range was no gap to 18.16 years (17.03-19.53). Mortality gaps were generally larger with lower educational attainment and inpatient care utilization and increased from depression to bipolar disorder to schizophrenia. This pattern was consistent across sexes, diagnoses, healthcare utilization levels, and educational attainment levels and was most pronounced for natural-cause mortality. Conclusions: Premature mortality among people with severe mental illness forms a continuum across socioeconomic disadvantage, healthcare utilization, and diagnosis. Combining these measures can identify subgroups with the greatest mortality burden and may help target preventive interventions.

Background: Mobile outreach initiatives have emerged to address persistent barriers to care for people experiencing homelessness, substance use, and mental illness. Although these models show promise, less is known about how and under what conditions they enable engagement and coordinated care. This study explains how, why, and under what circumstances a mobile, cross sector outreach model enables access to care for marginalized populations. Methods: We conducted a realist evaluation of Supportive Outreach Services (S.O.S.), a mobile, cross sector outreach program in Grey County, Ontario. Data included 31 semi structured interviews with outreach providers, partner organizations, system leaders, and clients, supplemented by document review and stakeholder feedback. Using retroductive reasoning and constant comparison, we developed and refined context mechanism outcome configurations to construct an explanatory program theory. Results: Five interconnected realist explanations account for how the model enables access to care. Trust built through repeated, non judgmental encounters supports engagement; proximity reduces barriers to participation; accessible support enables timely help seeking; cross sector relationships enable adaptive coordination; and visible results build legitimacy that sustains participation and resources. Together, these explanations provide a linked explanatory account of how mobile outreach reduces friction between marginalized populations and fragmented services while identifying the structural conditions that constrain its effectiveness. Conclusions: The effectiveness of mobile outreach depends less on the services delivered than on its capacity to reduce friction, sustain relationships, and adapt care across organizational boundaries. The resulting program theory offers transferable explanations for designing coordinated community based services while highlighting the structural conditions required for durable change.

Introduction: People living with HIV experience disproportionately high rates of mental health conditions, yet adult attention-deficit/hyperactivity disorder (ADHD) is largely absent from the HIV literature. Traits associated with ADHD, together with social exclusion, adverse life events, stigma, and barriers to accessing healthcare may increase vulnerability to HIV acquisition and complicate adherence to treatment and prevention, and a comparable pathway may apply to users of HIV pre-exposure prophylaxis (PrEP). Prevalence data on ADHD in people living with HIV are limited to two small-scale studies, and no data exist for PrEP users. The objective of this study is to estimate the prevalence of ADHD traits among people living with HIV and PrEP users in Switzerland and to describe sociodemographic, behavioural and clinical patterns. The study was co-created and is co-led by people who, beyond their academic and clinical practices, have experiential knowledge of the topics being explored Methods and analysis: This is a multicentre cross-sectional survey using a Critical ADHD Studies framework and nested within the Swiss HIV Cohort Study (SHCS) and SwissPrEPared cohort. Over a 12-month recruitment period, participants attending routine visits at participating sites will complete the six-item Adult ADHD Self-Report Scale Screener (ASRS-5). A positive screen is defined as a weighted score of 14 or higher. Three additional items capture the presence of traits in childhood before the age of 12, any previously established ADHD diagnosis, and the participants wish to receive their score and/or a follow-up consultation with a psychologist or psychiatrist. Screening data will be linked to routinely collected cohort variables. The primary objective is to estimate the prevalence of a positive ASRS-5 screen, with 95% Wilson score confidence intervals, in each cohort. Secondary objectives include comparing cohorts and examining associations between ADHD traits and substance use, sexual behaviour, sexually transmitted infections, depression and anxiety, treatment and prevention adherence, use of and interest in long-acting HIV treatment modalities, and gender identity and sexual orientation. A target sample of 800 participants per cohort was calculated for a 3% prevalence margin of error. Ethics and dissemination: The study is nested within the SHCS and SwissPrEPared and falls under their existing ethical approvals and general participant consent. Participants who screen positive and wish to be followed up will be offered a consultation with an ADHD-experienced psychologist or psychiatrist. Results will be publicly available on the study website, published in peer-reviewed journals, and shared with participants and communities through lay summaries and cohort communication channels.

