Social Psychiatry and Psychiatric Epidemiology

BackgroundImproving access to high-quality community-based crisis care and reducing inpatient admissions are key policy objectives in England, yet evidence on who uses crisis-related services and potential inequalities in access remains limited. AimsTo examine socio-demographic patterns in the use of six crisis-related services in England: 1) Crisis phonelines; 2) Crisis cafes; 3) Crisis Resolution and Home Treatment teams (CRHTs); 4) Voluntary inpatient admissions; 5) Compulsory inpatient admissions under the Mental Health Act 1983 (MHA); and 6) conveyance to a Place of Safety (PoS) by police under section 136 of the MHA. MethodWe conducted a retrospective observational study using the Mental Health Services Data Set between 2021/22 and 2023/24. Adults (aged 18+) using any of the six services were included. A multinomial logit regression model was used to estimate the average marginal effects for age, sex, ethnicity, and area-level deprivation, with robust patient-level standard errors and year fixed-effects. ResultsWithin this population using any crisis-related services, adjusted analysis showed people from several ethnic minority backgrounds were more likely to be compulsorily detained or brought to a PoS by police, and less likely to use CRHTs than White individuals, with largest disparities in compulsory admissions for Black (+15.0 percentage points [pp]) and Asian (+7.3 pp) groups. Compulsory admissions were more common among older adults and men (+1.5 pp). Crisis phonelines were less commonly used by older adults, men (-4.8 pp), and people from Black (-15.6 pp) and Asian (-4.7 pp) backgrounds. Crisis cafes showed more even demographic distributions. Although adjusted differences by deprivation were small (all <1.0 pp), over half of all users lived in the two most deprived quintiles. ConclusionsAmong crisis-related service users, demographic groups at greater risk of coercive care are less likely to access community crisis services. Addressing these disparities could improve access and reduce inequalities.

BackgroundUp to one-third of medical inpatients experience clinically relevant mental distress, yet many remain untreated. Stepped and collaborative care (SCC) models may improve access to mental health care, but predictors of service uptake are unclear. We examined patient- and ward-level predictors of psychosomatic-psychiatric consultation (PPC). MethodsWe analyzed data from SomPsyNet, a stepped-wedge cluster randomized trial targeting SOMatic inpatients across three Swiss tertiary hospitals, to prevent PSYchosocial distress by a care NETwork. Analyses focused on inpatients screening positive for mental distress. Multiple-imputed logistic regressions assessed predictors of four sequential service-use stages: PPC considered, offered, accepted, and received. ResultsAmong 589 distressed patients, 93.9% were offered PPC, 63.1% accepted, and 83.9% of acceptors received PPC, yielding a 50% overall receipt rate. Patients without Swiss citizenship showed higher odds of acceptance (odds ratio [OR]=1.82 [1.10, 3.00]) and eventual receipt (OR=1.62 [1.01, 2.62]). Being in a Geriatric ward facilitated PCC uptake, while patients from gynecology showed reduced progression through the care pathway. Age, gender, income, education, marital status, and living arrangement showed no statistically robust associations. ConclusionsAlmost two-thirds of mentally distressed medical hospital inpatients accepted an offered PPC, indicating high acceptability. About half ultimately received a consultation, highlighting substantial attrition along the SCC pathway. Ward specialty and nationality were key determinants of PPC uptake. These findings suggest that proactive, ward-oriented consultation-liaison models embedded in routine inpatient care may improve timely and equitable access to mental healthcare, including for migrant and minority patients who are otherwise less likely to access such care. HighlightsO_LIPsychosomatic-psychiatric consultation pathway of medically hospitalized inpatients C_LIO_LI63% accepted such a consultation when offered; overall 50% reached receipt. C_LIO_LINon-Swiss nationality increased odds of acceptance (OR 1.8) and receipt (OR 1.6). C_LIO_LIPatients at geriatrics wards showed higher, at gynecology wards lower transitions. C_LIO_LIResults support low-threshold, ward-oriented consultation-liaison models. C_LI

