Risks of all-cause and suicide mortality in mental disorders: a meta-review

Rare CRHR2 and GRM8 variants identified as candidate factors associated with eating disorders in Japanese patients by whole exome sequencing

Eating disorders (EDs) are a type of psychiatric disorder characterized by pathological eating and related behavior and considered to be highly heritable. The purpose of this study was to explore rare variants expected to display biological functions associated with the etiology of EDs. We performed whole exome sequencing (WES) of affected sib-pairs corresponding to disease subtype through their lifetime and their parents. From those results, rare single nucleotide variants (SNVs) concordant with sib-pairs were extracted and estimated to be most deleterious in the examined families. Two non-synonymous SNVs located on corticotropin-releasing hormone receptor 2 (CRHR2) and glutamate metabotropic receptor 8 (GRM8) were identified as candidate disease susceptibility factors. The SNV of CRHR2 was included within the cholesterol binding motif of the transmembrane helix region, while the SNV of GRM8 was found to contribute to hydrogen bonds for an α-helix structure. CRHR2 plays important roles in the serotoninergic system of dorsal raphe nuclei, which is involved with feeding and stress-coping behavior, whereas GRM8 modulates glutamatergic neurotransmission. Moreover, GRM8 modulates glutamatergic neurotransmission, and is also considered to have effects on dopaminergic and adrenergic neurotransmission. Thus, identification of rare and deleterious variants in this study is expected to increase understanding and treatment of affected individuals. Further investigation regarding the biological function of these variants may provide an opportunity to elucidate the pathogenesis of EDs.

Inclusion of the severe and enduring anorexia nervosa phenotype in genetics research: a scoping review

BACKGROUND

Anorexia nervosa has one of the highest mortality rates of all mental illnesses. For those who survive, less than 70% fully recover, with many going on to develop a more severe and enduring phenotype. Research now suggests that genetics plays a role in the development and persistence of anorexia nervosa. Inclusion of participants with more severe and enduring illness in genetics studies of anorexia nervosa is critical.

OBJECTIVE

The primary goal of this review was to assess the inclusion of participants meeting the criteria for the severe enduring anorexia nervosa phenotype in genetics research by (1) identifying the most widely used defining criteria for severe enduring anorexia nervosa and (2) performing a review of the genetics literature to assess the inclusion of participants meeting the identified criteria.

METHODS

Searches of the genetics literature from 2012 to 2023 were performed in the PubMed, PsycINFO, and Web of Science databases. Publications were selected per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The criteria used to define the severe and enduring anorexia nervosa phenotype were derived by how often they were used in the literature since 2017. The publications identified through the literature search were then assessed for inclusion of participants meeting these criteria.

RESULTS

most prevalent criteria used to define severe enduring anorexia nervosa in the literature were an illness duration of ≥ 7 years, lack of positive response to at least two previous evidence-based treatments, a body mass index meeting the Diagnostic and Statistical Manual of Mental Disorders-5 for extreme anorexia nervosa, and an assessment of psychological and/or behavioral severity indicating a significant impact on quality of life. There was a lack of consistent identification and inclusion of those meeting the criteria for severe enduring anorexia nervosa in the genetics literature.

DISCUSSION

This lack of consistent identification and inclusion of patients with severe enduring anorexia nervosa in genetics research has the potential to hamper the isolation of risk loci and the development of new, more effective treatment options for patients with anorexia nervosa.

Developing a risk prediction model for death at first suicide attempt-Identifying risk factors from Thailand's national suicide surveillance system data

More than 60% of suicides globally are estimated to take place in low- and middle-income nations. Prior research on suicide has indicated that over 50% of those who die by suicide do so on their first attempt. Nevertheless, there is a dearth of knowledge on the attributes of individuals who die on their first attempt and the factors that can predict mortality on the first attempt in these regions. The objective of this study was to create an individual-level risk-prediction model for mortality on the first suicide attempt. We analyzed records of individuals' first suicide attempts that occurred between May 1, 2017, and April 30, 2018, from the national suicide surveillance system, which includes all of the provinces of Thailand. Subsequently, a risk-prediction model for mortality on the first suicide attempt was constructed utilizing multivariable logistic regression and presented through a web-based application. The model's performance was assessed by calculating the area under the receiver operating curve (AUC), as well as measuring its sensitivity, specificity, and accuracy. Out of the 3,324 individuals who made their first suicide attempt, 50.5% of them died as a result of that effort. Nine out of the 21 potential predictors demonstrated the greatest predictive capability. These included male sex, age over 50 years old, unemployment, having a depressive disorder, having a psychotic illness, experiencing interpersonal problems such as being aggressively criticized or desiring plentiful attention, having suicidal intent, and displaying suicidal warning signals. The model demonstrated a good predictive capability, with an AUC of 0.902, a sensitivity of 84.65%, a specificity of 82.66%, and an accuracy of 83.63%. The implementation of this predictive model can assist physicians in conducting comprehensive evaluations of suicide risk in clinical settings and devising treatment plans for preventive intervention.

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

OBJECTIVE

We aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample.

METHODS

This study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA.

RESULTS

68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients.

CONCLUSION

Chronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

Distinctive intrinsic functional connectivity alterations of anterior cingulate cortex subdivisions in major depressive disorder: A systematic review and meta-analysis

Evidence of whether the intrinsic functional connectivity of anterior cingulate cortex (ACC) and its subregions is altered in major depressive disorder (MDD) remains inconclusive. A systematic review and meta-analysis were therefore performed on the whole-brain resting-state functional connectivity (rsFC) studies using the ACC and its subregions as seed regions in MDD, in order to draw more reliable conclusions. Forty-four ACC-based rsFC studies were included, comprising 25 subgenual ACC-based studies, 11 pregenual ACC-based studies, and 17 dorsal ACC-based studies. Specific alterations of rsFC were identified for each ACC subregion in patients with MDD, with altered rsFC of subgenual ACC in emotion-related brain regions, of pregenual ACC in sensorimotor-related regions, and of dorsal ACC in cognition-related regions. Furthermore, meta-regression analysis revealed a significant negative correlation between the pgACC-caudate hypoconnectivity and percentage of female patients in the study cohort. This meta-analysis provides robust evidence of altered intrinsic functional connectivity of the ACC subregions in MDD, which may hold relevance to understanding the origin of, and treating, the emotional, sensorimotor and cognitive dysfunctions that are often observed in these patients.

Self-Hatred: The Unaddressed Symptom of Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) often report chronic, severe self-hatred. It is frequently experienced as immutable, seen as a barrier to recovery, and is associated with risk for self-injury and suicide attempts. Yet self-hatred remains a poorly understood, underdiagnosed, and undertreated presentation of BPD. In this concept article and review, we describe the nature of self-hatred in BPD and related disorders, propose a theory as to the development of self-hatred in BPD, review the assessments of and interventions for self-hatred, and consider next steps in the research, assessment, and treatment of self-hatred in BPD. Through increased awareness, understanding, and measures of self-hatred in BPD, new treatment paradigms can be developed to ensure more comprehensive recovery.

Prescriptions of psychotropic and somatic medications among patients with severe mental disorders and healthy controls in a naturalistic study

PURPOSE

Psychotropic and somatic medications are both used in treating severe mental disorders (SMDs). Realistic estimates of the prevalence of use across medication categories are needed. We obtained this in a clinical cohort of patients with SMD and healthy controls (HCs).

MATERIALS AND METHODS

Prescriptions filled at Norwegian pharmacies the year before and after admittance to the Thematically Organized Psychosis (TOP) study were examined in 1406 patients with SMD (mean age 32.5 years, 48.2% women) and 920 HC (34.1 years, 46.2% women). Using data from the Norwegian Prescription Database (NorPD), the number of users in different anatomical therapeutic chemical (ATC) categories was compared using logistic regression. Population estimates were used as reference data.

RESULTS

Use of antipsychotics (N05A), antiepileptics (N03A), antidepressants (N06A), anxiolytics (N05B), hypnotics and sedatives (N05C), anticholinergics (N04A), psychostimulants, attention deficit hyperactivity disorder and nootropic agents (N06B) and drugs for addiction disorders (N07B) was significantly more prevalent in patients with SMD than HC. Use of diabetes treatment (A10), antithrombotic drugs (B01), beta blockers (C07), lipid modifiers (C10), and thyroid and endocrine therapeutics (H03) was also more prevalent in patients with SMD, but with two exceptions somatic medication use was comparable to the general population. Among HC, there was low prevalence of use for most medication categories.

