Social Psychiatry and Psychiatric Epidemiology

Aim: Schema Therapy (ST) is an evidence-based treatment for complex mental health problems rooted in early Adverse Childhood Experiences (ACEs). Although both individual and group formats have shown effectiveness, little is known about which format works best for whom. This question is particularly relevant for adolescents given their unique developmental needs. Despite over a decade of clinical experience with ST in adolescents, current research offers limited guidance on how to tailor the format to individual needs - resulting in a persistent gap between research and practice. This study aims to develop practice-based indication criteria for individual versus group schema therapy by integrating therapists expertise with experiences from adolescents who underwent ST. Methods: This qualitative study employs a constructivist Grounded Theory approach. Data will be gathered through focus group discussions with schema therapists and individual interviews with adolescents. Therapists will be purposively selected based on experience with both therapy formats and with traumatized adolescents. Adolescents are eligible if they have experienced ACEs and have completed at least 20 sessions of ST. Results: The analysis will result in a theoretical model that integrates therapists clinical reasoning and adolescents preferences. Conclusions: This study integrates schema therapists expertise and adolescents lived experiences to develop actionable indication criteria for choosing between individual and group ST. By supporting informed clinical decision-making, the findings contribute to treatment personalization in adolescent ST and address key challenges such as suboptimal outcomes and treatment dropout. Moreover, the identified criteria provide a foundation for future quantitative validation.

Background: Adolescent mental health disorders represent a growing public health concern globally, with a substantial proportion of young people experiencing unmet mental health needs. Despite this burden, help-seeking behavior among adolescents remains low, particularly in low- and middle-income countries (LMICs), where structural, social, and cultural barriers persist. In Tanzania, limited context-specific evidence exists on factors influencing mental health help-seeking among adolescents, particularly within school settings. Methods: A cross-sectional qualitative study was conducted among adolescents aged 15-19 years attending secondary schools in Moshi Urban, Kilimanjaro region, Tanzania, between April and May 2025. A total of 11 participants, including students, teachers, a school administrator, and a school healthcare provider, were recruited using convenience sampling. Data were collected using semi-structured questionnaires and focus group discussions, and audio-recorded for accuracy. Transcripts were analyzed using thematic analysis, following a systematic six-step approach. Codes were organized into subthemes and overarching themes. Results: Three major themes emerged: facilitators, barriers, and suggested strategies for improving mental health help-seeking behavior. Key facilitators included the presence of school-based support systems, encouragement from trusted individuals (peers, parents, and teachers), perceived severity of mental health problems, and positive experiences from others. Major barriers included lack of trust and concerns about confidentiality, fear of information disclosure, stigma and fear of judgment, rigid school schedules, and poor teacher-student relationships. Participants highlighted the need for confidential, professionally led counselling services, increased mental health education, strengthened school-based programs, and improved access to mental health information as critical strategies to enhance help-seeking behavior. Conclusion: Mental health help-seeking behavior among adolescents in Moshi Urban is influenced by a complex interplay of interpersonal, institutional, and individual factors. While supportive environments and social networks facilitate help-seeking, persistent barriers particularly related to trust, confidentiality, and stigma limit access to care. Strengthening school-based mental health services, improving mental health literacy, and ensuring confidential, youth-friendly support systems are essential to enhance help-seeking behavior and improve adolescent mental health outcomes in Tanzania and similar settings. Keywords: Adolescents; mental health; help-seeking behavior; qualitative study; Tanzania; barriers; facilitators; school-based interventions

Background: Body-focused repetitive behaviours (BFRBs), including hair pulling, skin picking and nail biting, are common but under-recognised behaviours that often emerge during adolescence. Their prevalence, associated distress, and relationship with mental health and social factors remain poorly characterised. Methods: 5,437 adolescents aged 11-18 years reported engagement in BFRBs, associated distress, and functional interference as part of the 2025 OxWell Student Survey. Participants. Problematic BFRBs were defined as at least one BFRB with moderate or high distress. Associations with gender, neurodivergence, bullying, and internalising symptoms were examined using multivariable logistic regression. Results: Overall, 58.5% of participants reported at least one BFRB. Nail biting was most common (43.6%), followed by skin picking (31.3%) and hair pulling (14.5%). Among those with BFRBs, 22.2% reported moderate-to-high distress, and 3.3% of the total sample reported the highest level of distress. Co-occurrence was common: more than half of those with BFRBs reported multiple behaviours. BFRBs were more common and more distressing in girls and trans/gender-diverse participants than in boys. Problematic BFRBs showed strong associations with internalising symptoms (6.3% in the normal range vs 34.2% in the clinical range) and bullying (9.6% with no bullying vs 27.1% with >weekly bullying). Internalising symptoms were the strongest predictor in multivariable models (OR 1.97 per 10-point increase), alongside independent contributions from gender and frequent bullying. Conclusions: BFRBs are common in adolescents, frequently co-occur, and are strongly associated with emotional distress and social adversity. Recognition of distress, rather than behaviour alone, may be important for identifying unmet need and guiding intervention.