ImportanceAs the percentage of young people in the United States identifying as transgender and gender diverse increases, more youth face identity-linked social and structural stigma and discrimination. Little is known about the impact of stigma on psychotic-like experiences in gender diverse youth. ObjectiveTo assess the impact of bullying victimization and state-level policies on psychotic-like experiences among gender diverse youth. DesignIn this prospective cohort study, cross-sectional and longitudinal analyses were conducted using data collected between 2017-2022 across 17 states. SettingThe Adolescent Brain Cognitive Development (ABCD) Study is a U.S. population-based longitudinal study that follows and deeply phenotypes adolescents from the age of 9 to 18. ParticipantsCross-sectional analyses included data from 9,112 participants (mean age=13 {+/-} 0.6) collected between 2019 and 2022. Longitudinal analyses comprised 4,529 participants with data collected across 5 waves between 2017 and 2022. ExposuresSelf-reported frequency of bullying victimization and data on annual state-level policies related to gender identity. Main OutcomesSelf-reported psychotic-like experiences and associated distress, measured by the Prodromal Questionnaire - Brief Child Version. ResultsBased on a dimensional measure of gender, 689 adolescents were identified as most gender diverse (i.e., least congruent with birth-assigned sex) and 8,240 as least gender diverse (i.e., most congruent with birth-assigned sex). Rates of bullying victimization and psychotic-like experiences were significantly elevated in the most vs. least gender diverse group, with bullying partially mediating the difference in psychotic-like experiences (indirect effect = 0.11, p < 2x10-16; direct effect = 0.52, p < 1x10-16). Gender diverse adolescents exhibited greater sensitivity to the effects of bullying on psychotic-like experiences (interaction {beta} = 0.14, 95% CI [0.09, 0.19], p = 8.5x10-08). Moreover, the persistence of unsupportive legislation across 4 years was associated with significantly greater increases in psychotic-like experiences over time in gender diverse youth (interaction {beta} = 0.30, 95% CI [0.20, 0.40], p = 2.2x10-8). ConclusionsThese findings indicate that bullying victimization and unsupportive legislation may explain greater and increasing rates of psychotic-like experiences in gender diverse youth. KEY POINTSO_ST_ABSQuestionC_ST_ABSDo bullying and state-level policy related to gender identity contribute to mental health problems in gender diverse youth in the United States? FindingIn this large U.S.-based sample of adolescents (ages 9-13), gender diverse adolescents reported more frequent experiences of bullying, which partially accounted for increased rates of subclinical psychotic-like experiences (PLEs). Between 2017 and 2022, gender diversity was associated with increasing PLEs only in states with consistently unsupportive policies; in all other states, PLE scores remained stable over time or decreased. MeaningResults suggest that PLEs in the context of gender diversity are partially attributable to the sociopolitical environment and that policy decisions at the state-level have far-reaching impacts on the mental health of youth in the United States.

KEY POINTSO_ST_ABSQuestionC_ST_ABSDid changes in mental health symptoms from pre-COVID-19 to during the pandemic differ by sex or gender? FindingsIn this systematic review and meta-analysis study of findings from 27 unique cohorts, changes from before to during the COVID-19 pandemic in mental health symptoms, including general mental health, anxiety, depression, and stress, were not statistically significantly different by sex or gender. MeaningThere were not likely substantial sex and gender differences in mental health symptom changes during the COVID-19 pandemic. ImportanceConcerns remain about whether COVID-19 affected mental health differently across sex or gender groups. We previously reported that changes in general mental health and anxiety symptoms, but not depression or stress, worsened more for females or women than males or men, but that was based on 12 studies published up to August 2021. ObjectiveTo investigate the sex or gender differences in mental health symptoms before and during the COVID-19 pandemic with updated evidence. Data SourcesMEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv, Open Science Framework Preprints searched to August 31, 2023. Study SelectionEligible studies included change data for general mental health, anxiety symptoms, depression symptoms, or stress from pre-to during COVID-19 by sex or gender. Two independent reviewers reviewed citations for eligibility. Data Extraction and SynthesisStandardized mean differences (SMDs) were extracted for changes of continuous outcomes and proportions for dichotomous outcomes. Two independent reviewers completed data extraction and risk of bias assessment with an adapted Joanna Briggs Institute Checklist for Prevalence Studies. Data were pooled by random-effects models. Main Outcomes and MeasuresDifference in change of SMDs and proportions between sex or gender groups pre-COVID-19 to COVID-19. ResultsWe included data from 27 unique cohorts (N = 102 to 18,127). Change differences by sex or gender were minimal and not statistically significant: general mental health (SMD changewomen-men = 0.01, 95% confidence interval [CI]:-0.07 to 0.10; proportion changewomen-men = -0.03, 95% CI: -0.08 to 0.03), anxiety (SMD changewomen-men = 0.09, 95% CI -0.04 to 0.22; proportion changewomen-men = -0.05, 95% CI: -0.20 to 0.11), depression (SMD changewomen-men = 0.10, 95% CI: -0.00 to 0.20; proportion changewomen-men = -0.13, 95% CI: -0.81 to 0.55), and stress (SMD changewomen-men = -0.08, 95% CI -0.16 to 0.01, proportion changewomen-men = 0.04, 95% CI -0.10 to 0.17). No studies reported eligible mental health outcomes for gender minorities. Conclusion and RelevanceWe found no significant sex or gender differences in mental health changes. Future research should report outcomes for gender minority groups, even if small numbers, to support evidence synthesis. RegistrationPROSPERO (CRD42020179703)