CONCLUSION

Patients were using psychiatric medications, but also several types of somatic medications, more often than HC. Still, somatic medication use was mostly not higher than in the general population. The results indicate that HC had low use of most medication types.

Mental health providers' perceptions of restrictive eating disorders: Relationship with client body weight

OBJECTIVE

This study investigated whether mental health providers have different diagnostic impressions and treatment recommendations for patients with restrictive eating disorders, depending on the patient's body weight.

METHOD

Participants were given one of three versions of a vignette depicting a patient who meets DSM-5 criteria for anorexia nervosa (AN) or atypical AN with the patient's weight described as either below, within, or above the average range for her age and height. Participants were then asked to respond to a series of questions about diagnosis, symptoms, and treatment recommendations. Results were compared between the three weight conditions with the goal of better understanding how a patient's body weight may influence different aspects of participants' clinical impressions.

RESULTS

Participants given the low weight version of the vignette were more likely to identify the presenting problem as an eating disorder and to agree that the patient experienced dietary restriction and weight loss, weight gain avoidance, and body image concerns. Participants given the low weight description were also more likely to recommend specialized eating disorder treatment and medical follow-up.

DISCUSSION

Findings suggest that mental health providers were generally more responsive to restrictive eating disorder symptoms when the patient was at a lower body weight. These results are concerning because they suggest patients with atypical AN may be less likely to receive an accurate diagnosis or adequate treatment compared to underweight patients with AN, despite experiencing the same symptoms.

PUBLIC SIGNIFICANCE

Restrictive eating disorders like AN and atypical AN can cause comparable physical and psychological symptoms in people of any body weight. Despite having the same symptoms, people with a higher body weight are less likely to receive a diagnosis or treatment. This study compared mental health providers' reactions to a description of a patient with an eating disorder at different body weights and found differences in diagnosis, detection of symptoms, and treatment recommendations.

Projecting the 10-year costs of care and mortality burden of depression until 2032: a Markov modelling study developed from real-world data

Background

Based on real-world data, we developed a 10-year prediction model to estimate the burden among patients with depression from the public healthcare system payer's perspective to inform early resource planning in Hong Kong.

Methods

We developed a Markov cohort model with yearly cycles specifically capturing the pathway of treatment-resistant depression (TRD) and comorbidity development along the disease course. Projected from 2023 to 2032, primary outcomes included costs of all-cause and psychiatric care, and secondary outcomes were all-cause deaths, years of life lived, and quality-adjusted life-years. Using the territory-wide electronic medical records, we identified 25,190 patients aged ≥10 years with newly diagnosed depression from 2014 to 2016 with follow-up until 2020 to observe the real-world time-to-event pattern, based on which costs and time-varying transition inputs were derived using negative binomial modelling and parametric survival analysis. We applied the model as both closed cohort, which studied a fixed cohort of incident patients in 2023, and open cohort, which introduced incident patients by year from 2014 to 2032. Utilities and annual new patients were from published sources.

Findings

With 9217 new patients in 2023, our closed cohort model projected the 10-year cumulative costs of all-cause and psychiatric care to reach US$309.0 million and US$58.3 million, respectively, with 899 deaths (case fatality rate: 9.8%) by 2032. In our open cohort model, 55,849-57,896 active prevalent cases would cost more than US$322.3 million and US$60.7 million, respectively, with more than 943 deaths annually from 2023 to 2032. Fewer than 20% of cases would live with TRD or comorbidities but contribute 31-54% of the costs. The greatest collective burden would occur in women aged above 40, but men aged above 65 and below 25 with medical history would have the highest costs per patient-year. The key cost drivers were relevant to the early disease stages.

Interpretation

A limited proportion of patients would develop TRD and comorbidities but contribute to a high proportion of costs, which necessitates appropriate attention and resource allocation. Our projection also demonstrates the application of real-world data to model long-term costs and mortality, which aid policymakers anticipate foreseeable burden and undertake budget planning to prepare for the care need in alternative scenarios.

Funding

Research Impact Fund from the University Grants Committee, Research Grants Council with matching fund from the Hong Kong Association of Pharmaceutical Industry (R7007-22).

Characteristics of Comorbid Physical Disease in Patients With Severe Mental Illness in South Korea: A Nationwide Population-Based Study (2014-2019)

OBJECTIVE

The purpose of this study was to identify the associations of chronic physical disease between patients with severe mental illness (SMI) and the general population of South Korea.

METHODS

This study was conducted with National Health Insurance Corporation data from 2014 to 2019. A total of 848,058 people were diagnosed with SMI in this period, and the same number of controls were established by matching by sex and age. A descriptive analysis was conducted on the sociodemographic characteristics of patients with SMI. Conditional logistic regression analysis was performed to identify the associations between comorbid physical disease in patients with SMI and those of the general population. SAS Enterprise Guide 7.1 (SAS Inc, Cary, NC, USA) were used to perform all statistical tests.

RESULTS

The analysis revealed significant differences in medical insurance, income level, and Charlson Comorbidity Index weighted by chronic physical disease, between patients with SMI and the general population. Conditional logistic regression analysis between the two groups also revealed significant differences in eight chronic physical diseases except hypertensive disease.

CONCLUSION

This study confirmed the vulnerability of patients with SMI to chronic physical diseases and we were able to identify chronic physical disease that were highly related to patients with SMI.

Temporal and bidirectional association of depression and physical illnesses: Analyzing the pooled data from independently conducted cross-sectional national surveys at three distinct time points

OBJECTIVE

Depression is a widespread mental health issue, often coexisting with physical conditions. Understanding its interplay with physical illnesses is crucial for holistic care.

METHODS

We analyzed the pooled data from three cross-sectional surveys of the Korea National Health and Nutrition Examination Survey (KNHANES) conducted in 2016, 2018, and 2020. Data on depression and physical illness for participants aged 19 and above were collected based on information provided by the participants.

RESULTS

In cases where depression and physical illnesses occur independently, the diagnosed age for depression is typically earlier than that of physical health conditions. Furthermore, when exploring scenarios where depression coexists with physical illnesses, it is observed that depression often precedes the development of these conditions in most cases. However, exceptions to this trend are found in diabetes mellitus, thyroid disorders, and asthma, where the presence of these diseases is linked to an elevated risk of depression onset. Interestingly, the study also implies that the mood state associated with depression, rather than the diagnosis itself, may influence health-related behaviors, potentially playing a role in the development of physical illnesses.

CONCLUSION

Depression and physical illnesses share complex associations. Early detection, interventions, and addressing lifestyle factors are vital. This study's insights underscore the need for comprehensive mental and physical health care, though further research is needed for deeper understanding. The findings emphasize the importance of considering depression as a potential risk factor for physical illnesses and highlight the interplay between depression and physical health.

Somatic multicomorbidity and disability in patients with psychiatric disorders in comparison to the general population: a quasi-epidemiological investigation in 54,826 subjects from 40 countries (COMET-G study)

BACKGROUND

The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.

METHODS

The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.

RESULTS

About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15-20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.

CONCLUSIONS

The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.

Taking better advantage of the activity-based anorexia model

The lack of specific treatments for anorexia nervosa (AN) is partly driven by an inadequate understanding of the neurobiological drivers of the condition. The activity-based anorexia (ABA) model recapitulates key characteristics of AN in rats and mice, and can be used to understand factors that predispose, maintain, and rescue anorectic behaviour. With the rapidly evolving suite of technologies to manipulate and record neural activity during the development of ABA, we are better placed than ever before to take advantage of this unique biobehavioural model in order to develop and refine novel treatments for AN. This will require a collective effort to bridge research disciplines in order to capitalise on knowledge gains from genetics, neurobiology, metabolism, and cognition.

Self-harm, suicide and brain death: the role of the radiologist

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

What are the key influences and challenges around weight management faced by patients in UK adult secure mental health settings? A focused ethnographic approach

OBJECTIVES

Excess weight is highly prevalent in secure (forensic) mental health services and impacts negatively on patients' physical and mental health. This study sought to identify the key influences and challenges around weight management in UK adult secure mental health settings.

DESIGN

Qualitative focused ethnography. Analysis of written fieldnotes was undertaken through a combined inductive and deductive approach, informed by thematic analysis.

