European Psychiatry

Background:Previous self-harm elevates the risk of repeat self-harm and suicide, but the prognostic value of events and clinician observations around the index event is unclear. We evaluated established and exploratory risk factors for suicide and repeat self-harm among patients presenting to emergency psychiatric units after a suicide attempt or nonsuicidal self-injury (NSSI). Methods: Multicentre cohort study in Sweden (n = 804). Outcomes were suicide and repeat self-harm at 1-year and 5-year follow-up, ascertained through linked national registers. Established risk factors included psychiatric diagnoses, prior suicidal behaviour, and sociodemographic characteristics; exploratory factors comprised past-week self-reported symptom changes and clinician observations. LASSO-regularised Cox regression models were fitted for established (n=21) and exploratory (n=11) risk factors. Results: During five-year follow-up, 285 (35%) individuals had a new episode of self-harm and 41 (5%) died by suicide. No risk factors reached statistical significance for suicide, although male sex was retained after regularisation (1-year hazard ratio [HR] = 3.57 [95% CI 0-8.33]; 5-year HR = 2.5 [0.03-4.55]). Three established risk factors were significantly associated with repeat self-harm: psychiatric inpatient care in the three months before the index event (1-year HR = 1.85 [1.3-2.6]; 5-year HR = 1.72 [1.23-2.65]), previous suicide attempt (1-year HR = 2.01 [0.79-2.4]; 5-year HR = 2.19 [1.27-2.6]), and borderline personality disorder (1-year HR = 1.82 [1.13-3]; 5-year HR = 1.67 [0.14-2.75]). Among exploratory risk factors, clinician-observed hopelessness (1-year HR = 1.72 [1.1-2.3]; 5-year HR = 1.51 [1.03-1.91]) and personality disorder features (1-year HR = 1.48 [0.96-2.05]; 5-year HR = 1.47 [1.04-1.95]) were associated with repeat self-harm. Conclusions: Risk factor profiles for repeat self-harm were consistent at 1 and 5 years. Beyond established risk factors, clinician-observed hopelessness and personality disorder features emerged as markers of risk, suggesting that qualitative clinician assessments may yield prognostic information not available from medical records alone.

Purpose: Suicide mortality is underestimated due to misclassification under undetermined and accidental deaths. This study examined national trends in suicide and related external causes of death in Portugal from 2002 to 2023, by sex and age group, assessing potential shifts suggesting masked suicide and quantifying the relationship between undetermined, suicide, and accident death rates through ratio indices. Methods: Using official mortality data from Portugal's Statistics Institute (INE) for 2002-2023, we calculated age-standardised (SDR) and age-specific death rates (ASDR) for suicide (X60-X84), undetermined intent deaths (Y10-Y34), and unintentional deaths (V01-X59), disaggregated by sex and four age groups (15-24, 25-44, 45-64, 65+). We estimated undetermined-to-suicide (UnD:Suic) and undetermined-to-accidents (UnD:Accs) rate ratios for SDRs and ASDRs. Trends were analysed using joinpoint regression (APC/AAPC) and structural breakpoint analysis (Chow test, BIC). Results: Suicide SDRs declined across the period for males (AAPC: -2.25%) and females (AAPC: -1.32%), with the sharpest reductions among males aged 25-44 (AAPC: -2.56%) and females aged 65+ (AAPC: -2.44%). Deaths of undetermined intent rose steeply from 2002 to 2005-2006 and declined thereafter. Unintentional deaths declined in most age groups, except females aged 65+ (AAPC: +1.41%). Both ratio series peaked around 2005-2009, declined progressively through the 2010s, and reached their lowest values in 2021-2022. Age-specific analyses revealed a significant and sustained increase in both ratios among females aged 45-64. Structural breakpoints clustered around 2004, 2013-2015, and 2019-2020. Conclusion: Suicide mortality declined in Portugal from 2002 to 2023, but divergent trends in undetermined and accidental deaths across sex and age subgroups highlight ongoing misclassification. Age- and sex-specific ratio analyses identify the population subgroups where misclassification is most concentrated, providing a foundation for future imputation-based estimates of probable suicide burden.