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

ObjectiveThis study aimed to identify characteristics that define population need groups with similar mental health service needs within prisons and describe the mix of services required to meet those needs. MethodsMixed methods were used, including three iterative, semi-structured focus groups, followed by an online survey, seeking information on the characteristics that define service needs, how these can identify groups of people who require mental health care in prisons and the services required by each group. Participation was sought from prison health services, prison mental health services, non-government service partners and people with a lived experience. Focus group transcripts and free text survey responses were thematically analysed. Descriptive statistics were generated for online survey responses to Likert Scales to determine the levels of agreement with survey content. ResultsThe characteristics and service needs of four distinct population groups who require mental health care in prisons were defined: indicated prevention, mild, moderate, severe and complex. These groups were delineated using characteristics including presence of a diagnosed mental illness, level of functional impairment, presence of added complexity and service response required. The required service mix varied across need groups, however service types common across all groups included assessments, psychological therapies, peer support, lifestyle interventions and carer support. ConclusionsThe identified need groups and service descriptions will contribute to the evidence required for needs-based planning of mental health care in Australian prisons. This information can be used for planning a responsive, equitable, and needs-based mental health service system within custodial environments.

BackgroundPredictive models in mental health can identify service users at risk of high-intensity care, enabling proactive interventions. However, false positive predictions may lead to over-medicalisation, inequitable resource use, and stigma. Understanding the factors associated with false positives can improve model interpretation and real-world application. AimsTo evaluate a previously validated prediction model for high-intensity (top decile) service use and identify false positive (FP) vs. true positive (TP) predictions, examining factors across three timeframes: baseline (e.g. demographics and referral information), the prediction period (W1; the first three months after initial mental health service assessment), and the immediate (three month) period following prediction (W2). MethodsOf mental health services users assessed between 2007-2024, 4,174 TP and 17,644 FP predictions were compared. Evaluated covariates included demographics, referral source, service use, diagnoses, medications, and recorded symptoms. Logistic regression was used to identify associations with FP outcomes across the three time periods. ResultsAt baseline, FP predictions were more common among Asian service users, those living with family, and users referred by their GP, whilst TP predictions were associated with voluntary or probation service referrals. During W1, FP predictions were associated with higher community treatment days, crisis attendances, and service users managed in the outpatient setting. TP predictions were associated with antipsychotic use and engagement with multiple care teams. In W2, TP predictions were more likely among service users who remained outpatients, had higher inpatient days, or received multidisciplinary care, and FP more likely among those with substance use, multiple address changes, or ongoing crisis attendances. ConclusionThe approach here to predictive modelling highlights the importance of considering features (here at baseline and W1) which may influence a models accuracy at the point the prediction is communicated, and those subsequent events (W2) which might indicate targets for intervention to prevent the adverse outcome. Both need to be incorporated in clinical interface communications if models are deployed in practice.

BackgroundWith rising referrals to child and adolescent mental health services (CAMHS), patient- and caregiver-facing digital platforms could streamline service delivery and research. With South London and Maudsley NHS Foundation Trust and Kings College London, the CAMHS Digital Lab developed myHealthE, a digital platform for families to access advice and support from the point of referral to CAMHS in South London, submit routine outcome measures, and consent to be contacted about relevant research studies. MethodThis secondary analysis descriptively summarised data from n=10,151 families under CAMHS invited to register on myHealthE between 2021 and 2023. Referral details, demographic and clinical characteristics were derived via the Clinical Record Interactive Search. myHealthE engagement was measured using Google Analytics. Routine outcome measures (particularly the Strengths and Difficulties Questionnaire [SDQ]) were collected via myHealthE. ResultsOf the invited families, 87.1% registered on myHealthE, and 85.4% completed at least one SDQ via the platform during their care episode. Overall, families completed n=29,906 SDQs during their episode of CAMHS support, mostly via myHealthE (93.2%) rather than conventional pen-and-paper methods (6.8%). Families engaged with resources on myHealthE, with 7,900 views of Your Referral and Information While You Wait pages over six-months. The platform also increased capacity for research recruitment, with 65.5% of families who consented for research contact over a 12-month period doing so via myHealthE. ConclusionsmyHealthE provides a valuable tool for patients, caregivers, clinicians and researchers. Such platforms can fulfil multiple functions. This is advantageous for both informing clinical service delivery, and for conducting research.