SETTING

Low secure male mental health ward and associated patient activities and events, in a National Health Service Trust delivering mental health, intellectual disability and neurorehabilitation services in the UK.

PARTICIPANTS

12 males (primarily white British) on the low secure ward; additional male participants from low and medium secure services, who took part in group events and activities; and multidisciplinary low and medium secure services staff. Approximately 23 hours of observation were undertaken over a 6-month period from April 2022.

RESULTS

Secure mental healthcare delivered an environment predisposing patients to excessive weight gain and sedentary behaviour, which was often perceived as inevitable. Key themes highlighted the heightened salience of food in secure settings; inadequacy of catered hospital food and shortcomings of alternative food options; limited physical activity opportunities; and a ward culture that was not conducive to healthy behaviours. Perceptions and behaviour towards the ethnographer were primarily positive and accepting.

CONCLUSIONS

Weight management in secure services is a complex challenge. In future, whole setting-based interventions to promote healthy weight are likely to be required. These should integrate physical and mental health, incorporate underpinning determinants such as adequate staffing and a culture promoting weight management, and involve both patients and staff.

Unexpected identification of obesity-associated mutations in LEP and MC4R genes in patients with anorexia nervosa

Mutations leading to a reduced or loss of function in genes of the leptin-melanocortin system confer a risk for monogenic forms of obesity. Yet, gain of function variants in the melanocortin-4-receptor (MC4R) gene predispose to a lower BMI. In individuals with reduced body weight, we thus expected mutations leading to an enhanced function in the respective genes, like leptin (LEP) and MC4R. Therefore, we have Sanger sequenced the coding regions of LEP and MC4R in 462 female patients with anorexia nervosa (AN), and 445 healthy-lean controls. In total, we have observed four and eight variants in LEP and MC4R, respectively. Previous studies showed different functional in vitro effects for the detected frameshift and non-synonymous variants: (1) LEP: reduced/loss of function (p.Val94Met), (2) MC4R: gain of function (p.Val103Ile, p.Ile251Leu), reduced or loss of function (p.Thr112Met, p.Ser127Leu, p.Leu211fsX) and without functional in vitro data (p.Val50Leut). In LEP, the variant p.Val94Met was detected in one patient with AN. For MC4R variants, one patient with AN carried the frameshift variant p.Leu211fsX. One patient with AN was heterozygous for two variants at the MC4R (p.Val103Ile and p.Ser127Leu). All other functionally relevant variants were detected in similar frequencies in patients with AN and lean individuals.

Correlative relationship between body mass index and heart rate variability in psychiatric disorders

OBJECTIVE

Indicators of heart rate variability (HRV) have been used to assess the autonomic activity. However, the influence of obesity on HRV in these patients remains to be determined. This study aimed to examine how obesity (measured with the body mass index [BMI]) affects HRV and determine whether the effect varies among different psychiatric disorders. We recruited 3159 consecutive patients, including 1744 with schizophrenia, 966 with mood disorders, and 449 with anxiety disorders. Patients were divided into four groups based on BMI: underweight (< 18.5), normal weight (18.5-23.9), overweight (24-27.9), and obese (≥ 28). The cardiovascular status was assessed using several time- and frequency-based HRV indicators, measured via electrocardiogram signals recorded for 5 min. The mean BMI of the participants was 23.6 ± 4.0. The patients in the overweight and obese groups were 29.4% and 13.6% of the total, respectively. The HRV indicators were higher in underweight and normal-weight patients than in the overweight and obese ones. After stratification based on the psychiatric diagnosis, the patients with mood disorders showed lower HRV than those with schizophrenia or anxiety disorder in the normal-weight group. In contrast, in the overweight and obese groups the patients with mood disorders showed higher HRV than those with the other disorders. The HRV variables were significantly associated with BMI, and higher BMI was associated with higher heart rates and lower HRV. These results indicate that weight gain in psychiatric disorders is associated with an imbalance in autonomic nerve activity. However, the relationship between autonomic activity, weight gain, and psychiatric disorders warrants further investigation.

General practitioners' experiences of providing lifestyle advice to patients with depression: A qualitative focus group study

OBJECTIVE

Depression is an increasingly common mental health disorder in the UK, managed predominantly in the community by GPs. Emerging evidence suggests lifestyle medicine is a key component in the management of depression. We aimed to explore GPs' experiences, attitudes, and challenges to providing lifestyle advice to patients with depression.

METHOD

Focus groups were conducted virtually with UK GPs (May-July 2022). A topic guide facilitated the discussion and included questions on experiences, current practices, competence, challenges, and service provision. Data were analysed using template analysis.

RESULTS

'Supporting Effective Conversations'; 'Willing, but Blocked from Establishing Relational Care'; 'Working Towards Patient Empowerment'; and 'Control Over the Prognosis' were all elements of how individualised lifestyle advice was key to the management of depression. Establishing a doctor-patient relationship by building trust and rapport was fundamental to having effective conversations about lifestyle behaviours. Empowering patients to make positive lifestyle changes required tailoring advice using a patient-centred approach. Confidence varied across participants, depending on education, experience, type of patient, and severity of depression.

CONCLUSIONS

GPs play an important role in managing depression using lifestyle medicine and a patient-centred approach. Organisational and educational changes are necessary to facilitate GPs in providing optimal care to patients with depression.

Remaining Between the Cracks - The Long-Term Effect of Different Suicide Risk Exclusion Criterion on Outcomes of an Online Intervention for Depression

Background: Previous studies have demonstrated that excluding individuals at risk of suicide from online depression interventions can impact recruited sample characteristics. Aim: To determine if a small change in suicide risk exclusion criterion led to differences in the usage and effectiveness of an Internet depression intervention at 6 months of follow-up. Method: A partial sample of a recently completed online depression intervention trial was divided into two groups: those with no risk of suicide versus those with some risk. The two groups were compared for baseline demographic and clinical measures, as well as intervention uptake and treatment success across 6 months. Results: Overall, individuals with less risk of suicide at baseline reported significantly less severe clinical symptoms. Both groups interacted with the intervention at the same rate, but specific use of modules was different. Finally, the impact of intervention usage on outcomes over time did not vary by group. Limitations: While different suicide risk exclusion criteria can change recruited sample characteristics, it remains unclear how these differences impact intervention uptake and success. Conclusion: Overall, the findings suggest that researchers should exercise caution when excluding individuals at risk of suicide, as they greatly benefit from web-based interventions.

Umbrella Review of the Global Prevalence of Conduct Disorder in Children and Adolescents

With the ever-increasing prevalence of mental health issues worldwide, a robust synthesis of existing epidemiological data on the prevalence of Conduct disorder (CD) in children and adolescents is needed to strengthen the knowledge base. This quantitative umbrella review aims to provide a robust synthesis of evidence on the prevalence of CD children and adolescents from meta-analytic systematic reviews. We searched PubMed, Web of Science, PsychINFO, and Scopus to identify relevant articles. The study protocol has been registered with PROSPERO (CRD42023447620). The methodological quality of the studies was evaluated by using a Measurement Tool to Assess Systematic Reviews (AMSTAR). Invariance variance weighted random-effect meta-analysis was performed to pool prevalence estimates from the included articles. Seven meta-analyses, encompassing 138 primary studies and slightly over 48 million CD cases were included in this umbrella review. The quantitative analysis of these studies found a pooled prevalence of CD 3.0% (95%CI 2.0-5%) in children and adolescents, based on random effect meta-analyses. In a stratified analysis, the prevalence estimate of CD was 2.6 times higher in boys compared to girls. Evidence from our quantitative umbrella review showed that the prevalence of CD is relatively high in children and adolescents with boys 2.6 times more likely to experience the disorders when compared to girls. Our findings underlie that attention should be given to preventing, identifying, and treating CD in children and adolescents.

Risk Factors for Suicide Reattempt among Adolescents and Young Adults: The Role of Psychiatric Disorders

Suicidal behaviour among young people is a serious public health concern. Each suicide attempt is related to further suicide attempts and completed suicide. This study aims to explore risk factors associated with repeated suicide attempt among adolescents and young adults. The cohort included 510 patients aged 12-29 years residing in Piedmont Region in North-Western Italy, who had been admitted to hospital or emergency department with a diagnosis of suicide attempt between 2010 and 2020. Cox regression models were used to evaluate potential risk factors for repeated suicide attempt. During the 11-years follow-up, 20.6% of adolescents and young adults repeated suicide attempt, 24.8% of females and 12.3% of males. Nearly 90% of youth who attempted suicide had a diagnosis of psychiatric disorder. After adjustment, younger age of onset of suicidal behaviour, and diagnosis of schizophrenia, bipolar disorder, depressive disorder, anorexia nervosa and personality disorder were significantly associated with repeated suicide attempt. The early identification of patients at higher risk of repetition of suicidal behaviour is of crucial importance. Better understanding of risk factors and effective treatment of mental disorders could help suicide prevention to reduce the burden of the problem among young people. Special attention should be paid during the initial months following discharge from hospital or emergency department, when suicide reattempt risk is very high.