Background: The course of major depressive disorder is heterogeneous, with UK Biobank (UKB) participants reporting episode durations ranging from <1 month to >24 months. Here, we identify predictors of episode duration, characterise its genetic architecture, and examine links to treatment seeking and response. Methods: In UKB participants meeting criteria for major depressive disorder, we examined clinical, sociodemographic, and genetic predictors of short (0-3 months) and long (>24 months) episode duration, fitted in predictor-specific, domain-level, and combined models. We also conducted genome-wide association studies in European-ancestry participants (n = 40,858) and estimated common-variant heritability. Results: Clinical features were most informative: higher childhood trauma scores, a stressful trigger, and recurrence showed the most consistent associations with short and long durations across models (ORcombined: short = 0.75-0.95; long = 1.13-1.45; all p[&le;]0.02). Higher neuroticism scores were also associated with both durations (ORcombined: short = 0.977; long = 1.053; p<0.001). Polygenic risk for depression was associated with episode duration, though its independent contribution was modest. Long episodes were more predictable than short in validation analyses (AUC = 0.705 vs 0.601) and were associated with greater treatment engagement but lower perceived benefit; SNP-based heritability was nominally significant. Conclusions: Clinical features captured most of the predictable variance in episode duration, with the same predictors largely operating in opposite directions for short and long episodes, consistent with a continuum of chronicity. Those at risk for long episodes emerge as a priority for early identification and intervention.

Background. The Perinatal Grief Scale (PGS) is a widely used instrument for assessing grief following pregnancy loss, yet no study has validated it specifically in men despite documented use in several studies. This gap is critical given fathers' persistent underrepresentation in perinatal bereavement research and the absence of empirically supported screening thresholds for this population. Methods. This cross-sectional validation study used data from the OPALE project (Observatory on PerinatAL hEalth) conducted by the CiaoLapo Foundation in Italy. Among 276 fathers who experienced stillbirth or miscarriage, we examined criterion validity by testing the association between PGS scores and trauma-related symptomatology assessed via three validated instruments: the Revised Impact of Event Scale (RIES, n=103), National Stressful Events Survey Short Scale (NSESSS, n=95), and SCL-90 (n=173). We systematically tested multiple threshold combinations to identify optimal discriminative performance. Results. The PGS demonstrated excellent criterion validity. The optimal threshold (PGS >=92) showed sensitivity 81.0%, specificity 81.8%, and Youden's J index 0.628. Fathers scoring >=92 had 19.12 times the odds of high trauma symptoms (95% CI: 9.35 to 39.14, p<0.001). ROC analysis yielded AUC=0.829 (95% CI: 0.778 to 0.880). Associations remained robust across all three trauma instruments in stratified analyses and after adjusting for time since loss, father's age, living children, and loss type. Conclusion. This is the first men-specific validation of the PGS, demonstrating strong criterion validity and establishing a clinically meaningful screening threshold (>=92) for identifying fathers at elevated risk following perinatal loss.

The present study examined the relationship between the DSM-5 diagnostic criteria for gambling disorder (GD) and gambling severity via an item response theory (IRT) analysis in two large German population survey data sets (Buth et al. (2022, 2024)). IRT-based person fit analyses may reveal atypical response patterns (e.g. endorsing criteria linked to higher levels of disorder severity, but not criteria linked to lower levels). We examined the link of such atypical response patterns and mental health as measured by the MHI-5, employing a 2-parameter-logistic (2PL) IRT model and a linear mixed model with random intercepts. Results largely replicated previously reported item severity rankings across both samples: GD criteria such as loss chasing and a preoccupation with gambling were generally linked to lower severity levels, whereas criteria such as withdrawal symptoms or job/family problems where generally linked to higher severity levels. Modelling revealed a reduced assessment sensitivity in lower gambling severity ranges. Furthermore, person fit analyses suggest that atypical symptom patterns may be linked to poorer mental health (MHI-5). Implications for the interpretability of total scores of endorsed criteria and the validity of diagnostic practices determining eligibility for treatment and financial compensation are discussed.