BackgroundThe COVID-19 pandemic, coupled with concurrent social instabilities, has raised concerns about the long-term impact on the population mental health. While existing studies have primarily focused on the acute phase, less is known about how anxiety and depression symptoms have evolved throughout prolonged societal disruption. This study aimed to identify distinct anxiety and depression symptom trajectories and to determine the individual, relational, and societal protective and risk factors that influence anxiety and depression scores among Belgian adults from 2020 to 2024. MethodsWe used longitudinal data from five waves of the COVID-19 Health Surveys and the BELHEALTH study (n = 10,063) among Belgian adults, collected between April 2020 and June 2024. Anxiety and depression were assessed using the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9, respectively. Covariates were selected based on the social-ecological framework and included both time-invariant and time-dependent variables. Latent class linear mixed models identified subgroups with distinct trajectories. Multilevel linear mixed effects models examined associations between symptom severity and predictors across individual, relationship, and societal levels. The final model, selected based on the lowest AIC (Akaike Information Criterion), included the full set of covariates. ResultsFour depression and five anxiety trajectories were identified. While most participants maintained stable mild symptoms, 11.3% experienced increasing depression and 8.4% showed increasing anxiety over time. Financial difficulty, female gender, and younger age were overrepresented in moderate and severe symptom trajectories. Protective factors such as social support, satisfying social contact, and life satisfaction were associated with lower symptom severity. Over time, life satisfaction demonstrated an increasing protective effect, while the influence of social contact on reducing symptoms weakened progressively. Risk factors included financial and job-loss worry, loneliness, psychotropic medication use, and high mental health stigma. ConclusionsOur results demonstrate persistent heterogeneity in mental health responses, with a substantial share of the population experiencing worsening symptoms years after the pandemic began. Public mental health strategies must therefore go beyond short-term crisis response, address long-term risks such as financial insecurity, social isolation, and stigma, while fostering individual and collective resilience.

Depression is a common and clinically significant mental health condition among university students, particularly those experiencing academic failure and course repetition, and is associated with adverse effects on cognitive functioning, emotional regulation, and academic performance. This study evaluated the efficacy of an internet-based cognitive behavioural therapy (iCBT) intervention, MoodGYM, in reducing depressive symptoms among repeating undergraduate students at the University of Zambia Ridgeway Campus. A quasi-experimental quantitative study design was employed. Seventy-five repeating undergraduate students with depressive symptoms were enrolled, with 33 assigned to the MoodGYM intervention group and 42 to a control group. Depressive symptom severity was assessed using the Beck Depression Inventory (BDI) at baseline and after an eight-week intervention period. Statistical analyses included within-group and between-group comparisons, difference-in-differences estimation, and fixed-effects regression modelling. At baseline, participants exhibited predominantly moderate to severe depressive symptoms, with no statistically significant differences between the intervention and control groups. Following the eight-week intervention, the MoodGYM group demonstrated a statistically and clinically significant reduction in depressive symptoms, with median BDI scores decreasing from 22 to 16 (p < 0.001), representing a large effect size (Cohens d = 1.02). In contrast, the control group showed persistence or worsening of depressive symptoms over the same period. Difference-in-differences analysis confirmed a robust intervention effect, with an approximately 10-point greater reduction in depression scores among MoodGYM participants compared with controls (p < 0.001). These findings indicate that MoodGYM is an effective internet-based intervention for reducing depressive symptoms among repeating undergraduate students and offers a feasible and scalable approach to addressing student mental health needs in low-resource university settings.