Childhood abuse influences clinical features of major depressive disorder by modulating the functional network of the right amygdala subregions

Childhood trauma and the amygdala play essential roles in major depressive disorder (MDD) mechanisms. However, the neurobiological mechanism among them remains unclear. Therefore, we explored the relationship among the amygdala subregion's abnormal functional connectivity (FC), clinical features, and childhood trauma in MDD. We obtained resting-state functional magnetic resonance imaging (fMRI) in 115 MDD patients and 91 well-matched healthy controls (HC). Amygdala subregions were defined according to the Human Brainnetome Atlas. The case vs. control difference in FCs was extracted. After controlling for age, sex, and education years, the mediations between the detected abnormal FCs and clinical features were analyzed, including the onset age of MDD and the Hamilton Depression Scale-24 (HAMD-24) reductive rate. Compared with HC subjects, we found, only the right amygdala subregions, namely the right medial amygdala (mAmyg.R) and the right lateral amygdala (lAmyg.R), showed a significant decrease in whole-brain FCs in MDD patients. Only childhood abuse experiences were significantly associated with amygdala subregion connectivity and clinical features in MDD patients. Additionally, The FCs between the mAmyg.R and extensive frontal, temporal, and subcortical regions mediated between the early life abuses and disease onset or treatment outcome. The findings indicate that the abnormal connectivity of the right amygdala subregions is involved in MDD's pathogenesis and clinical characteristics.

Digital advance care planning with severe mental illness: a retrospective observational cohort analysis of the use of an electronic palliative care coordination system

BACKGROUND

People living with severe mental illness (SMI) face significant health inequalities, including in palliative care. Advance Care Planning (ACP) is widely recommended by palliative care experts and could reduce inequalities. However, implementing ACP with this group is challenging. Electronic Palliative Care Coordination Systems such as Coordinate my Care (CMC) have been introduced to support documentation and sharing of ACP records with relevant healthcare providers. This study explores the use of CMC amongst those with SMI and aims to describe how those with a primary diagnosis of SMI who have used CMC for ACP, and makes recommendations for future research and policy.

METHOD

A retrospective observational cohort analysis was completed of CMC records created 01/01/2010-31/09/2021 where the service user had a primary diagnosis of SMI, with no exclusions based on comorbidities. Descriptive statistics were used to report on characteristics including: age, diagnosis, individual prognosis and resuscitation status. Thematic analysis was used to report on the content of patients' statements of preference.

RESULTS

1826 records were identified. Of this sample most (60.1%) had capacity to make treatment decisions, 47.8% were aged under 70, 86.7% were given a prognosis of 'years' and most (63.1%) remained for full cardio-pulmonary resuscitation in the event of cardio-pulmonary arrest. Records with completed statements of preferences (20.3%) contained information about preferences for physical and mental health treatment care as well as information about patient presentation and capacity, although most were brief and lacked expression of patient voice.

DISCUSSION

Compared to usual CMC users, the cohort of interest are relatively able, younger people using CMC to make long-term plans for active physical and mental health treatment. ADM is a service user-driven process, and so it was expected that authentic patient voice would be expressed within statements of preference, however this was mostly not achieved.

CONCLUSIONS

This digital tool is being used by people with SMI but to plan for more than palliative care. This cohort and supporting professionals have used CMC to plan for longer term physical and mental healthcare. Future research and policy should focus on development of tailored digital tools for people with SMI to plan for palliative, physical and mental healthcare and support expression of patient voice.

Association between triglyceride glucose index (TyG) and psychotic symptoms in patients with first-episode drug-naïve major depressive disorder

OBJECTIVE

Major depressive disorder (MDD) sufferers frequently have psychotic symptoms, yet the underlying triggers remain elusive. Prior research suggests a link between insulin resistance (IR) and increased occurrence of psychotic symptoms. Hence, this study sought to investigate the potential association between psychotic symptoms in Chinese patients experiencing their first-episode drug-naïve (FEDN) MDD and the triglyceride glucose (TyG) index, an alternative measure of insulin resistance (IR).

METHODS

Between September 2016 and December 2018, 1,718 FEDN MDD patients with an average age of 34.9 ± 12.4 years were recruited for this cross-sectional study at the First Hospital of Shanxi Medical University in China. The study collected clinical and demographic data and included assessments of anxiety, depression, and psychotic symptoms using the 14-item Hamilton Anxiety Rating Scale (HAMA), the 17-item Hamilton Depression Rating Scale (HAMD-17), and the positive subscales of the Positive and Negative Syndrome Scale (PANSS), respectively. Measurements of metabolic parameters, fasting blood glucose (FBG), and thyroid hormones were also gathered. To assess the correlation between the TyG index and the likelihood of psychotic symptoms, the study used multivariable binary logistic regression analysis. Additionally, two-segmented linear regression models were employed to investigate possible threshold effects in case non-linearity relationships were identified.

RESULTS

Among the patients, 9.95% (171 out of 1,718) exhibited psychotic symptoms. Multivariable logistic regression analysis showed a positive correlation between the TyG index and the likelihood of psychotic symptoms (OR = 2.12, 95% CI: 1.21-3.74, P = 0.01) after adjusting for confounding variables. Moreover, smoothed plots revealed a nonlinear relationship with the TyG index, revealing an inflection point at 8.42. Interestingly, no significant link was observed to the left of the inflection point (OR = 0.50, 95% CI: 0.04-6.64, P = 0.60), whereas beyond this point, a positive correlation emerged between the TyG index and psychotic symptoms (OR = 2.42, 95% CI: 1.31-4.48, P = 0.01). Particularly, a considerable 142% rise in the probability of experiencing psychotic symptoms was found with each incremental elevation in the TyG index.

CONCLUSIONS

Understanding the non-linear link between the TyG index and the risk of psychotic symptoms in Chinese patients with FEDN MDD highlights the potential for targeted therapeutic approaches. By acknowledging the threshold effect observed, there is an opportunity to mitigate risk factors associated with IR-related psychiatric comorbidities through tailored interventions. These preliminary results stress the need for further longitudinal research to solidify these insights and contribute to more effective therapeutic strategies.

Analysis of telomere length and the relationship with neurocognitive functions in euthymic bipolar disorder: A cross-sectional pilot study

BACKGROUND

Telomere shortening has been considered a potential biological marker related to disease susceptibility and aging in psychiatric disorders. However, the relationship between telomere length and bipolar disorder (BD-I and BD-II) is uncertain. Moreover, whether telomere shortening is an independent factor of cognitive impairment in BD patients is still inconclusive.

METHODS

We explore telomere length and cognitive function in patients with bipolar disorder and the relationship between them. We enrolled three groups (35 patients with euthymic BD-I, 18 with euthymic BD-II, and 38 healthy controls). Telomere length was measured by fluorescent quantitative polymerase chain reaction (q-PCR), and cognitive function was evaluated by the MATRICS Consensus Cognitive Battery (MCCB). SPSS 24.0 was used for statistical analysis.

RESULTS

The telomere length of euthymic patients with BD-I and BD-II was shorter than that of healthy controls (F = 8.228, P = 0.001, η2 = 0.176). Telomere length was not significantly different between BD-I and BD-II. Compared to HCs, poor performance was detected in attention and vigilance in BD-I patients (F = 3.473, P = 0.036). Working memory was positively correlated with telomere length in BD-II patients (Beta = 0.5, P = 0.041, Adjusted R2 = 0.2).

CONCLUSIONS

The current study provided evidence of shortened telomere length in euthymic BD patients, indicating that telomere shortening might be a promising biomarker of susceptibility to bipolar disorder. The telomere length predicted the working memory in BD-II patients. Further studies are needed to clarify the role of accelerated aging on cognitive functioning in a young group of patients with BD.