Background: Suicide prediction models in psychiatry often rely on purely data-driven feature selection, which can produce unstable and clinically opaque predictor sets in modest-sized samples. We developed Evidence-Based AI LASSO (EBAL), an evidence-guided regularization framework that incorporates curated clinical evidence into feature-specific penalty factors for interpretable prediction. Methods: Baseline data from 136 youth with confirmed bipolar spectrum disorder in the Greater Houston Area Bipolar Registry were analyzed using 20 candidate clinical predictors. Forty higher-level evidence documents on suicidality and related predictor domains were curated through a structured evidence synthesis workflow and indexed as an auditable evidence corpus. An open-weight large language model assigned feature-specific penalty factors using a prespecified scoring rubric, and these penalties were used to fit a weighted LASSO model. EBAL was compared with a standard evidence-agnostic LASSO using nested leave-one-out cross-validation. Results: For suicidal ideation, EBAL achieved an AUROC of 0.768, balanced accuracy of 0.757, sensitivity of 0.758, and specificity of 0.757. The standard LASSO achieved an AUROC of 0.760 and balanced accuracy of 0.715. EBAL improved balanced accuracy (+0.042, p=0.010) and Matthews correlation coefficient (+0.079, p=0.010), while retaining fewer stable predictors than standard LASSO (11/20 vs 18/20). The strongest positive predictors were current depressed mood, duration of mood disorder illness, and comorbid generalized anxiety disorder. For suicidal behavior, both models performed near chance and retained all candidate predictors. Limitations: The study was cross-sectional, single-site, and modest in sample size, with no external validation cohort. Conclusions: EBAL produced a sparser and more clinically coherent model for suicidal ideation in pediatric bipolar disorder, but did not improve prediction of suicidal behavior. These findings support evidence-guided regularization as a transparent strategy for aligning psychiatric prediction models with prior clinical knowledge while preserving interpretability.

Background Individuals with severe mental illness (SMI), including schizophrenia spectrum disorders (SSD) and bipolar disorder (BD), have been shown to have an elevated risk of violent perpetration. However, no population-wide study has systematically examined how this risk varies across psychiatric comorbidity patterns and specific violent crime types. Methods Using the first nationwide Norwegian registry linkage comprising mental health and crime data, we included 3,612,215 individuals aged 15-79 years living in Norway on Jan 1, 2008, and followed them until Dec 31, 2022. We estimated absolute and relative risks (RRs) of violent offending overall and by specific violent crimes among individuals with SSD and BD. To capture clinically relevant comorbidity patterns, we included substance use disorders (SUD), common personality disorders (PD), and hyperkinetic disorders (ADHD). RR models were adjusted first for sex and age, and subsequently for co-occurring mental disorders. Findings At the population level, individuals with SMI accounted for a minority of violent offenders (SSD: 8.7%; BD: 4.6%), whereas SUD was present among a substantially larger proportion (36.8%). Absolute risk of violent offending increased markedly with psychiatric comorbidity, from e.g., 5.0% among individuals with SSD alone to 43.9% for SSD combined with SUD and PD. Compared with the remaining general population, the RR of violent offending for SSD decreased from 6.58 (95% CI 6.4-6.8, adjusted for sex and age), to 2.0 (2.0-2.1) after further adjustment for other mental disorders. Similar attenuation patterns were observed across specific violent crime types, although varying in magnitude. In contrast to SMI, elevated risks associated with SUD remained substantial after full adjustment across most crime categories. Interpretation The association between SMI and violent offending is strongly influenced by psychiatric comorbidity, particularly SUD, and varies across crime types. Our findings underscore the importance of identifying and treating co-occurring mental disorders and substance use, both in the clinical management of SMI and in population-level violence prevention strategies.