IntroductionMental health problems disproportionately affect marginalised communities rural, coastal, and socioeconomically disadvantaged communities. This is especially true for Norfolk and Suffolk, UK, where anxiety and depression are above national averages, suicide is the leading cause of death among those with mental ill-health, and access to care is poor. These communities are also underserved by research, leaving significant needs unmet. AimsThis project aimed to establish mental health research priorities informed by the views of key stakeholders in Norfolk and Suffolk, including people with lived experience of mental ill-health, members of the public, clinicians, charities, and policymakers. Methods and analysisWe conducted a mixed-methods research-priority-setting exercise involving an online survey (n=156, of whom 64.7% had lived experience) and two in-person prioritisation workshops with people with lived experience (n=10) and health and social care professionals (n=15). Following Delphi principles and guided by the James Lind Alliance approach, the survey asked participants to rate research priority statements across eight mental-health domains using a 3-point Likert scale (0 = low, 1 = moderate, 2 = high). Statements rated as high priority by [&ge;]50% of the respondents were shortlisted for the workshops. During the two-day workshops, participants discussed the shortlisted statements in small groups before voting individually on those they considered most important. Scores were calculated separately for each workshop, then combined to produce a final ranked list of the Top 10 research priorities. EthicsThe University of East Anglias Faculty of Medicine and Health Research Ethics Committee granted ethical approval (reference: ETH2324-2542). ResultsOf the 70 original priority statements, 40 met the threshold for inclusion in the prioritisation workshops. Participants in the two prioritisation workshops identified and agreed on the final Top 10 priorities, spanning youth mental health, physical-mental health integration, access to care, impacts of rural and coastal living, social and health inequalities, health promotion and prevention, and big-data solutions. ConclusionsStakeholders in this study identified local mental health needs and highlighted areas where research is urgently required. These priorities will inform future studies, support policymaking, and guide resource allocation to improve mental healthcare and reduce inequalities in rural and coastal communities. Strengths and limitations of this studyO_LIThis study brought together key stakeholders, including people with lived experience, mental health service providers, local authorities, policymakers, voluntary organisations, academics, and members of the public, to identify mental health research priorities specific to Norfolk and Suffolk populations. C_LIO_LIOur in-depth research priority-setting exercise identified the Top 10 research priority areas to inform future research and service planning. C_LIO_LIWhile the current study included family carers or parents of children with mental health difficulties, future mental health research priority-setting involving children is still needed. C_LI

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

BackgroundHumanitarian settings in Pakistan face major gaps in mental health service delivery, with limited specialist resources and a high burden of untreated conditions. The WHO mhGAP-Humanitarian Intervention Guidelines (mhGAP-HIG) aim to strengthen the capacity of primary care physicians (PCPs) to identify and manage common mental health conditions in humanitarian contexts. However, the evidence for multidimensional training outcomes remains limited. This study evaluated the effectiveness of mhGAP-HIG training to improve outcomes in terms of knowledge, skills, attitudes and confidence among PCPs across different humanitarian contexts in Pakistan. MethodsAs part of implementing an evidence-based digital MHPSS service model, seven mhGAP-HIG workshops were held between September and November 2025 across two provinces and a federal area facing humanitarian contexts. We conducted a quasi-experimental, mixed-methods evaluation where a total of 149 PCPs completed standardized assessments of knowledge (mhGAP-HIG), therapeutic skills (ENACT), attitudes (MICA-4), and confidence. Paired sample t-tests and ANCOVA were used to assess within-group and between-group changes, respectively. Quantitative feedback on training quality was obtained and qualitative reflections on learning experiences were evaluated using thematic analysis. ResultsA modest improvement in attitude and significant improvements across all other domains were observed. The participants from KP showed greater gains in knowledge, while participants from GB showed greater gains in skills, as compared to other provinces. Participants expressed a high level of satisfaction in all workshops, and reported improvements in knowledge, confidence, and ability to identify, manage and refer people with common mental health conditions. ConclusionSystematic efforts to adapt and implement mhGAP-HIG may lead to significant improvements across multidimensional competencies of PCPs, including their knowledge, skills, attitudes and confidence.

ImportanceAI-enabled features may improve the effectiveness of routine mental health care, yet large-scale real-world evidence remains limited. ObjectiveTo evaluate whether access to AI-enabled continuous care features embedded within routine psychotherapy delivery is associated with improved treatment engagement and clinical outcomes under real-world conditions. DesignPreregistered cluster-level, matched, quasi-experimental study using a real-world rollout of AI-enabled continuous care features compared with psychotherapy alone (intention-to-treat framework). SettingAn employer-sponsored behavioral health program providing outpatient psychotherapy for employees and dependents. ParticipantsAdults initiating a new episode of psychotherapy from 25 employers with access to continuous care features and 75 matched employers without access. Treatment engagement was assessed over 7 weeks (n=26,208), and clinical outcomes were evaluated for up to 180 days (n=5,518). ExposureEmployer-level access to AI-enabled continuous care features supporting engagement and continuity before and between psychotherapy sessions, compared with psychotherapy alone. Main OutcomesEarly treatment engagement (number of psychotherapy sessions attended and time to second session) and changes in depressive and anxiety symptom severity measured using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). ResultsCompared with matched controls receiving psychotherapy alone, the intervention group attended 5% more psychotherapy sessions during the first 7 weeks (rate ratio, 1.05 [1.01, 1.10]) and completed their second session sooner (mean difference, -0.62 days [-1.05, -0.18]). Both groups demonstrated substantial symptom improvement over time; however, access to continuous care features was associated with additional improvement in depressive symptoms (d=0.16) and anxiety symptoms (d=0.15) at the median duration of care (day 44). These effects translated into clinically meaningful differences in reliable improvement by the median duration of care (NNT=25 for both outcomes). Conclusions and RelevanceIn this real-world evaluation, access to AI-enabled continuous care features embedded within routine psychotherapy delivery was associated with greater early engagement and a higher likelihood of reliable symptom improvement beyond psychotherapy alone. These findings suggest that augmenting routine psychotherapy with AI-enabled continuous care can meaningfully shift recovery trajectories during a standard treatment episode, strengthening early treatment momentum and improving outcomes at scale. Key PointsO_ST_ABSQuestionC_ST_ABSIs access to AI-enabled continuous care features embedded within routine psychotherapy delivery associated with improved treatment engagement and clinical outcomes under real-world conditions? FindingsIn this cluster-level, matched, quasi-experimental study of adults receiving psychotherapy within an employer-sponsored behavioral health program, access to AI-enabled continuous care features was associated with significantly greater early treatment engagement and faster improvement in depressive and anxiety symptoms compared with psychotherapy alone. MeaningAI-enabled support features may incrementally enhance the delivery and effectiveness of established psychotherapies when implemented as complements to routine care at scale.