Psychiatric profiles in suicidal attempters: Relationships with suicide behaviour features

BACKGROUND

Suicide constitutes a major health concern worldwide, being a significant contributor of death, globally. The diagnosis of a mental disorder has been extensively linked to the varying forms of suicidal ideation and behaviour. The aim of our study was to identify the varying diagnostic profiles in a sample of suicide attempters.

METHODS

A sample of 683 adults (71.3% females, 40.10±15.74 years) admitted at a hospital emergency department due to a suicide attempt was recruited. Latent class analysis was used to identify diagnostic profiles and logistic regression to study the relationship between comorbidity profile membership and sociodemographic and clinical variables.

RESULTS

Two comorbidity profiles were identified (Class I: low comorbidity class, 71.3% of attempters; Class II: high comorbidity class, 28.7% of attempters). Class I members were featured by the diagnosis of depression and general anxiety disorder, and low comorbidity; by contrast, the high comorbidity profile was characterized by a higher probability of presenting two or more coexisting psychiatric disorders. Class II included more females, younger, with more depressive symptoms and with higher impulsivity levels. Moreover, Class II members showed more severe suicidal ideation, higher number of suicide behaviours and a greater number of previous suicide attempts (p<.01, for all the outcomes), compared to Class I members.

CONCLUSIONS

Psychiatric profiles may be considered for treatment provision and personalized psychiatric treatment in suicidal attempters as well as tackle suicide risk.

Genome-wide association study implicates the role of TBXAS1 in the pathogenesis of depressive symptoms among the Korean population

Although depression is an emerging disorder affecting many people worldwide, most genetic studies have been performed in European descent populations. Herein, a genome-wide association study (GWAS) was conducted in Korean population to elucidate the genomic loci associated with depressive symptoms. Two independent cohorts were used as discovery datasets, which consisted of 6474 (1484 cases and 4990 controls) and 1654 (557 cases and 1097 controls) Korean participants, respectively. The participants were divided into case and control groups based on the Beck Depression Inventory (BDI). Meta-analysis using the two cohorts revealed that rs6945590 was significantly associated with the risk of depressive symptoms [P = 2.83 × 10-8; odds ratio (OR) = 1.23; 95% confidence interval (CI): 1.15-1.33]. This association was validated in other independent cohorts which were another Korean cohort (258 cases and 1757 controls) and the East Asian study of the Psychiatric Genomics Consortium (PGC) (12,455 cases and 85,548 controls). The predicted expression levels of thromboxane A synthase 1 gene (TBXAS1), which encodes the enzyme thromboxane A synthase 1 and participates in the arachidonic acid (AA) cascade, was significantly decreased in the whole blood tissues of the participants with depressive symptoms. Furthermore, Mendelian randomization (MR) analysis showed a causal association between TBXAS1 expression and the risk of depressive symptoms. In conclusion, as the number of risk alleles (A) of rs6945590 increased, TBXAS1 expression decreased, which subsequently caused an increase in the risk of depressive symptoms.

How do explicit, implicit, and sociodemographic measures relate to concurrent suicidal ideation? A comparative machine learning approach

INTRODUCTION

Suicide is a leading cause of death, and decades of research have identified a range of risk factors, including demographics, past self-injury and suicide attempts, and explicit suicide cognitions. More recently, implicit self-harm and suicide cognitions have been proposed as risk factors for the prospective prediction of suicidal behavior. However, most studies have examined these implicit and explicit risk factors in isolation, and little is known about their combined effects and interactions in the prediction of concurrent suicidal ideation.

METHODS

In an online community sample of 6855 participants, we used different machine learning techniques to evaluate the utility of measuring implicit self-harm and suicide cognitions to predict concurrent desire to self-harm or die.

RESULTS

Desire to self-harm was best predicted using gradient boosting, achieving 83% accuracy. However, the most important predictors were mood, explicit associations, and past suicidal thoughts and behaviors; implicit measures provided little to no gain in predictive accuracy.

CONCLUSION

Considering our focus on the concurrent prediction of explicit suicidal ideation, we discuss the need for future studies to assess the utility of implicit suicide cognitions in the prospective prediction of suicidal behavior using machine learning approaches.

Mental health and access to care among the Roma population in Europe: A scoping review

The Roma are Europe's largest ethnic minority group, and often face discrimination and social exclusion. Social strife and lack of access to healthcare are associated with increased symptoms of psychopathology. We aimed to review evidence on mental health outcomes and on access to mental healthcare among the Roma population in Europe. We systematically searched five databases (PsycINFO, Global Health, Social Policy and Practice, Web of Science and PubMed) and conducted a grey literature search in August 2020. We identified 133 studies, 26 of which were included for final analysis. We present the results using a narrative synthesis. The available literature indicates a relatively high prevalence of anxiety, depression and substance abuse among Roma, and females seem to be more affected than males. Roma children exhibit more externalizing and internalizing disorders when compared with non-Roma children. Mental health and perceived well-being among the Roma population are strongly linked to social determinants of health such as housing or economic income. Access to mental healthcare is limited for Roma people because of several barriers pertaining to language, lack of information regarding available services, and the insurance and economic status of Roma people. Roma people report mainly negative experiences with mental health services, including a lack of understanding from healthcare providers, and instances of racism and discrimination. There is a need for more research on mental health and access to healthcare in Roma people. Future studies should be participatory in order to provide guidelines for mental healthcare that addresses the needs of the Roma population.

Review of Australia's funding commitments for suicide prevention from 2021-22 to 2026-27

Objective Examine the distribution of funding for suicide prevention in Australia from 2021-22 to 2026-27. Methods Government websites were reviewed to locate budget documents related to suicide prevention funding. Information was extracted on the program/service to be funded, and the funder entity, duration, and year allocation. Extracted data was reviewed to identify commonly targeted sub-populations. Results The majority of suicide prevention-related funding was allocated to aftercare for persons who have attempted suicide, consistent with the effectiveness of these services, followed by programs targeting the general population. Little funding was allocated to other specific sub-populations, such as young people and Aboriginal and Torres Strait Islander peoples. The amount of funding allocated to suicide prevention varied across jurisdictions, which is only partially explained by suicide rates. Conclusions There is a need for greater investment in care for specific sub-populations who are at higher risk of suicide. This study provides a baseline for comparing future investments in suicide prevention in Australia.

Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

Assessing the Effectiveness of ChatGPT in Delivering Mental Health Support: A Qualitative Study

Background

Artificial Intelligence (AI) applications are widely researched for their potential in effectively improving the healthcare operations and disease management. However, the research trend shows that these applications also have significant negative implications on the service delivery.

Purpose

To assess the use of ChatGPT for mental health support.

Methods

Due to the novelty and unfamiliarity of the ChatGPT technology, a quasi-experimental design was chosen for this study. Outpatients from a public hospital were included in the sample. A two-week experiment followed by semi-structured interviews was conducted in which participants used ChatGPT for mental health support. Semi-structured interviews were conducted with 24 individuals with mental health conditions.

Results

Eight positive factors (psychoeducation, emotional support, goal setting and motivation, referral and resource information, self-assessment and monitoring, cognitive behavioral therapy, crisis interventions, and psychotherapeutic exercises) and four negative factors (ethical and legal considerations, accuracy and reliability, limited assessment capabilities, and cultural and linguistic considerations) were associated with the use of ChatGPT for mental health support.

Conclusion

It is important to carefully consider the ethical, reliability, accuracy, and legal challenges and develop appropriate strategies to mitigate them in order to ensure safe and effective use of AI-based applications like ChatGPT in mental health support.

A Retrospective Chart Review Suggests That Coordinated, Multidisciplinary Treatment for Patients with Anorexia Nervosa Improves Odds of Weight Restoration

Purpose

The objective of this study was to conduct a secondary data analysis of clinical information documented in the electronic medical record to assess the clinical outcomes of patients who received three different treatment approaches on clinical outcomes for treatment of patients with anorexia nervosa (AN).

Patients and methods

Historical electronic medical record (EMR) data on patients aged 6 to 80 years diagnosed with AN seen in a healthcare system between 2007 and 2017 were stratified, according to services received, into three groups: Group A (n = 48) received hospital-based services; Group B (n = 290) saw one or two provider types; Group C (n = 26) received outpatient coordinated multidisciplinary care from three provider types. Clinical outcomes [body mass index for adults (BMI), body mass index percentile (BMI%ile) for pediatric patients] defined AN severity and weight restoration. EMR data were analyzed using a generalized mixed-effects model and a Markov Transition model to examine the odds of weight restoration and the change in odds of weight restoration across the number of provider visits, respectively.