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.

Background: Various explanations have been proposed for increasing trends in diagnosed depression in the UK, including increases in the proportion of the population that experience symptoms, changes in the threshold for seeking treatment and changes in clinical recognition or coding practices. Identifying trends over time for the relationship between the experiences of psychological distress and receiving a diagnosis can help explain wider trends in the incidence of clinical depression, such as whether the threshold for seeking treatment and receiving a diagnosis of depression has changed. Aims: This study aims to examine trends in the incidence of diagnosed depression, and relationships between psychological distress and recent depression diagnosis among UK adults between 2011 and 2022. We also assess whether the difference in psychological distress between adults with and without a recent depression diagnosis has changed over time and examine these relationships across subgroups (sex, ethnicity, age, cohort, education and financial stress). Methods: Data were from 66,360 adults (341,764 observations) aged 16 or older from the UK Household Longitudinal Study (UKHLS) across nine fieldwork periods spanning 2011-2022. Psychological distress was reported with the GHQ-12 used as a continuous variable and as a binary variable indicating caseness. Recent depression diagnoses were self-reported. Analyses we run for the overall population and stratified by different sociodemographic characteristics. Results: Incidence of diagnosed depression has not increased over time in the overall sample, but there was a notable increase in some sub-groups, most clearly seen for women aged 16 to 24. There has been a clear increase in the number of cases of psychological distress, but who have not received a recent diagnosis of depression. The level of psychological distress experienced by adults recently diagnosed with depression has slightly increased over time, whilst the difference in psychological distress experienced by adults with and without a recent depression diagnosis remained stable. Subgroup analyses show differences in the distress experienced by those with and without a recent diagnosis based on sex, age, cohort, ethnicity, education and financial situation: temporal trends were mostly similar across groups. Conclusions: Stable trends in (a) the distress experienced by adults recently diagnosed with depression, and (b) the difference in psychological distress experienced by adults with a recent depression diagnosis compared to adults without suggests little support for the hypothesis that depression is being diagnosed at lower levels of psychological distress. Instead, our findings suggest there may be a growing population who are not receiving clinical support for high levels of distress.

Importance Anxiety and depression frequently co occur and show developmentally patterned co-development from childhood to adolescence. Adult psychiatric outcomes vary according to the timing, sequencing, and persistence of early symptoms, yet it remains unclear whether patterns of co development are comparable across high income and low and middle income country contexts. Objective Examine joint developmental trajectories of anxiety and depression from childhood to adolescence and their associations with anxiety and depression diagnoses in young adulthood. Design, Setting and Participants Population based prospective cohort studies in the UK (Avon Longitudinal Study of Parents and Children [ALSPAC], N=9,586) and Brazil (Pelotas 2004 Birth Cohort, N=3,815). Main Outcomes and Measures Trajectories were derived using parallel process latent growth models and latent class growth analyses of anxiety and depression using the Development and Well Being Assessment at early childhood (6-7 years), middle childhood (10-11 years), and adolescence (13-15 years). Diagnoses of anxiety and depression at 18 years were assessed via the Clinical Interview Schedule (ALSPAC) and the Mini International Neuropsychiatric Interview (Pelotas). Results Prevalence of anxiety and depression from early childhood to adolescence was similar across cohorts. Co-development was stronger in ALSPAC, with modest increases in both conditions, whereas in Pelotas, anxiety increased rapidly while depression showed little average change. In both cohorts, four trajectory classes were identified: stable-low (ALSPAC, 41%; Pelotas, 54%), increasing (31%; 28%), decreasing (23%; 15%), and persistent-high anxiety/increasing depression (5%; 3%). Compared with the stable-low class, youth in the increasing and persistent-high classes had elevated odds of depression (ALSPAC: OR=2.0 [95% CI, 1.4-2.8] and 4.2 [2.6-6.7]; Pelotas: 2.2 [1.5-3.3] and 2.9 [1.4-6.0]) and anxiety in young adulthood (ALSPAC: 1.6 [1.2-2.2] and 4.8 [3.2-7.0]; Pelotas: 1.7 [1.2-2.6] and 2.9 [1.5-5.8]). No increased risk was observed in the decreasing class. Conclusions and Relevance Patterns of anxiety and depression co development were comparable across the UK and Brazil, suggesting shared developmental pathways. However, more rapid increases in anxiety among Brazilian youth may reflect context specific risk factors. Persistence or emergence beyond early childhood was critical for identifying later diagnostic risk in both settings, highlighting the importance of early monitoring and intervention.