Background Little is known about the provision of diagnoses to young people with mental health disorders. We investigated diagnosis provision by NHS mental health services, focusing on 17-year-olds in South London between 2009-2024, and compared with estimated disorder prevalence. Methods To examine diagnosis provision in the population, we extracted diagnosis data from records of the NHS mental healthcare provider serving South London, using the Maudsley Biomedical Research Centre Clinical Record Interactive Search application; we then compared these data with the corresponding population size, obtained from the Office for National Statistics. To assess diagnosis provision in those with mental health disorders, we compared diagnosis data with the number of young people estimated to have met criteria for a disorder, derived from epidemiological interview data collected in the Environmental Risk (E-Risk) Longitudinal Twin Study and weighted according to characteristics of 17-year-old South Londoners. To assess diagnosis provision in those with mental health disorders within health services, we compared diagnosis data with the number estimated to have met criteria for a disorder and used any health service for their mental health, again derived from weighted E-Risk Study data. Findings Of 17-year-olds from South London in 2009-2024, 4.0% (n=8,958/223,404) had a diagnosis in mental health records during the previous year. This diagnosis provision covered <1 in 16 of those estimated to have had a mental health disorder, and <1 in 4 of those estimated to have also used health services. Diagnosis provision was lower in girls than boys and in young people with Black/Asian/Mixed/Other ethnicity than those with White ethnicity, in those estimated to have had a mental health disorder and used health services. Interpretation These findings demonstrate gaps and biases in mental health diagnosis provision for young people, including within health services, and reveal the imperative need to strengthen young people's mental healthcare.

Background Autistic people experience disproportionately high rates of co-occurring mental illness and suicide, yet mental healthcare services routinely fail to meet their needs. Patients unrecognised as autistic are at risk of ineffective or harmful treatment. Autistic psychiatrists occupy a unique position: as members of both medical and autistic communities, they offer dual insider perspectives that may directly shape patient outcomes. Despite being the second largest specialty group in Autistic Doctors International (ADI), this workforce remains largely unrecognised and underutilised. This study examines autistic psychiatrists' perspectives on mental healthcare for autistic people. Methods Loosely structured interviews were conducted with seven senior autistic psychiatrists across child and adolescent, adult, and liaison psychiatry, recruited from a psychiatry-specific subgroup of ADI. Data were analysed using reflexive thematic analysis: codes related to patient care and mental health services were extracted and analysed as a focused subset. Outcomes Nine themes were identified: autistic-to-autistic therapeutic rapport; benefit of recognition and diagnosis; early recognition and education as preventive factors; iatrogenic harm from non-recognition and systemic pathways to misdiagnosis; knowledge gaps and stereotypes; inaccessible services; resource constraints and diagnostic thresholds; autistic psychiatrists as an underutilised resource; and pathways to change. Interpretation Autistic psychiatrists' dual insider positionality affords a unique and under-acknowledged vantage point on what autistic patients experience and where mental healthcare fails them. The mental health burden autistic people carry is substantially shaped by systems not designed for them. Embedding neurodiversity-affirmative practice, closing training gaps, reforming diagnostic pathways, and recognising autistic psychiatrists as a clinical and epistemic resource offer a coherent pathway to improving mental health outcomes for autistic people.