Introduction: Self-rated health is an important patient-centred measure of health. The relationship between cannabis use and self-rated health has been previously studied, although with methodologic concerns which we aimed to address in this investigation. Methods: Propensity score weighted analyses of the National Health and Nutrition Examination Survey (NHANES) 2009-2018 were conducted. The primary exposure was self-reported cannabis use in the 30 days prior to survey response. The primary outcome was self-rated health measured on a five-level ordinal scale. Secondary outcomes included the number of days in the past months with: i) poor physical health, ii) poor mental health, and iii) activity limitations related to poor health. A weighted proportional odds regression model was used for the primary analysis and weighted zero-inflated negative binomial regression models were used for each secondary analysis. Results: Among 22,055 adults aged 20-59 responding to the NHANES cannabis questionnaire, 14.4% endorsed use in the past 30 days. After reweighting the sample to balance cannabis users and non-users across sociodemographic, medical, and lifestyle characteristics, there was no statistically significant association between recent cannabis use and higher levels of self-rated health (OR 0.90, 95% CI 0.80-1.01). Cannabis use was associated with poor mental health and activity limitations in the past month, but not poor physical health. Conclusions: Recent cannabis use was not associated with self-rated health but was associated with poor mental health and activity limitations in the past month. Cannabis users at risk of poor mental health should be connected with clinicians to help guide therapy.

Importance: Excess mortality associated with mental disorders is well established, but estimates are largely based on specialist psychiatric populations. Whether they characterize mortality in the broader diagnosed population is uncertain. Objective: To characterize heterogeneity in excess mortality by diagnosis, psychiatric care setting, substance use disorder (SUD), and time since diagnosis. Design: Nationwide population-based cohort study with follow-up from January 1, 2011, through December 31, 2023. Setting: Primary and specialist health care and population registers in Finland. Participants: Residents aged 5 to 95 years without a recorded prevalent mental disorder at cohort entry. Exposures: Mental, behavioural, and neurodevelopmental disorders classified using ICD-11, with time-varying psychiatric care setting and SUD status. Main Outcomes and Measures: All-cause mortality, mortality rate ratios (MRRs), and 10-year differences in restricted mean survival time (RMST). Results: Among 5,526,599 individuals (2,784,897 [50.4%] women), 1,463,064 (26.5%) received a mental disorder diagnosis. Excess mortality varied substantially by diagnosis, clinical subgroup, and time since diagnosis. Among those aged 5 to 64 years with any mental disorder, adjusted MRRs across care setting and SUD strata ranged from 1.54 (95% CI, 1.39-1.71) to 8.97 (7.86-10.24). MRRs were highest immediately after first diagnosis and declined during the first 2 to 3 years. At 3 years, MRRs for depressive, anxiety or fear-related, and stress-related disorders among individuals without SUD treated outside specialist psychiatric care ranged from 0.88 (0.79-0.98) to 1.20 (1.12-1.29) in men and from 0.81 (0.73-0.89) to 1.13 (1.04-1.22) in women, whereas MRRs for schizophrenia and other primary psychotic disorders remained 1.84 (1.60-2.12) in men and 1.55 (1.37-1.75) in women. Ten-year survival loss across all mental disorders was 0.53 years (95% CI, 0.53-0.54) in men and 0.34 years (0.33-0.34) in women and was greater for natural than external causes. Conclusions and Relevance: Excess mortality varied markedly by diagnosis, clinical context, and time since diagnosis and was small in some common disorders outside specialist psychiatric care without SUD. Estimates derived from specialist psychiatric populations or averaged across follow-up may therefore provide an incomplete picture of mortality in the broader diagnosed population.