Relatively little is known regarding suicide among older adults in nursing homes. The aim of this study was to compare the incidence of suicide among older nursing home residents (NHR) with community-dwelling older people (CDP) using newly available, national, individual-level register data, and to assess differences with regard to socio-demographic characteristics. We obtained data on all older adults aged 65+ who were living in Austria at the end of October 2018 (n=1,665,450), including 155,020 NHR. Death by suicide was followed until the end of 2023. A total of 114 and 2,136 suicides were observed among NHR and CDP; corresponding to cumulative incidences of 14 and 27 per 100,000, respectively. Among NHR, suicide incidence was higher among males (28.0, 95% CI=22.1, 35.5), those aged 65-74 years (20.2, 95% CI=13.3, 30.6), with tertiary education (23.3, 95% CI=10.6, 50.6), divorced (25.0, 95% CI=16.2, 38.5), and residing in urban nursing homes (22.0, 95% CI=17.0, 28.4). Compared to CDP, more suicides in NHR occurred by poisoning and but few by firearms. In conclusion, we found that suicide incidence was lower among older NHR compared to CDP. More research on and preventive efforts against suicide among older NHR are needed.

Background: Previous trauma research includes many limitations, such as the scarcity of pretraumatic health measurements and assessment of traumatic experiences with a broad scope across the lifespan. To respond to these gaps, we aimed to develop a new, prospective, population-based trauma dataset from childhood to middle age. Methods: We used the Young Finns Study that is a population-based, multi-generational, prospective study (n = 3596 for the main generation). It has started in 1980 (baseline assessment) and includes follow-ups in 1983, 1986, 1989, 1992, 1997, 2001, 2007, 2011/2012, and 2018-2020. From the 38-year follow-up and ten measurement points of the YFS, we collected all relevant trauma variables, including both free-format and structured questions that both the participants and their parents responded to. By a data-driven case-to-case analysis, we developed a scale to numerically capture variation in the quality of the experiences. Results: Our final dataset captured a total of 7769 traumatic experiences. We also developed the Traumatic Experience Severity Scale (TESS), including six subscales such as shamefulness, rarity, danger to life or health, effects on everyday life, human-made physical threat, and whether the target person was within or outside one's household. We also preprocessed the dataset to be later easily interleaved with other psychological, cardiovascular, and epigenetic variables of the YFS. Conclusions: We believe this new trauma dataset with thousands of experiences across the lifespan provides new opportunities to multidisciplinary, lifelong trauma research.

Background. UK clinical guidance recommends that structured risk prediction tools and risk stratification should not be used in self-harm, to predict suicide or determine who is offered treatment. Underpinning this position is the premise that routinely collected health data contain no useful predictive signal, which has received little direct scrutiny. Objective. To test whether routinely collected electronic health record data can distinguish groups at higher and lower risk of severe outcomes following paracetamol overdose. Methods. We analysed 4,095 adults presenting to NHS Lothian emergency departments with paracetamol overdose (2017-2023). Elastic-net logistic regression was fitted to 37 routinely collected electronic health record features to predict a composite of death or mental health inpatient admission at 0-7, 8-30 and 31-365 days following attendance, evaluated on a held-out 20% test set with bootstrapping. Findings. Events occurred in 5.5% of patients at 0-7 days, 2.0% at 8-30 days and 7.9% at 31-365 days, dominated by mental health admission. Bootstrap AUROC 95% confidence intervals lay above 0.5 in every window (0.65-0.82, 0.63-0.90, 0.71-0.85): models ranked patients better than chance. Calibration slopes (1.04, 1.14, 1.07) were close to one. Ranking drew primarily on mental health-related features. Conclusions. Routinely collected health data carried predictive signal for severe outcomes after paracetamol overdose, although discrimination fell short of what is needed for individual-level clinical use. Clinical implications. These models are not proposed for clinical deployment; however, treating risk prediction as a settled question will redirect research efforts, potentially excluding this patient population from machine learning advances driving improvements in care in other medical specialties.