Background: While growing enthusiasm for the therapeutic potential of classic psychedelics has led to a rise in non-clinical use, attention to persisting adverse effects has emerged with delay. A subset of individuals reports persisting complications such as hallucinogen persisting perception disorder (HPPD), depersonalization/derealization disorder (DDD), anxiety and depression. Yet few medical services are equipped to address these complications. Aims: This qualitative study examines how societal, medical, and media discourses shape the experiences of individuals with persisting psychedelic-related complications, focusing on help-seeking trajectories. Methods: Thirteen semi-structured interviews with adults experiencing persisting psychedelic-related psychological symptoms (four women, nine men, age 19-49 years; HPPD (n = 10), DDD (n = 6), depression (n = 1), and anxiety (n = 1)) were conducted within a larger study on these complications. Data were analysed using reflexive thematic analysis. Reporting followed the COREQ guidelines. Results: Three interrelated themes emerged: (1) The dissonance between expectation and harm - idealised media and scientific portrayals of psychedelics shaped initial use and complicated recognition of adverse outcomes; (2) Stigma, silence, and self-blame - prohibitionist discourse and internalised shame significantly inhibited help-seeking; and (3) Between systemic absence and self-organised support - participants encountered clinical unpreparedness and epistemic dismissal, which often led them to rely on online peer communities and self-management strategies. Positive clinical encounters, characterised by professional expertise and nonjudgmental engagement, were experienced as helpful. Conclusions: Adequate clinical and conceptual frameworks for persisting psychedelic-related complications are lacking. An interdisciplinary, experience-informed approach integrating realistic risk communication, clinician training, and destigmatisation is required to support affected individuals.

Objective: Biopsychosocial models recognize multiple determinants of post-trauma mental disorders, but their relative and interactive effects remain unclear. We quantified the independent contribution of traumatic event severity, preexisting vulnerability, social support, and coping capacity, and tested mediation pathways. Methods: In a Brazilian clinical sample reporting traumatic or stressful events (N = 612), constructs were operationalized as composite scores and a dichotomous clinical outcome was derived from intake assessments. Logistic regression (n = 594) and structural equation modeling evaluated prediction and mediation. Results: Vulnerability was the strongest risk factor (OR = 1.46, p < .001) and social support the main protective factor (OR = 0.60, p < .001). Traumatic event severity remained an independent predictor (OR = 1.39, p < .001), whereas coping capacity was not significant (OR = 0.94, p = .410). Discrimination was good (AUC = 0.80). Mediation indicated vulnerability reduced social support and coping capacity, with a significant indirect effect via social support. Conclusions: Findings support a multifactorial model centered on a triad of vulnerability, social support, and traumatic exposure. Risk is shaped primarily by preexisting vulnerability and relational context, alongside a direct trauma effect, providing a clinically relevant framework for assessment and intervention.

Background: This study examined the association between caregiving demands and depression symptoms among caregivers of individuals with Down syndrome during the COVID-19 pandemic. Method: We conducted an online survey of 200 caregivers of children and adults with Down syndrome, including demographic data, the Patient Health Questionnaire-8 (PHQ-8), and questions about lack of childcare and taking over instruction during the pandemic. A multiple linear regression analysis identified predictors of caregiver depression symptoms. Results: Household income (B = -3.45, p < .001) and having to take over instruction (B = 2.24, p < .001) were significant predictors of PHQ-8 scores. Child age, caregiver gender, difficulty paying for health insurance, and lack of childcare were not significant predictors. Conclusions: Lower income and instructional caregiving demands were associated with higher depression symptoms among caregivers of individuals with Down syndrome, suggesting potential targets for policy and intervention during future public health emergencies.

Objectives To explore caregiver and clinicians perspectives on implementing mental health conversations and supports for caregivers of children with chronic conditions in paediatric outpatient clinics. Specifically, views were sought on (a) screening approaches and measures (phase 1) and (b) how feedback and support could be provided to caregivers experiencing mental health difficulties (phase 2). Methods Caregivers and clinicians from two outpatient clinics (neuromuscular and diabetes) at a tertiary paediatric hospital in Melbourne, Australia participated in online focus groups in July and August 2024. Caregivers were recruited from outpatient clinics and clinicians were recruited via email. Both groups were combined for phase 1 before separating into breakout rooms for phase 2. Two authors conducted reflexive thematic analysis of transcripts using NVivo. Results Sixteen participants (caregivers n = 8; and clinicians n = 8) took part in in two semi-structured focus groups. Analysis generated two overarching domains, each comprising multiple themes. Domain 1, Addressing caregiver mental health, captured themes of overwhelm and invisibility, diverse caregiving roles, and the need for time and resources to support wellbeing conversations. Domain 2, Housing the mental health conversation, encompassed themes of screening preferences, caregiver agency in confidentiality, delivery of feedback, and access to tailored supports. Conclusions Caregivers and clinicians support routine caregiver mental health discussions in paediatric outpatient settings. Caregivers favour screening at diagnosis and key transitions, with clear, and actionable feedback delivered away from the child. Questions about record-keeping warrant further exploration, as do the perspectives of fathers.