Results

Patients receiving coordinated multidisciplinary care had significantly higher odds of weight restoration compared with patients receiving hospital-based services only (OR = 3.76, 95% CI [1.04, 13.54], p = 0.042). In addition, patients receiving care from 1 to 2 providers (OR = 1.006, 95% CI [1.003, 1.010], p = 0.001) or receiving coordinated multidisciplinary care (OR = 1.005, 95% CI [1.001, 1.011], p = 0.021) had significantly higher odds of weight restoration per provider visit day compared with patients receiving hospital-based services only.

Conclusion

This retrospective chart review supports the coordinated, multidisciplinary care model for the weight restoration in patients with AN in an outpatient setting.

Suicides in degenerative neurocognitive disorders and traumatic brain injuries

BACKGROUND

Neuropsychiatric symptoms in major neurocognitive disorders have been strongly associated with suicidality.

METHODS

The objectives were to explore suicide rates in degenerative neurocognitive disorders (DNDs), alcohol-related neurocognitive disorders (ARNDs), and traumatic brain injuries (TBIs). Patients who received these diagnoses between 1998 and 2015 (N = 231,817) were identified from nationwide registers, and their mortality was followed up until December 31, 2018. We calculated incidences of suicides per 100,000 person-years, types of suicides, and suicide rates compared with the general population (standardized mortality ratio [SMR]).

RESULTS

During the follow-up, 0.3% (95% confidence interval [95% CI]: 0.2-0.5) of patients with DNDs, 1.1% (0.7-1.8) with ARNDs, and 1.0% (0.7-1.3) with TBIs committed suicide. Suicide mortality rate was higher in men (58.9, 51.3, to 67.4 per 100,000) than in women (9.8, 7.5, to 12.5 per 100,000). The highest suicide rate was in ARNDs (98.8, 65.1, to 143.8 per 100,000), followed by TBIs (82.0, 62.4, to 105.8 per 100,000), and DNDs (21.2, 18.3, to 24.5 per 100,000). The SMRs (95% CI) were 3.69 (2.53-5.38), 2.99 (2.31-3.86), and 1.31 (1.13-1.51), respectively, and no sex difference emerged. The most common cause of death was self-inflicted injury by hanging or drowning (12.4, 10.3, to 14.8 per 100,000).

CONCLUSIONS

Suicide rates were higher in all three patient groups than the general population. Suicide risk remained elevated for more than 10 years after diagnosis. The suicide methods were mostly violent.

TCF4 and RBFOX1 as peripheral biomarkers for the differential diagnosis and treatment of major depressive disorder

BACKGROUND

Recent genome-wide association studies on major depressive disorder (MDD) have indicated the involvement of LRFN5 and OLFM4; however, the expression levels and roles of these molecules in MDD remain unclear. The present study aimed to determine the serum levels of TCF4 and RBFOX1 in patients with MDD and to investigate whether these molecules could be used as biomarkers for MDD diagnosis.

METHODS

The study included 99 drug-naïve MDD patients, 90 drug-treated MDD patients, and 81 healthy controls (HCs). Serum TCF4 and RBFOX1 levels were measured by ELISA. Pearson's correlation analysis was conducted to determine the association between TCF4/RBFOX1 and clinical variables. Linear support vector machine classifier was used to evaluate the diagnostic capabilities of TCF4 and RBFOX1.

RESULTS

Serum TCF4 and RBFOX1 levels were substantially higher in MDD patients than in HCs and significantly lower in drug-treated MDD patients than in drug-naïve MDD patients. Moreover, serum TCF4 and RBFOX1 levels were associated with the Hamilton Depression Scale score, duration of illness, serum lipids levels, and hepatic function. Thus, both these molecules showed potential as biomarkers for MDD. TCF4 and RBFOX1 combination exhibited a higher diagnostic performance, with the mean area under the curve values of 0.9861 and 0.9936 in the training and testing sets, respectively.

LIMITATIONS

Small sample size and investigation of only the peripheral nervous system.

CONCLUSIONS

TCF4 and RBFOX1 may be involved in the pathogenesis of MDD, and their combination may serve as a diagnostic biomarker panel for MDD.

Gender differences in prevalence and clinical risk factors of suicide attempts in young adults with first-episode drug-naive major depressive disorder

BACKGROUND

Suicide rates in adolescents with major depressive disorder (MDD) change with age and gender. Early adulthood is an important transitional stage between late adolescence and adulthood, in which an individual's mind gradually matures. However, there are fewer studies on prevalence and variables linked to the suicide attempts of young adults with MDD.

AIMS

To explore gender differences in the prevalence and risk factors associated with suicide attempts in young adults with first-episode drug-naive MDD.

METHOD

The Hamilton Rating Scale for Depression (HRSD), Hamilton Rating Scale for Anxiety (HRSA) and Positive Subscale of the Positive and Negative Syndrome Scale (PANSS) were used to assess depression, anxiety and psychotic symptoms respectively and various biochemical indicators were assessed.

RESULTS

Among 293 young adults with first-episode drug-naive MDD, the prevalence of suicide attempts was 15.45% (19/123) for males and 14.12% (24/170) for females. Males with suicide attempts had higher levels of thyroid-stimulating hormone (TSH) and higher PANSS Positive Subscale scores, whereas females with suicide attempts had higher TSH, serum total cholesterol, fasting blood glucose and diastolic blood pressure levels and higher scores on the HRSD, HRSA, PANSS Positive Subscale (all Bonferroni corrected P < 0.05). In males, PANSS Positive Subscale score (B = 0.17, P = 0.03, OR = 1.19, 95% CI 1.02-1.38) was a risk factor for suicide attempts.

CONCLUSIONS

There were significant gender differences in the risk factors for suicide attempts in young adults with first-episode drug-naive MDD.

Preliminary study: cognitive behavioural therapy for insomnia in adolescents with anorexia nervosa

PURPOSE

Insomnia and anorexia nervosa (AN) are frequently comorbid, negatively affecting the evolution and the prognosis of AN. Within this framework, the management of sleep disorders appears as critical. The aim of this retrospective study is to assess, for the first time, the efficacy of cognitive and behavioural therapy for insomnia (CBT-I) on sleep disturbances in adolescents with AN. To do so, we investigated the impact of CBT-I on sleep disturbances and sleep-related outcomes, in BMI, AN symptoms, anxiety and depressive symptoms, emotionality and quality of life. These features were compared between two groups of patients with AN, one following CBT-I, and the other receiving the regular treatment at the psychiatric unit.

METHODS

Data collection occurred between January and May 2022. The study included 42 adolescents in-treatment at the Eating Disorders care specialised unit at Salvator Hospital in Marseille. They were randomly assigned to the CBT-I group (N = 31) or the control group (N = 11). Several clinical elements were assessed using sleep diaries and self-report questionnaires.

RESULTS

Participants undergoing CBT-I showed a significant improvement in sleep latency, total wake time and sleep efficacy, as well as in physical well-being. No significant effects were found regarding AN symptoms.

CONCLUSION

These preliminary findings provide support for CBT-I effectiveness in adolescents with AN, as shown by significant improvements in several sleep parameters, as well as in physical well-being. These promising results, underline the relevance of this topic and its potential benefits for a more appropriate treatment for adolescents with AN.

LEVEL OF EVIDENCE

Level V, retrospective study.

Physical Exercise as an Intervention for Depression: Evidence for Efficacy and Mu-Opioid Receptors as a Mechanism of Action

Physical exercise is often cited as an important part of an intervention for depression, and there is empirical evidence to support this. However, the mechanism of action through which any potential antidepressant effects are produced is not widely understood. Recent evidence points toward the involvement of endogenous opioids, and especially the mu-opioid system, as a partial mediator of these effects. In this chapter, we discuss the current level of empirical support for physical exercise as either an adjunctive or standalone intervention for depression. We then review the extant evidence for involvement of endogenous opioids in the proposed antidepressant effects of exercise, with a focus specifically on evidence for mu-opioid system involvement.