Background Childhood adversity can affect propensity to risk-taking behaviors. We aim to investigate the relation between childhood adversity and risk-taking behaviors in youth using emergency room (ER) admissions and survey data. Method Using the DANLIFE study, we included 1.2 million Danes. Individuals were assigned into five groups based on childhood adversity exposure from ages 0 to 15 years. We applied survival analyses on repeated outcomes to model ER-admissions due to substances, violence and unintentional injury in the full cohort between ages 16 and 24. We applied logistic regression models to weighted survey data on frequent binge drinking, cannabis use, drug use, and unsafe sex in a nested subsample of 34,064 18 year olds from the Danish National Birth Cohort. Results The high adversity group was at highest risk of ER-admissions due to substances (HR=3.27, 95% CI [3.10, 3.46]), violence (HR=2.67, 95% CI [2.58, 2.76]) and unintentional injuries (HR=1.30, 95% CI [1.28, 1.33]). In the nested subsample, the high adversity was at highest risk of cannabis use (OR=1.59, 95% CI [1.21, 2.09]), drug use (OR=2.44, 95% CI [1.71, 3.49]) and unsafe sex (OR=1.72, 95% CI [1.34, 2.22]), but at lower risk of frequent binge drinking (OR=0.57, 95% CI [0.37, 0.87]). Conclusion These findings highlight how childhood adversity is associated with increased engagement in and harm from risk-taking behaviors. To prevent inequalities in health in youth, there is a need for interventions and policies that promote child welfare, as well as targeted support for youth with harmful behavioral patterns.

Stress-related disorders are among the most common and burdensome mental health conditions worldwide, yet the mechanisms that allow most trauma-exposed individuals to maintain or regain mental health remain poorly understood. Decades of research have focused on identifying risk factors for psychopathology rather than the active processes that promote resilience and recovery. Here, we present the study protocol for Stress and Trauma Resilience: Opportunities for National Growth (STRONG), a multi-tiered, multi-domain, multi-level investigation of resilience conducted in Israel in the aftermath of the October 7, 2023 attack and the prolonged national adversity that followed. STRONG uses a nested design that integrates nationally representative longitudinal data with in-depth neurobehavioral assessment. STRONG-1 is a longitudinal, population-based study of approximately 4,600 Israeli adults assessed across five waves over three years, characterizing individual, social, and societal predictors of resilience trajectories. STRONG-2 is a controlled laboratory study of highly resilient and highly vulnerable individuals selected from STRONG-1, assessing behavioral and physiological mechanisms alongside cognitive tests and ecological momentary assessment. STRONG- 3 examines a subset of these individuals in the MRI scanner, capturing structural and functional neural markers with synchronized physiological and eye-tracking data. Advanced computational approaches will integrate data across tiers, levels, and domains into predictive models of resilience. STRONG will establish Israel's first nationally representative dataset on stress resilience and provide a rare opportunity to study human adaptation at scale and in a real-world context. These findings will inform early detection strategies and the development of empirically grounded, modifiable targets for intervention.