The early childhood environment influences later mental health, but it remains unclear which aspects are most important for reducing inequalities. We quantified how socioeconomic inequalities in mental health at 5 and 17 years (y) would change under hypothetical interventions on five aspects of the early childhood environment. We analysed parent-reported data from the UK Millennium Cohort Study (n=15513). Socioeconomic circumstances (SEC) were assessed using maternal education at 9 months. Mental health was measured using the Strengths and Difficulties Questionnaire total difficulties score at both ages. Five mediator pathways - neighbourhood, social support, material home environment, household adversity, and parent-child relations - were identified through stakeholder consultation and literature. Interventional Disparity Measures (IDMs) estimated how mental health inequalities would change if the confounder-adjusted mediator distributions for children in low SEC were shifted to match those in high SEC, using Monte Carlo simulations with imputed missing data. Mental health difficulties were higher among children in the low SEC (Primary or Lower) compared to high SEC (Tertiary) group (5y: 3.3[95%CI: 3.0;3.6] points; 17y: 3.1[2.8;3.5] points). Shifting all five pathways reduced these inequalities by around one-third (5y: -32%[-40;-23]; 17y: -35%[-48;-26]). At 5y, most of the inequality reduction was attributable to shifts in parent-child relations (-22% [-27;-16]). At 17y, both parent-child relations (-15%[-22;-9]) and social support (-11%[-21;-6]) were equally important. To reduce socioeconomic inequalities in mental health, policymakers should prioritise early interventions that improve parent-child relations and access to social support, while recognising the broader influence of neighbourhood, material, and household psychosocial contexts on these pathways.

BackgroundMental well-being encompasses positive psychological functioning, life satisfaction, and engagement with daily activities. It is influenced by multiple interrelated factors, including symptoms of stress, anxiety, depression, and psychological inflexibility. Network analysis provides a data-driven framework for examining the complex interconnections between these components and for identifying elements that may play a central role in the mental well-being system. The present study aimed to identify key elements related to stress, anxiety, depression, and psychological inflexibility associated with mental well-being in individuals seeking online psychological support. MethodsThis cross-sectional study analyzed data drawn from the Online Well-being intervention. A total of 967 Mexican participants were included. A psychological network comprising seventy-four items was estimated, and centrality indices (strength, closeness, and betweenness) were computed to determine the relative importance of individual elements within the network. Network comparisons by gender were conducted to evaluate global and local differences. ResultsThe network revealed multiple inter-domain associations, particularly negative relationships between mental well-being and symptoms of depression, anxiety, negative stress, and psychological inflexibility. Items reflecting self-evaluation and emotional well-being consistently emerged as the most central elements in the network across centrality metrics. Gender-based comparisons indicated overall structural similarity between networks, although differences were observed in the strength of specific connections. ConclusionsNetwork analysis identified central elements linking mental well-being with psychological distress and inflexibility in a population seeking online psychological support. These findings contribute to a systems-level understanding of mental well-being and highlight potential targets for psychological interventions to enhance well-being and reduce distress.