Eating disorders among queer and trans individuals: Implications for conceptualization, assessment, and treatment

Eating disorders (EDs) have been traditionally viewed as a disorder affecting cisgender, heterosexual women. Yet, the prevalence of EDs among queer and trans (QnT) individuals, coupled with the lack of interventions that attend to contextual factors related to sexual orientation and gender identity, underscore a critical health disparity issue requiring urgent attention. Here, we first review factors pertaining to QnT individuals' minoritized sexual and gender identities that are important to consider in ED conceptualization for this population (e.g., minority stressors, identity-based body image standards). Next, we describe problematic assumptions present in existing ED assessment and propose more inclusive approaches. Lastly, we provide suggestions for practices that providers can implement within their treatment of EDs among QnT individuals.

Permissive epigenetic regulatory mechanisms at the histone level are enhanced in postmortem dorsolateral prefrontal cortex of individuals with schizophrenia

BACKGROUND

Susceptibility to schizophrenia is determined by interactions between genes and environment, possibly via epigenetic mechanisms. Schizophrenia has been associated with a restrictive epigenome, and histone deacetylase (HDAC) inhibitors have been postulated as coadjuvant agents to potentiate the efficacy of current antipsychotic drugs. We aimed to evaluate global histone posttranslational modifications (HPTMs) and HDAC expression and activity in the dorsolateral prefrontal cortex (DLPFC) of individuals with schizophrenia.

METHODS

We used postmortem DLPFC samples of individuals with schizophrenia and controls matched for sex, age, and postmortem interval. Schizophrenia samples were classified into antipsychotic-treated or antipsychotic-free subgroups according to blood toxicology. Expression of HPTMs and HDAC was quantified by Western blot. HDAC activity was measured with a fluorometric assay.

RESULTS

H3K9ac, H3K27ac, and H3K4me3 were globally enhanced in the DLPFC of individuals with schizophrenia (+24%-42%, p < 0.05). HDAC activity (-17%, p < 0.01) and HDAC4 protein expression (-20%, p < 0.05) were downregulated in individuals with schizophrenia. Analyses of antipsychotic-free and antipsychotic-treated subgroups revealed enhanced H3K4me3 and H3K27ac (+24%-49%, p < 0.05) and reduced HDAC activity in the antipsychotic-treated, but not in the antipsychotic-free subgroup.

LIMITATIONS

Special care was taken to control the effect of confounding factors: age, sex, postmortem interval, and storage time. However, replication studies in bigger cohorts might strengthen the association between permissive HPTMs and schizophrenia.

CONCLUSION

We found global HPTM alterations consistent with an aberrantly permissive epigenome in schizophrenia. Further studies to elucidate the significance of enhanced permissive HPTMs in schizophrenia and its association with the mechanism of action of antipsychotic drugs are encouraged.

Investigating the Theory of Clinical Perfectionism in a Transdiagnostic Eating Disorder Sample Using Network Analysis

Eating disorders are deadly psychiatric illnesses, with treatments working for less than half of individuals who seek treatment. The transdiagnostic theory of eating disorders proposes that eating disorders share similar maintaining symptoms, such as what this theory calls clinical perfectionism (i.e., high levels of concern over mistakes and personal standards). However, it has been difficult to examine the interrelationship of specific aspects of perfectionism, beyond assessing moderation effects, which have generally not found support for the theory of clinical perfectionism in eating disorders. Thus, we used network analysis to test the theory of perfectionism by testing the interrelationships between maladaptive perfectionism facets (concern over mistakes, personal standards, parental criticism, parental expectations, and personal standards) and eating disorder symptoms in 397 individuals diagnosed with an eating disorder. Concern over mistakes was a central symptom and demonstrated the strongest interrelationships with eating disorder symptoms compared to the other aspects of perfectionism, connecting to eating concerns and cognitive restraint. Objective binge eating had a strong negative connection to personal standards. We identified specific central symptoms and illness pathways of perfectionism, which partially supports the theory of clinical perfectionism. Results, if replicated, may suggest that concern over mistakes might be best reconceptualized as part of eating disorder pathology and be targeted to improve treatment outcomes for eating disorders.

Estimating Changes in Weight and Metabolic Parameters Before and After Treatment With Cariprazine: A Retrospective Study of Electronic Health Records

PURPOSE

Weight gain and associated negative cardiometabolic effects can occur as a result of mental illness or treatment with second-generation antipsychotics (SGAs), leading to increased rates of morbidity and mortality. In this analysis, we evaluated the effect of the SGA cariprazine on weight and metabolic parameters in a real-world, retrospective, observational dataset.

METHODS

Electronic health records from the Optum Humedica database (October 1, 2014-December 31, 2020) were analyzed during the 12-month period before starting cariprazine (baseline) and for up to 12 months following cariprazine initiation; approved and off-label indications were included. Body weight trajectories were estimated in the overall patient cohort and at 3-, 6-, and 12-month timepoints (primary objective). Changes in hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides were also evaluated (secondary objectives). Percentages of patients with clinically relevant shifts in body weight, total cholesterol, and fasting triglycerides were also determined. Discontinuation rates for metabolic regulating medications were calculated. Average predicted values were estimated by linear mixed-effects regression models.

FINDINGS

A total of 2,301 patients were included; average duration of follow-up was 133.7 days. Average predicted weight change for patients during the cariprazine overall follow-up period was +2.4 kg, with predicted weight changes of +0.8 kg (n = 811), +1.1 kg (n = 350), and +1.4 kg (n = 107) at months 3, 6, and 12, respectively. Overall, the majority of patients did not experience clinically significant (≥7%) weight gain (82.8%) or loss (90.5%) after starting cariprazine. Average predicted HbA1c levels (n = 189) increased during baseline (0.15%/year) and decreased during cariprazine treatment (-0.2%/year). Average predicted triglyceride levels (n = 257) increased during baseline (15.0 mg/dL/year) and decreased during cariprazine treatment (-0.7 mg/dL/year). Predicted LDL (n = 247) and HDL (n = 255) values decreased during baseline (-7.3 and -1.1 mg/dL/year, respectively); during cariprazine treatment, LDL increased by 5.6 mg/dL/year and HDL decreased by -0.6 mg/dL/year. During follow-up, most patients did not shift from normal/borderline to high total cholesterol (<240 to ≥240 mg/dL; 522 [90.2%]) or fasting triglyceride (<200 to ≥200 mg/dL; 143 [88.8%] patients) levels; shifts from high to normal/borderline levels occurred in 44 (61.1%) patients for total cholesterol and 38 (57.6%) patients for fasting triglycerides. After starting cariprazine, the discontinuation rate per 100 patient-years was 60.4 for antihyperglycemic medication and 87.4 for hyperlipidemia medication.

IMPLICATIONS

These real-world results support short-term clinical trial findings describing a neutral weight and metabolic profile associated with cariprazine treatment and they expand the dataset to include long-term follow-up.

Incidence, prevalence, and mortality of schizophrenia from 2016 to 2020 in Shandong, China

The epidemiology of schizophrenia has been reported in many countries. However, due to the limitations of those studies, the findings cannot be generalized to other parts of the world, especially in China. In this study, the incidence, prevalence, and mortality of schizophrenia in Shandong, China were calculated using data from the National Severe Mental Disorder Registration System collected between 2016 and 2020 and census data from 2010 to 2020. The overall incidence decreased from 9.61 per 100,000 in 2016 to 4.40 per 100,000 in 2020, the aggregate prevalence was approximately 3.20 per 1000, and the overall mortality ranged from 6.17 per 100,000 to 7.71 per 100,000. The evidence from this study indicated that the incidence, prevalence, and mortality of schizophrenia were higher in rural areas than in urban areas. Females had higher incidence, prevalence, and mortality than males. This study provided epidemiological information on schizophrenia and opened avenues for future research.

Clinical Characteristics of US Adolescents Hospitalized for Eating Disorders 2010-2022

BACKGROUND AND OBJECTIVES

Eating disorders (EDs) affect a substantial number of American adolescents, with an increasing number seeking care for EDs during the coronavirus disease 2019 pandemic. We assessed the prevalence and clinical characteristics of adolescents hospitalized with EDs during 2010 to 2022.

METHODS

We used data from a national database of 12 children's hospitals (PEDSnet). Adolescents aged 12 to 21 years hospitalized for ED, disordered eating, binge ED, anorexia nervosa, bulimia nervosa, avoidant-restrictive food intake disorder (ARFID), or other EDs were included. Patients with complex or chronic illness or with EDs hospitalized for another reason were excluded. We analyzed demographic data, clinical characteristics, cardiac manifestations, coexistence of psychiatric conditions, and hospital stay characteristics.