Objectives. To determine whether three established comorbidity scores (Charlson Comorbidity Index, Elixhauser Comorbidity Sum, van Walraven Score), applied with a single formula to both sexes, are equally well calibrated and equally discriminating in women and men, and whether any difference reaches a pre-specified threshold of clinical relevance. Design. Population-based retrospective cohort study; external validation of three pre-existing prediction models (TRIPOD Type 4) with sex-stratified evaluation. The analysis plan was fixed in the time-stamped Research Data Centre submission syntax before any aggregated data existed. Setting. Germany; complete national enumeration of acute somatic Diagnosis-Related Group (DRG)-billed adult inpatient cases, reporting years 2010 to 2024. Participants. 166 693 491 adult inpatient cases meeting a pre-specified nine-step eligibility filter. Main outcome measures. In-hospital mortality. Primary axis: calibration (calibration-in-the-large, CITL; calibration slope; observed mortality per score quintile). Secondary axis: discrimination (area under the receiver operating characteristic curve, AUC). Pre-specified thresholds: between-sex slope difference of at least 0.05, absolute AUC difference of at least 0.01. Results. Calibration-in-the-large was effectively perfect in both sexes (|CITL| [&le;] 0.0004). The scores diverged in how prediction kept pace with rising risk, and in opposite directions for women and men: for the Charlson index the calibration slope was 0.968 in men and 1.034 in women (difference 0.066), with smaller differences for the Elixhauser-Sum (0.039) and the van Walraven Score (0.029). At the same score quintile, observed mortality was higher in men at most quintiles, with a maximum risk ratio of 1.21 (95 % CI 1.20 to 1.22); two van Walraven quintiles ran the other way (0.87 and 0.97). Differences in discrimination were small (random-effects AUC difference: Charlson -0.0076, 95 % CI -0.0095 to -0.0057; Elixhauser-Sum +0.0074; van Walraven -0.0026). Conclusions. Applied with a single formula to both sexes, three established comorbidity scores are calibrated differently in women and men, whereas their discrimination differs only marginally. Because these scores are reused at scale in research and in risk-adjusted mortality comparisons between hospitals, a systematic difference in calibration does not average out. This supports sex-specific recalibration. The downstream effect on hospital benchmarking is not yet quantified and should not be presumed negligible. Study registration. OSF DOI 10.17605/OSF.IO/P3QAW.

Objective: To examine if food insecurity moderates the relationship between rurality and mental health outcomes (suicide mortality, poor mental health days, frequent mental distress) and to assess if these effects vary across U.S. Census divisions. Methods: This county-level (n=2,397) cross-sectional study used OLS and spatial error regression to analyze public data from sources including the County Health Rankings and USDA. We modeled suicide mortality, poor mental health days, and frequent mental distress as functions of the Index of Relative Rurality (IRR) and food insecurity, controlling for median income and provider rates. The suicide model was also tested across nine U.S. Census divisions. Results: Baseline models revealed a paradox: rurality was a direct risk factor for suicide (B=0.400) but protective for poor mental health days (B=-0.224). The national multivariable model revealed a significant, positive rurality-food insecurity interaction for suicide mortality (B=0.861), indicating a synergistic risk. This interaction was not significant for general mental distress, which was more strongly predicted by income and food insecurity. Regional analysis confirmed the suicide interaction was potent in five divisions, including the Pacific (B=3.048) and Mountain (B=1.712) , but absent in others (e.g., South Atlantic). Conclusions: The drivers of suicide are distinct from those of general mental distress and are geographically heterogeneous. The interaction of rurality and food insecurity creates a compounded risk for suicide. Suicide prevention must be regionally-tailored and address structural inequalities, such as food insecurity, alongside clinical care.