Background: Biopsychosocial factors associated with functional changes, including changes in personality, communication, movement, and weight, were evaluated in individuals with Down syndrome (DS) during the COVID-19 pandemic. Method: Caregivers of individuals with DS (aged [&ge;]12, n = 118) completed an online survey. Elastic net regression with bootstrap resampling assessed 31 candidate predictors. Results: Pandemic-related mental health was most strongly associated with functional changes ({beta} = 0.388). Healthcare access barriers were also reliably selected: inability to access mental health treatment, difficulty affording insurance, difficulty accessing specialists, and residing in a low-income health professional shortage area. The model explained 35.2% of variance. Conclusions: Mental health and healthcare access barriers were biopsychosocial correlates of functional changes for people with DS during COVID-19.

Background Escalating mental health service demands have created a need to better identify young people most likely to require continued support from mental health services at the transition between childhood and adulthood. Anxiety is the most common adolescent mental health condition, yet its clinical significance and prognosis are not well understood. We aimed to examine the risk of young adult-onset psychiatric disorders in individuals with an adolescent anxiety disorder, and identify stratifiers of risk of subsequent psychiatric disorders in this group. Methods Individuals from the Norwegian Mother, Father, and Child Cohort Study (MoBa) with linked health records and aged 18 or over as of the 31st December 2023 were included. Those diagnosed with any ICD-10 anxiety disorder when aged 10-17 years were defined as having an adolescent anxiety disorder (n=2107, controls n=47,582). Polygenic scores (PGS) for psychiatric and neurodevelopmental conditions were calculated using LDpred2. Anxiety, comorbidities, and parental psychiatric history were defined through linked ICD-10 diagnoses. Sex was defined through linked records. Individuals were defined as having a young adult-onset psychiatric disorder if they first received any new psychiatric diagnosis aged 18-24. Results Adolescent anxiety diagnosis was associated with increased risk of all adult-onset psychiatric disorders (HR= 2.33-8.65). Post-traumatic stress disorder PGS, parental history of severe mental illness, and female sex were associated with increased risk of transition to a young adult-onset psychiatric disorder in people with an adolescent anxiety disorder. Conclusions Adolescent anxiety greatly increases the risk of a psychiatric disorder during the transition to adult life. Clinicians should consider female sex and parental psychiatric history when prioritising young people with anxiety for adult mental health service support. Future research needs to further consider whether polygenic scores would aid risk stratification in clinical practice.

Background: Observational studies have consistently reported associations between social media use (SMU) and poorer mental health outcomes; however, such designs cannot establish causality. This study synthesised evidence from randomized experiments to estimate the effects of restricting SMU on mental health outcomes. Methods: A systematic search was conducted across MEDLINE, Embase, PsycINFO, and Cochrane CENTRAL to identify experimental trials evaluating interventions that constrained SMU for at least 24 hours and included an unconstrained control condition. Multilevel random-effects meta-analyses were used to synthesise effect estimates. Prespecified meta-regressions explored study-level moderators, and population-level impact fractions were estimated relative to global SMU prevalence. Results: From 7,784 screened records, 37 reports representing 35 distinct studies were included (pooled N = 7,160). Most interventions lasted one to three weeks and targeted college-aged youth. Pooled estimates favoured SMU constraints across outcomes, with magnitude and precision varying by domain. Confidence intervals were entirely above zero, consistent with a beneficial response for depressive symptoms (g = 0.22; 95% CI, 0.12 to 0.32), perceived stress (g = 0.15; 95% CI, 0.01 to 0.29), anxiety symptoms (g = 0.19; 95% CI, 0.05 to 0.34), fear of missing out/nomophobia (g = 0.14; 95% CI, 0.04 to 0.24), and well-being (g = 0.36; 95% CI, 0.10 to 0.63). Heterogeneity was substantial for several outcomes (I2 > 75%). In bivariate meta-regressions, higher baseline SMU was associated with larger effects for anxiety symptoms ({beta} = 0.13; 95% CI, 0.03 to 0.22), and longer interventions were associated with larger effects for depressive symptoms ({beta} = 0.16; 95% CI, 0.02 to 0.30). Inferences revealed that a short-term reduction in SMU globally could plausibly mitigate 17.5% and 15.4% of depressive and anxiety symptom cases, respectively. Conclusions: Experimental design-based evidence supports the causal case for an effect of SMU on mental health, with constraints producing improvements across multiple outcomes and no evidence of harm. Population-level inferences suggest that even individually modest effects may translate into meaningful public health benefits given the high prevalence of SMU exposure. These findings suggest that reducing SMU may represent a low-intensity, low-cost, scalable strategy to support mental health and improve well-being.