RESULTS

We included 13 403 hospitalizations by 8652 patients in this study. We found a gradual increase in hospitalizations for patients with EDs before the pandemic and a large increase during the pandemic. Mean age was 15.8 years with 85.9% described as female and 71.8% as white. Anorexia nervosa was the most common ED (57.5%), though hospitalization for patients with ARFID is increasing. Patients' median BMI percentage was 90.3%. Patients' malnutrition was classified as none (50.9%), mild (25.0%), moderate (18.6%), or severe (5.4%). Significant numbers of patients had a diagnosis of depression (58.5%) or anxiety (57.0%); 21.9% had suicidal thoughts. Nearly one-quarter (23.6%) required rehospitalization for ED treatment within 1 year.

CONCLUSIONS

Hospitalizations for EDs among American adolescents are increasing, with a spike during the coronavirus disease 2019 pandemic. Significant numbers of patients hospitalized with EDs have suicidal thoughts. Trends in patients with ARFID require monitoring.

The efficacy of zuranolone in postpartum depression and major depressive disorder: a review & number needed to treat (NNT) analysis

INTRODUCTION

Major depressive disorder (MDD) is a common and debilitating mental illness. Postpartum depression (PPD) impacts women globally and is one of the most common complications of childbirth that is underdiagnosed and undertreated, adversely impacting the mental health of women, children, and partners.Available antidepressant medications require weeks to months before showing effect. In this setting, zuranolone, an oral neuroactive steroid and a positive allosteric modulator of GABAA receptors, is an attractive alternative as a rapid-acting antidepressant treatment.

AREAS COVERED

This article reviews zuranolone (SAGE217), focusing on available clinical studies in individuals with PPD and MDD. This paper adds to the extant literature by presenting the efficacy data as Number Needed to Treat (NNT) to facilitate indirect comparisons with other antidepressants.

EXPERT OPINION

Zuranolone is a novel rapid-acting (i.e. two week course) oral antidepressant for the treatment of adults with PPD with ongoing clinical trials evaluating its efficacy in adults with MDD. Zuranolone is well tolerated with no significant safety concerns in any clinical trials completed to date. Zuranolone will be scheduled by the Drug Enforcement Agency (DEA).

[The Eating Attitude Test (EAT-26): assessment of psychometric characteristics in a sample of patients with depression]

OBJECTIVE

To analyze the psychometric properties of the Eating Attitudes Test (EAT-26) in a Russian sample of patients with a depressive episode (DE) and recurrent depressive disorder (RDD).

MATERIAL AND METHODS

This multicenter cross-sectional study included 338 people (216, 63.9% women), aged 18-59 years, with diagnoses of DE/ RDD. Concomitant current eating disorder (ED) was diagnosed in 10.1% (n=34) of patients, including 2.4% (n=8) with anorexia nervosa and 7.7% (n=26) with bulimia nervosa. All participants underwent a structured «Mini International Neuropsychiatric Interview» to verify the clinical diagnosis, as well as a psychometric examination to assess EDs using EAT-26. Statistical analysis was performed in RStudio v1.4.1717.

RESULTS

Results of correlation analysis of EAT-26 items revealed that item 26 had a negative adjusted correlation coefficient (-0.052) and was excluded for the analysis of subsequent stages. The six-factor structure of EAT-25 was revealed, including the subscales «Bodily control», «Social pressure», «Dietary restrictions», «Bulimia», «Ritual nutrition» and «Loss of self-control.» Item 19 («I have self-control over food») was inverted, as it had a negative factor load, as well as a negative meaning. The internal consistency of EAT was analyzed on 25 questionnaire items, as well as on individual subscales, and was quite high. When checking the convergent validity of EAT with established diagnoses of ED, it was revealed that patients with ED had a significantly higher score on EAT, as well as on the subscales «Body control», «Dietary restrictions», «Bulimia» and «Loss of self-control» compared with patients without a diagnosis of ED. According to the «Ritual nutrition» subscale, no links with ED were found.

CONCLUSION

The EAT demonstrated good psychometric characteristics in a Russian sample of patients diagnosed with DE/RDD.

COVID-19 and Adolescent Outpatient Mental Health Service Utilization

OBJECTIVE

The COVID-19 pandemic created challenges in accessing mental health (MH) services when adolescent well-being declined. Still, little is known about how the COVID-19 pandemic affected outpatient MH service utilization for adolescents.

METHODS

Retrospective data were collected from electronic medical records of adolescents aged 12-17 years at Kaiser Permanente Mid-Atlantic States, an integrated health care system from January 2019 to December 2021. MH diagnoses included anxiety, mood disorder/depression, anxiety and mood disorder/depression, attention-deficit/hyperactivity disorder, or psychosis. We used interrupted time series analysis to compare MH visits and psychopharmaceutical prescribing before and after the COVID-19 onset. Analyses were stratified by demographics and visit modality.

RESULTS

The study population of 8121 adolescents with MH visits resulted in a total of 61,971 (28.1%) of the 220,271 outpatient visits associated with an MH diagnosis. During 15,771 (7.2%) adolescent outpatient visits psychotropic medications were prescribed. The increasing rate of MH visits prior to COVID-19 was unaffected by COVID-19 onset; however, in-person visits declined by 230.5 visits per week (P < .001) from 274.5 visits per week coupled with a rise in virtual modalities. Rates of MH visits during the COVID-19 pandemic differed by sex, mental health diagnosis, and racial and ethnic identity. Psychopharmaceutical prescribing during MH visits declined beyond expected values by a mean of 32.8 visits per week (P < .001) at the start of the COVID-19 pandemic.

CONCLUSIONS

A sustained switch to virtual visits highlights a new paradigm in care modalities for adolescents. Psychopharmaceutical prescribing declined requiring further qualitative assessments to improve the quality of access for adolescent MH.

The HPA Axis as Target for Depression

Major depressive disorder (MDD) is a stress-related mental disorder with a lifetime prevalence of 20% and, thus, is one of the most prevalent mental health disorders worldwide. Many studies with a large number of patients support the notion that abnormalities of the hypothalamus-pituitaryadrenal (HPA) axis are crucial for the development of MDD. Therefore, a number of strategies and drugs have been investigated to target different components of the HPA axis: 1) corticotrophinreleasing hormone (CRH) 1 receptor antagonists; 2) vasopressin V1B receptor antagonists, 3) glucocorticoid receptor antagonists, and 4) FKBP5 antagonists. Until now, V1B receptor antagonists and GR antagonists have provided the most promising results. Preclinical data also support antagonists of FKBP5, which seem to be partly responsible for the effects exerted by ketamine. However, as HPA axis alterations occur only in a subset of patients, specific treatment approaches that target only single components of the HPA axis will be effective only in this subset of patients. Companion tests that measure the function of the HPA axis and identify patients with an impaired HPA axis, such as the dexamethasone-corticotrophin-releasing hormone (dex-CRH) test or the molecular dexamethasonesuppression (mDST) test, may match the patient with an effective treatment to enable patient-tailored treatments in terms of a precision medicine approach.

Making meaning of multimorbidity and severe mental illness: A viewpoint

People living with severe mental illness, such as schizophrenia and bipolar affective disorder, frequently experience poorer physical health compared to those without mental illness. This issue has hitherto been approached through the disease-centred construct of comorbidity, where subsequent conditions are viewed as secondary to an 'index condition'. In contrast, this Viewpoint sets out to explain why multimorbidity, a patient-centred concept that instead refers to the coexistence of multiple chronic illnesses, is a more versatile and robust framework for tackling the issue of poor physical health in people with severe mental illness. In establishing this argument, this Viewpoint has sought to address three key areas. First, this article will discuss the epidemiology of both physical and psychiatric multimorbidity, with respect to how they manifest at greater frequency and at younger ages in people with severe mental illness. Second, the profound consequences of this multimorbidity burden will be explored, with respect to the 'three D's' of death (premature mortality), disability (functional impacts) and deficit (health-economic impacts). Finally, the utility of multimorbidity as a framework will be illustrated through a proposal for a three-dimensional multimorbidity construct composed of (1) quantity, (2) severity and (3) duration of an individual's chronic illnesses. Consequently, this Viewpoint aims to capture why it is necessary for modern psychiatry to grasp the concept of multimorbidity to facilitate holistic healthcare for people living with severe mental illness.