Background and AimIndividuals with non-binary gender commonly face minority stress such as invisibility, identity invalidation or even hostility within various social contexts. The COVID-19 pandemic represented an exceptional form of societal stress that presented mental health challenges in the population and probably even more so for vulnerable groups including non-binary gender individuals. We investigated whether there are gender differences in the impact of the COVID-19 pandemic on functional ability. MethodUniversity students and personnel (n=1998) responded to an online survey in May 2021, when the measures for preventing COVID-19 infections had sustained about a year and a half. Based on the gender option responses, groups of non-binary and binary (male or female) gender identity were formed. Current functioning (FUNCT), and subjective assessment of the effect of COVID-19 on functioning (COFUNCT) were recorded. Psychosocial and mental health characteristics were included in the statistical models. ResultsThe non-binary group represented 3,6 % of all study participants. The gender option "Male" was selected by 23.8% and the gender option "Female" by 72.7% of respondents. Compared to the binary group, those in the non-binary group exhibited poorer socioeconomic living situation and less favourable previous psychosocial development. Non-binary participants reported lower FUNCT and more negative COFUNCT than binary participants. In non-binary participants, a poor work situation was directly associated with poor FUNCT, while multiple adverse childhood experiences and loneliness were indirectly associated with lower FUNCT via depressive symptoms. Conversely, high family support and previous mental health care were directly associated with more negative COFUNCT, and loneliness was indirectly associated with low COFUNCT via depression. In binary participants, family support, good economy, resilience and active physical exercise associated with good FUNCT, while age, family support, good economy, resilience, active physical exercise and adverse childhood experiences associated with good COFUNCT. ConclusionsIndividuals with non-binary gender are more vulnerable for functional deficits in a period of serious societal stress such as COVID-19 pandemic. The related psychosocial and mental health factors should be taken into account when planning tailored interventions for vulnerable groups during periods of exceptional societal circumstances. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=113 SRC="FIGDIR/small/25343131v1_ufig1.gif" ALT="Figure 1"> View larger version (45K): org.highwire.dtl.DTLVardef@1bd9d76org.highwire.dtl.DTLVardef@1acee78org.highwire.dtl.DTLVardef@5c1eaeorg.highwire.dtl.DTLVardef@1e26602_HPS_FORMAT_FIGEXP M_FIG C_FIG

Structured AbstractO_ST_ABSObjectiveC_ST_ABSThis mixed-methods study investigated the lived-experience perspectives of receiving a novel, brief digital mental health intervention after psychological trauma. The online gamified imagery-competing task intervention (ICTI) involves one researcher-guided session followed by self-use. Tested in two randomised controlled trials (GAINS-01; GAINS-02), ICTI led to fewer intrusive memories at week-4, with the reduction sustained over 24 weeks, alongside reductions in post-traumatic stress. Here, we contrasted user experiences of ICTI with an Active Control (AC; music-listening task), and explored longer-term impact in qualitative interviews to contextualise GAINS-02 findings. Methods and AnalysisThe GAINS-02 trial randomised healthcare staff experiencing intrusive memories after work-related trauma to ICTI (N=40), AC (N=39), or treatment-as-usual (TAU; N=20). Expectancy was assessed before the researcher-guided session (Day 0), acceptability at week-4, and usage tracked for 24-weeks. Semi-structured interviews (N=27) were conducted in ICTI and AC arms only (15 at week-4; 12 during 12-24-weeks). Interviews were analysed using reflexive thematic analysis. ResultsPrior to use, many trial participants did not think the intervention would work, favouring AC over ICTI. However, after completing the tasks, participants found ICTI more acceptable and relevant to intrusive memories than AC. After the one guided session, median ICTI usage the next four weeks was 4.00 times with little additional use (once more) over the next 20 weeks because of lack of need. Potential implementation facilitators included ease of use, and advantages over existing interventions due to not needing to talk about the trauma, brevity, and lesser resource commitment. Perceived barriers included a lack of staff and manager education about the nature and consequences of intrusive memories, with a need for workplace buy-in and demonstration of organisational benefits. ConclusionHealthcare staff experiencing workplace-related trauma found ICTI to be acceptable and effective for reducing intrusive memories with low effort and emotional burden, even among participants who initially expressed scepticism. Participants highlighted implementation considerations including offering ICTI both within and outside the workplace, and providing a self-guided version of ICTI with optional support. Future work should assess cost-effectiveness, impacts on presenteeism and retention, and real-world implementation including the feasibility and effectiveness of a self-guided ICTI. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSIn a previous randomised controlled trial (GAINS-01) with Intensive Care Unit (ICU) staff exposed to work-related trauma, a brief online gamified imagery-competing task intervention (ICTI) reduced intrusive memories compared to usual care at four-weeks. What this study addsThe GAINS-02 randomised controlled trial replicated GAINS-01 and extended results by comparing ICTI to an active control (AC; music listening) task, enrolling hospital staff from outside ICU, and a follow-up period of 24-weeks. Qualitative interviews found that, despite initial scepticism from healthcare staff prior to using the intervention, ICTI was more acceptable than an AC due to specific effects on swiftly reducing intrusive memories and requiring minimal support or usage after an initial researcher-guided session. After one guided session, ICTI was used 4 more times in the first four weeks, with little additional usage (once) thereafter because of lack of need (i.e., no longer experiencing intrusive memories). How this study might affect research, practice or policyICTI is an efficacious scalable intervention to relieve staff of intrusive memories with effects sustained for at least 6-months. It was found to be more acceptable to participants than alternatives, requiring less time commitment than standard psychological treatments.