Introduction: Youth mental health presentations are largely heterogenous, making it difficult to match individuals to the most appropriate interventions. Personalised, measurement-based care has the potential to improve clinical decision-making and support shared decision-making, but remains challenging to implement in routine practice. Advances in digital monitoring and causal modelling offer new opportunities to identify individual-level processes driving mental health difficulties and to generate personalised decision-support. This pilot study aims to evaluate the feasibility and acceptability of the Minding Your Mind computational decision-support approach, a newly developed approach integrating routine outcome monitoring, individual-level causal modelling, and personalised feedback to support shared decision-making between young people and their clinicians. Methods and analysis: The study involves two phases. Phase 1 will recruit young people aged 15-25 years and mental health clinicians to participate in workshops to co-design the decision-support approach and its implementation into routine practice. Phase 2 is a prospective, single-arm feasibility study involving young people receiving mental health care and their treating clinicians. Primary outcomes include feasibility, acceptability, appropriateness, and usability of the decision-support approach, assessed via self-report and objective process indicators. Secondary outcomes include changes in use and experiences with shared decision-making, and clinical and functional outcomes. Quantitative analyses will be primarily descriptive, with exploratory pre-post comparisons and sensitivity analyses. Qualitative interviews will explore user experiences and implementation barriers and facilitators. Ethics and dissemination: This study has been approved by the Sydney Local Health District (RPAH Zone) Human Research Ethics Committee (X25-0341). All participants will provide informed consent prior to participation. Findings will be disseminated through peer-reviewed publications, conference presentations, and accessible summaries co-developed with young people with lived experience.

Background: Adults with severe mental health conditions (often referred to as severe mental illness, SMI) experience 15 to 20 year mortality gap relative to the general population, with lung cancer a significant contributor. National cancer policy targets earlier diagnosis but does not explicitly address how pathways function for this group. Aims: This study aimed to describe lung cancer risk, prevalence, screening eligibility, referral activity and diagnostic pathway performance for adults with SMI in South East London (SEL), and to examine where along the pathway inequalities arise. Methods: Co-designed with experts with lived experience and voluntary sector, this exploratory mixed-methods service evaluation combined quantitative analysis of routinely collected data from the Quality Outcomes Framework (QOF), SMI Register and Cancer Waiting Times Record (April 2023-March 2024) with semi-structured qualitative interviews (n=11 clinical staff) and focus groups (n=6 adults with lived experience of SMI). Quantitative and qualitative data were analysed using descriptive statistics and framework-based thematic analysis respectively, and findings were integrated using a joint display approach, organised by the Consolidated Framework for Implementation Research (CFIR). Results: Lung cancer prevalence was approximately double among adults with SMI (0.17% vs 0.09% in the general population). Despite Urgent Suspected Cancer (USC) referral rates being more than twice as high in the SMI population (63 vs 28 per 100,000), fewer cancers were detected via planned general practice (GP) routes (11% vs 20%), the 28-day Faster Diagnosis Standard was not met for any SMI patient diagnosed with lung cancer during the study period; overall FDS performance was 76% in the SMI population compared with 84% in the general population; and appointment non-attendance was more than double that in the general population (6% vs 3%). Qualitative findings identified individual, service and system-level mechanisms, including stigma, diagnostic overshadowing, fragmented coordination, and rigid pathway protocols, that compound disadvantage across lung cancer pathway stages. Conclusions: Inequality in lung cancer outcomes for adults with SMI accumulates across the pathway rather than arising at a single point of failure. Addressing this requires proportionate adaptations within existing cancer pathways, alongside routine reporting of cancer outcomes stratified by SMI population. Keywords: severe mental health conditions, lung cancer, health inequalities, cancer screening, diagnostic pathway, mixed methods