Background: Although barriers to mental health help-seeking among Asian American populations are well documented, less is known about how favorable individual attitudes toward mental health treatment coexist with family and community influences among South Asian American young adults or which intervention strategies members of this population themselves prioritize. Methods: A cross-sectional mixed-methods survey was completed by 191 South Asian American young adults aged 18-30 years residing in Texas between May and June 2026 using convenience sampling. Participants completed 5-point Likert-scale measures assessing mental health attitudes, stigma, help-seeking, and barriers to care. 144 participants also provided responses to optional open-ended questions exploring barriers to mental health care and recommendations for improving access to mental health support. Quantitative data were analyzed using IBM SPSS Statistics, and qualitative responses underwent thematic analysis in MAXQDA. Results: Participants reported generally positive attitudes toward mental health care and high perceived importance of mental health despite family- and community-level barriers. Greater family pressure was strongly associated with increased mental health stigma (r = 0.711, p < 0.001) and perceived barriers to care (r = 0.654, p < 0.001), while greater perceived barriers were associated with less favorable help-seeking attitudes (r = -0.158, p = 0.036). Qualitative responses contextualized these findings, identifying anticipated community judgment, family expectations, privacy concerns, and limited mental health literacy among older generations as barriers to care. Participants emphasized culturally responsive care and recommended mental health education involving parents, elders, faith leaders, and trusted community institutions. Conclusions: South Asian American young adults may hold favorable attitudes toward professional mental health care while navigating family, community, and cultural contexts that constrain help-seeking. Participant-generated recommendations prioritized culturally responsive care and community-level mental health education involving parents, elders, faith leaders, and trusted institutions, suggesting that interventions targeting individual attitudes alone may be insufficient.

Child maltreatment (CM) is a global phenomenon, yet its prevalence, acceptability, and psychosocial consequences vary across cultures. This study examined self-reported CM, its perceived acceptability, and associations with psychosocial outcomes among 1,617 adults (Mage = 25.21, SD = 6.74) across 13 countries and regions. Participants completed an online survey assessing physical neglect, physical abuse, emotional maltreatment, sexual abuse, and witnessing domestic violence, alongside perceived acceptability, post-traumatic growth, resilience, perceived social support, post-traumatic symptoms, and psychological distress. Country/region differences were tested via mixed-effects; whether CM-outcome associations varied by country/region was tested via fixed-effects interaction models. Significant cross-country/region variability emerged for most CM subtypes, especially for emotional maltreatment. Witnessing domestic violence rates did not differ significantly, though its acceptability still varied significantly, as did all other types. Greater CM exposure was linked to poorer mental health for several subtypes and to greater acceptability of maltreatment, raising concerns about intergenerational normalisation. CM-outcome associations were largely consistent across countries/regions, with only isolated, exploratory exceptions. Findings show that while CM's adverse psychosocial impact shows little cross-national variation, its prevalence and normative framing are culturally shaped, underscoring the need for culturally sensitive assessment and intervention.

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

Background: Depression is a risk factor for overdose and is more commonly diagnosed among females. However, sex-differences in the association between depression, in isolation and in combination with substance use disorder (SUD), and overdose have not been examined at the population level in British Columbia (BC). This study described sex-and-age differences in associations between documented history of depression and/or SUD diagnoses and risk of fatal (FOD) and non-fatal overdose (NFOD). Methods: This study used linked administrative health data from the Provincial Health Services Authority Platform for Analytics and Data. The sample included BC residents aged 19-79 as of January 1st, 2015 (n=3,996,690). Exposures were classified as documented diagnosis history of 1) depression; 2) substance use disorder (SUD); 3) depression and SUD; and 4) neither condition, using physician billing and hospitalization records from 2010-2014. FOD (BC Coroners Service records) and NFOD (BC Emergency Health Services records) were ascertained from 2015 to 2024. Incidence rates per 10,000 person-years and unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CI) were estimated using Poisson regression, with neither diagnosis as reference, overall and stratified by sex and age. Results: There were 14,281 FOD (78.59% male) and 43,555 NFOD (69.45% male) cases. FOD incidence was higher among males overall; however, relative associations between diagnosis history and FOD risk were stronger among females. Depression diagnosis history was associated with a FOD IRR of 3.95 (CI: 3.56-4.38) among females and 2.46 (CI: 2.32-2.61) among males. IRRs for SUD and for depression and SUD were larger among females (108.07 [CI: 95.83-121.73] and 116.70 [CI: 106.51-127.96]) than males (26.69 [CI: 25.57-28.18] and 31.21 [CI: 29.81-32.67]). NFOD findings were similar but attenuated (depression IRR: 3.22 [CI: 3.08-3.38]) in females; 2.29 [CI: 2.21-2.37] in males). Conclusion: A documented history of depression and/or SUD was more strongly associated with FOD and NFOD risk among females, despite higher incidence overall among males. Future research should consider the potential role of other sociodemographic factors in explaining sex differences in associations between diagnosis history and overdose risk.