Importance Childhood sexual abuse (CSA) is linked to adverse psychiatric outcomes in adulthood, but evidence on its association with cardiovascular disease and mortality from large, diagnostically ascertained cohorts remains limited. Objective To assess the 10-year risk of all-cause mortality, suicide or self-harm, drug overdose or poisoning, and cardiovascular disease among patients with a diagnosed history of CSA compared with a matched unexposed cohort. Methods In this retrospective cohort study, we used deidentified electronic health record data from 68 health care organizations in the TriNetX US Collaborative Network. Patients diagnosed with confirmed or suspected childhood sexual abuse (CSA) before age 18 between January 1, 2003, and December 31, 2015, who had a subsequent adult encounter, were propensity score matched 1:1 with unexposed patients on age, sex, race and ethnicity, and baseline psychiatric and medical comorbidities (n = 9,083 per cohort). Outcomes--all-cause mortality, suicide or self-harm, drug overdose or poisoning, and cardiovascular disease--were assessed over 10 years from the index adult encounter using risk and time-to-event analyses to estimate risks, risk ratios, and hazard ratios. Results Among 18,166 matched patients (mean [SD] age, 19.0 [2.0] years; 14,813 [81.6%] female), CSA was associated with significantly elevated risk of suicide or self-harm (5.1% vs 2.8%; risk ratio [RR], 1.84; 95% CI, 1.57-2.16), drug overdose or poisoning (5.5% vs 3.7%; RR, 1.47; 95% CI, 1.28-1.69), and cardiovascular disease (12.3% vs 9.3%; RR, 1.31; 95% CI, 1.20-1.44), with concordant hazard ratios (all P < .001). All-cause mortality was numerically higher but not statistically significant (0.5% vs 0.4%; RR, 1.16; 95% CI, 0.75-1.79; P = .51). Conclusions and Relevance A diagnostically confirmed history of CSA was associated with substantially elevated 10-year risk of self-harm, overdose, and cardiovascular disease, independent of baseline demographic and psychiatric comorbidity. These findings support integrated psychiatric and cardiovascular screening for adult survivors of CSA and trauma-informed care extending beyond mental health services alone.

Background: Adolescent suicide is a leading cause of death in Australia, arising from multiple determinants. Psychological distress, lifestyle behaviours and socioeconomic factors are associated with adolescent suicidality. Existing research has predominantly employed cross-sectional designs, limiting our understanding of how these factors interact over time. Longitudinal and data-driven approaches are needed to help identify the factors associated with the emergence of suicidality throughout adolescence. Method: Participants aged 12-17 years completed longitudinal measures of suicidal ideation, psychological distress, sleep quality, mindfulness, physical activity, eating habits, and social connectedness. Subgroups were determined via hierarchical cluster analysis, based on average scores across later timepoints (9-15). ANOVA and pairwise effect size calculations were used to compare clusters across variables, and their preceding developmental trajectories were examined using generalised additive mixed models (across earlier timepoints; 1-8). Clusters were also compared on self-reported wellbeing, long-term suicidality, and socioeconomic status. Result: Three clusters characterised by low-, moderate-, and high-severity of suicidal ideation and psychological distress, and poorer sleep, social connectedness, physical activity, mindfulness, and eating habits were identified. Across earlier timepoints, the high-severity group showed consistently elevated suicidality and deteriorating wellbeing and lifestyle scores. Conclusion: Youth with high levels of suicidality had greater psychological distress, lower wellbeing, lower socioeconomic status, and poorer lifestyle behaviours. This subgroup was also found to have poorer scores on wellbeing and lifestyle factors in their early adolescence. Findings highlight the importance of early, preventative interventions targeting both mental health and lifestyle factors to reduce suicidality in adolescents.