Background: Dissociative experiences encompass a variety of discontinuities in awareness and perception that are elevated in the dissociative disorders and associated with extensive comorbid symptomatology. Accumulating evidence points to developmental trauma and trait responsiveness to verbal suggestions (REVS) as factors that confer risk for severe dissociative symptoms, but they have typically been studied in isolation. This study integrated these measures using prediction modelling to better understand their predictive value for the risk of dissociative psychopathology. Method: 1,104 non-clinical participants completed measures of trauma, dissociation and trait REVS. The predictive model was developed using elastic net logistic regression, internally validated with 10-fold cross-validation, and assessed using receiver operating characteristic (ROC) curve and area under the ROC (AUROC). Variables entered into the model were components of REVS, trauma, age, and their interactions. Results: A dissociative psychopathology at-risk group (7%) was characterised by younger age, greater trauma and elevated REVS, particularly involuntariness during cognitive-perceptual suggestions. The prediction model retained nine of ten predictors, with an AUROC of .77 [95% CI: .73, .82], reflecting good discrimination with moderate sensitivity (78%) but modest specificity (67%). Conclusions: These findings reinforce trauma and trait REVS as risk factors for dissociative psychopathology and demonstrate that they can be integrated in a model that can identify at-risk individuals. Further validation and extension of the model is necessary to improve the identification of individuals at risk for severe dissociative symptomatology and the diagnosis of dissociative disorders with implications for outcome trajectories.

Background: Whole-population linked administrative data platforms provide an opportunity to generate evidence on early life multidimensional disadvantage to inform resourcing and service provision to families with complex needs. Methods: We used individual-level de-identified data from nine administrative data sources included in the Better Evidence Better Outcomes Linked Data (BEBOLD) platform. The population included all children born in South Australia between 2004-2011 (n=143,083), and their parents. We described the prevalence and distribution of multiple disadvantages affecting children from the 12 months before birth to age 5. Eleven domains of parental disadvantage were created: economic, education, access to services, mental health, substance misuse, smoking during pregnancy, domestic and family violence, health, child protection contact, justice system contact, and death. We investigated the concordance of our measure with an area-level socioeconomic measure used in government reporting. Results: One in two children (48%) were exposed to at least one disadvantage domain, and one in seven (14%) were exposed to three or more domains before age five. Economic disadvantage was most prevalent, affecting one in four (27%) children, of which 75% were exposed to additional forms of disadvantage. Substance misuse, domestic and family violence, and justice system contact were the least likely domains to occur in isolation. Only 54.4% who experienced five or more disadvantage domains were classified in the area-level socioeconomic measure's 'most disadvantaged' quintile. Conclusion: Early life exposure to parental disadvantage can be highly multidimensional. Measurement across different systems is important for informing coordinated service provision for families with complex needs.

Objectives We aimed to describe the characteristics of children and young people referred to social prescribing across the UK and understand what social prescribing looks like for these young people. Additionally, we aimed to explore whether access to and experiences of social prescribing vary with age and have changed from 2017 to 2025. Overall, we aimed to identify whether social prescribing reduces or exacerbates health inequalities among children and young people, and whether this has changed over time. Design Analysis of social prescribing electronic health records Setting Social prescribing hubs and services across the UK that use Access Elemental (a cloud-based social prescribing platform) Participants 52,585 individuals referred to social prescribing in 2017-2025 aged 4-25 years (mean=20.04, SD=4.71), of whom 57% were female, 39% male, <2% were in other gender groups, and 3% did not disclose their gender Primary and secondary outcome measures We summarised the characteristics of young people and described the care pathway received. We then used regression models to test whether these factors differed by age and over time. Results Most individuals were aged 18 and over, 91% lived in urban areas and 58% lived in the top three most deprived deciles of the UK. Most were referred by GPs or other allied health workers (79%) and mental health was the leading reason for referral (44%). The typical pathway included 4.64 social prescribing contacts (SD=7.70) totalling 66 minutes (SD=108), with 34% receiving an onward referral to community support. The average age of those referred to social prescribing increased over time. Conclusions Our findings indicate that social prescribing currently has limited reach for those under 18 and this disparity may be increasing. It was promising that children and young people referred to social prescribing were more likely to live in deprived areas. However, given current findings, more work is needed to increase the reach of social prescribing for children and young people across the UK.