BackgroundDespite widespread recognition of the value of lived experience (LE) involvement in healthcare research and increased LE involvement activity, we lack established implementation methods and instruments for reporting and evaluating impact. We present a protocol for an innovative LE-led Impact Log tool and co-production framework, which may help to address some fundamental barriers to co-production. The Impact Log will be implemented within a five-year multidisciplinary transdiagnostic research project on severe mental illness, the Brain and Genomics Hub of the UKRI Mental Health Platform, and is also designed for wider adaptation and use. Part I presents a short narrative review of literature pertaining to defining, evaluating, and enhancing the impact of co-production, to provide in-depth background and aid future development. Part II presents the Impact Log protocol. MethodsThe Impact Log framework is designed to integrate inclusive and impactful co-production throughout all research stages, and to record and evaluate its impact across three domains using an accessible short form. The three research domains are: design and delivery; interpersonal and environmental aspects; systems and processes. Impact Log design and implementation is led by LE study leads and a specialist advisory panel, who are integrated fully within the wider research team, and all have combined research experience and LE of bipolar or psychotic disorders. All Hub research participants will be offered accessible opportunities for remunerated lived experience input, and there will be outreach to ensure diverse representation, aided by the Hubs charity partners. Data collection and analysis will be LE led and will include iterative analysis to inform continuing development. Diverse formal and informal dissemination throughout the project will maximise wider stakeholder engagement. DiscussionThe potential value of this research is to implement a novel tool and framework for facilitating, recording and evaluating co-production in complex mental health research, which can be adapted for wider use. Strengths in design are LE leadership and cross-cutting LE research integration, incorporation of multiple domains, and a focus on facilitating diversity and inclusion within co-production. Potential limitations for this project and wider adaptation may include limited resources, risk of bias and health challenges. Lay SummaryWe have provided a brief lay summary to help people without a research background understand our project. This article explains our plan to develop and test a new way of understanding how research changes when people with personal experience of a mental health condition are part of the research team. We are a team of mental health researchers and many of us have direct experience of bipolar and psychosis. We work alongside other researchers, including people who might also have worked in mental health services or in charities that provide support. Our research project aims to better understand what is happening in the brain, body, lives and experiences of people who have bipolar and psychosis. Many people believe that research is better when it includes the views of people who have direct experience of the health condition being studied. This is called "lived experience". We have developed a structured approach to make sure that people with lived experience are meaningfully involved in our research team. We have also created a simple tool, called the Impact Log, to record when lived experience members contribute and to help us understand how their involvement influences the research. Finally, we wanted to better understand what other researchers have said about lived experience involvement. We reviewed many published academic studies and reports and brought their findings together in what is called a "narrative review". This review summarises what is already known about the difference lived experience involvement can make in research.

BackgroundApproximately 1 in 5 Canadians experience a mental health illness in any given year. While most individuals can be successfully treated within a primary care setting, a subset of individuals present with a severity and complexity requiring specialist care. Unfortunately, a shortage of psychiatrists (especially in rural regions) can result in wait times of months to years. MethodsWe designed the Alberta Network for Community Health Outreach and Rural Mental Health. ANCHOR-MH is a 12-week program that includes a unique educational intervention, collaborative case conferencing, and a community of practice between family medicine (FM) physicians and psychiatrists. We enrolled two pilot cohorts of n=20 FM physicians each and measured participants confidence and comfort in diagnosing, managing, and treating psychiatric conditions. We also conducted qualitative analyses of their experience. ResultsData from participants that completed both the pre- and post-program survey (n=34) showed increased confidence in screening for, diagnosing, and managing psychiatric issues, as well as increased comfort discussing mental health concerns with patients and families and reduced stigma towards certain psychiatric conditions. Qualitative thematic analysis (n=39) reflected this increased confidence, revealed an increased sense of connectedness to the mental healthcare landscape, and highlighted specific examples of practice changes. Participants broadly agreed that the program improved their ability to provide mental healthcare and would improve psychiatric outcomes within their practice. InterpretationANCHOR-MH improved FM physicians confidence and ability to deliver mental healthcare in their primary care settings. Increasing the reach of this program may improve mental healthcare in underserved communities.