Purpose: Involuntary psychiatric hospitalization under court orders requires careful balancing of legal obligations and clinical needs. Identifying factors that influence the length of these hospital stays helps clarify the relationship between legal frameworks and psychiatric treatment. This study aims to describe the socio-demographic, clinical, and legal profiles of individuals hospitalized under court warrants and to identify factors independently associated with the duration of forensic hospitalization. Methods: A retrospective study was conducted on 119 patients discharged between 2018 and 2023. Data were collected from medical and legal records, including socio-demographic details, psychiatric diagnoses, offense types, hospital stay lengths, and legal proceedings. Results: Most patients were men (91.6%) diagnosed with schizophrenia or schizoaffective disorder (97.5%), with high rates of comorbid substance use disorder (79.0%) and unemployment (85.7%). The median hospital stay was 19.0 months, representing 40% of the maximum statutory sentence. Patients with low-severity offenses served a larger share of their maximum sentence (47%) than those with high-severity offenses (24%). Time to first discretionary leave was the strongest predictor of total stay duration in univariable analysis. Conclusion: The finding that patients with minor offenses have longer hospital stays than those with serious offenses confirms that clinical factors, rather than offense severity, primarily influence discharge decisions. These findings support moving toward personalized, clinically focused, and family-inclusive forensic discharge planning while maintaining public safety.

Bipolar disorder (BD) is a chronic psychiatric condition affecting approximately 1-2% of the population, characterized by depressive and manic episodes. BD comprises two main subtypes, defined by the presence of mania (BD-I) or hypomania (BD-II). Commonly used clinical scales, including the Global Assessment of Functioning (GAF), Clinical Global Impressions (CGI), and World Health Organization Disability Assessment Schedule (WHODAS), assess functional impairment at the time of evaluation. However, they may not adequately capture cumulative lifetime illness burden or provide a retrospective measure of clinical severity. Here, we introduce the Index of Number of Events and Severity (INES), a novel instrument designed to quantify longitudinal illness-course severity in BD by integrating cumulative clinical events with illness duration. INES incorporates psychosis and rapid cycling as dichotomous variables and quantifies hospitalizations, suicide attempts, and affective episodes as discrete categories. INES was evaluated in 307 individuals from the MadManic cohort. It correlated moderately with GAF and CGI, while its strongest association was observed with WHODAS (r=0.347). Factor analysis over the four scales supported a two-factor structure, where INES loaded alongside WHODAS, capturing the variability of structured instruments. Linear modelling indicated that traditional scales explained only 14.4% of the variance of INES, suggesting that this scale captures clinical information largely unaccounted by the other instruments. INES was the only to differentiate between BD subtypes, with higher severity observed in individuals with BD-I. These findings support INES as a reproducible tool for capturing cumulative lifetime severity in BD, with potential utility in clinical and genetic studies.

Background: Personality change is a debilitating consequence of traumatic brain injury (TBI), yet its prevalence, characteristics, and treatment remain poorly understood. Methods: We completed a pre-registered (CRD42023440990) systematic review and meta-analysis searching four databases (MEDLINE, PsycINFO, EMBASE and CINAHL) for primary studies assessing personality change after TBI. We synthesised conceptualisation, prevalence, longitudinal outcome, lesion location and treatment. Prevalence was estimated using a random effect meta-analysis using the Paule-Mandel estimator, with subgroup, meta-regression and robustness analyses. Results: 101 studies were included in this review, seventeen of which were suitable for meta-analysis. Personality change was defined inconsistently although common symptoms involved the emergence or increase of affective, behavioural, and social disturbances, including irritability, depression, emotional instability, anger outbursts, social withdrawal, anxiety, impulsivity, restlessness, aberrant motor behaviours, and aggression. The prevalence of secondary personality disorder was estimated as 29.1% (CIs 22.5% - 36.2%) and prevalence of broad personality change was 68.1% (CIs 53.4% - 81.2%). Robustness analyses showed that the estimate for broad personality change should be treated with caution as it was unstable when adjusted for risk of bias and potential publication bias. Follow-up studies, although of varying quality, consistently showed personality change remained stable over long follow-up periods. The relationship between personality change and specific lesion locations in TBI remains unclear, likely due to the poor methodological quality of studies examining this association. Perhaps most concerning, there is limited evidence and very few systematic studies addressing treatment. Conclusion: Personality change is a common and persistent consequence of TBI. Varying definitions, and the lack of high-quality lesion mapping studies and systematic investigations into treatment highlights critical gaps in understanding and management.