Mental health problems, including emotional problems, are linked to adverse educational outcomes among children and adolescents. This study examines the association between early onset of mental health problems generally, and emotional problems specifically, at ages 5-14, and outcomes from the General Certificate of Secondary Education (GCSE), a secondary education qualification, at age 16 for 4,783 students in England, using the Millennium Cohort Study dataset linked to the National Pupil Database. We found that the onset of mental health problems at ages 5, 7, 11 and 14 had a significant and negative association with all GCSE outcomes. We also found negative associations between early onset emotional problems and GCSE outcomes, although results were most stark for emotional problems that onset at age 11, with statistically significant negative associations with all GCSE outcomes. School absence was identified as a potential mediator of the negative association. Furthermore, this study found that the potential loss of productivity related to mental health problems in general and emotional problems in particular was over 23,000 sterling and 11,000 sterling per affected individual, respectively, which could translate into approximately 2.57 billion sterling and 1.6 billion sterling, respectively at the population level for England. These findings highlight the importance of early intervention for children and adolescents with mental health problems to improve educational and future outcomes.

Depression remains a major public health concern globally, particularly in low resource settings where access to quality mental health care is limited and treatment outcomes are often suboptimal. In this context, the quality of the clinician patient relationship has been increasingly recognised as a critical determinant of therapeutic success. This study examined the influence of clinician patient therapeutic alliance and relational factors on treatment outcomes among patients with depression in Benue State, Nigeria. A crosssectional correlational design was adopted, involving patients diagnosed with depression and receiving care in selected health facilities. Data were analysed using Structural Equation Modelling to test hypothesised relationships among therapeutic alliance, relational factors, and treatment outcomes. The measurement model demonstrated strong psychometric properties, with all factor loadings exceeding 0.60, composite reliability above 0.90, and adequate convergent and discriminant validity. Results revealed that therapeutic alliance significantly predicted treatment outcomes, while relational factors also had a significant positive effect. Therapeutic alliance further significantly predicted relational factors. The model explained 61 percent of the variance in treatment outcomes. Mediation analysis indicated that relational factors partially mediated the relationship between therapeutic alliance and treatment outcomes, accounting for 29 percent of the total effect. The study concludes that therapeutic alliance, strengthened through trust, empathy, and collaboration, plays a central role in improving depression outcomes. Strengthening relational competencies in clinical practice is therefore essential for enhancing mental health care delivery in Nigeria.

Background: The COVID-19 pandemic caused major disruptions to maternity care, breastfeeding support, and social networks. These changes may have increased the risk of postpartum depression, anxiety, and stress among breastfeeding mothers, a population that has been underrepresented in previous reviews. This systematic review and meta-analysis aimed to compare maternal mental health outcomes among breastfeeding mothers before and during the COVID-19 pandemic. Methods: We searched MEDLINE, EMBASE, AMED, Web of Science, WanFang Data, MedRxiv, WHO COVID-19 databases, and grey literature from database inception to December 2023. Eligible studies compared mental health outcomes in breastfeeding mothers before and during the COVID-19 pandemic using validated assessment tools, including the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder Scale (GAD-7), State-Trait Anxiety Inventory (STAI), or Perceived Stress Scale (PSS). Studies with fewer than 10 participants per group were excluded. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Joanna Briggs Institute checklist or Newcastle-Ottawa Scale, depending on study design. Random-effects meta-analysis was performed when at least two studies reported comparable outcomes. Results: Twenty-three studies involving breastfeeding mothers from 15 countries were included. Meta-analysis showed significantly higher depressive symptoms during the pandemic compared with the pre-pandemic period, measured by EPDS (standardized mean difference [SMD] = 0.21, 95% confidence interval [CI] 0.14 to 0.29). Maternal anxiety measured by GAD-7 was also significantly higher during the pandemic (SMD = 0.27, 95% CI 0.13 to 0.41). Findings for perceived stress were mixed across studies and could not be pooled because of heterogeneity in reporting methods. Limited evidence suggested that mother-infant bonding did not substantially decline during the pandemic despite increased maternal psychological distress. Conclusions: Breastfeeding mothers experienced increased postpartum depression and anxiety symptoms during the COVID-19 pandemic. These findings highlight the importance of maintaining breastfeeding support services, ensuring access to maternal mental health screening, and developing flexible models of postpartum care during future public health emergencies. PROSPERO registration: CRD42022354670.