Although deficits in affective processing are a core component of anorexia nervosa (AN), we lack a detailed characterization of the neurobiological underpinnings of emotion regulation impairment in AN. Moreover, it remains unclear whether these neural correlates scale with clinical outcomes.

We investigated the neural correlates of negative emotion regulation in a sample of young women receiving day-hospital treatment for AN (n = 21) and healthy controls (n = 21). We aimed to determine whether aberrant brain activation patterns during emotion regulation predicted weight gain following treatment in AN patients and were linked to AN severity. To achieve this, participants completed a cognitive reappraisal paradigm during functional magnetic resonance imaging. Skin conductance response, as well as subjective distress ratings, were recorded to corroborate task engagement.

Compared to controls, patients with AN showed reduced activation in the dorsolateral prefrontal cortex (dlPFC) during cognitive reappraisal [pFWE<0.05, threshold-free cluster enhancement (TFCE) corrected]. Importantly, psycho–physiological interaction analysis revealed reduced functional connectivity between the dlPFC and the amygdala in AN patients during emotion regulation (pFWE<0.05, TFCE corrected), and dlPFC-amygdala uncoupling was associated with emotion regulation deficits (r = −0.511, p = 0.018) and eating disorder severity (r = −0.565, p = .008) in the AN group. Finally, dlPFC activity positively correlated with increases in body mass index (r = 0.471, p = 0.042) and in body fat mass percentage (r = 0.605, p = 0.008) following 12 weeks of treatment.

Taken together, our findings indicate that individuals with AN present altered fronto-amygdalar response during cognitive reappraisal and that this response may serve as a predictor of response to treatment and be linked to clinical severity.

Prognosis and disposition among older emergency department (ED) patients with suspected infection remains challenging. Frailty is increasingly recognized as a predictor of poor prognosis among critically ill patients; however, its association with clinical outcomes among older ED patients with suspected infection is unknown.

We conducted a multicenter prospective cohort study at two tertiary care EDs. We included older ED patients (≥75 years) with suspected infection. Frailty at baseline (before index illness) was explicitly measured for all patients by the treating physicians using the Clinical Frailty Scale (CFS). We defined frailty as a CFS 5–8. The primary outcome was 30-day mortality. We used multivariable logistic regression to adjust for known confounders. We also compared the prognostic accuracy of frailty with the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) criteria.

We enrolled 203 patients, of whom 117 (57.6%) were frail. Frail patients were more likely to develop septic shock (adjusted odds ratio [aOR], 1.83; 95% confidence interval [CI], 1.08–2.51) and more likely to die within 30 days of ED presentation (aOR 2.05; 95% CI, 1.02–5.24). Sensitivity for mortality was highest among the CFS (73.1%; 95% CI, 52.2–88.4), compared with SIRS ≥ 2 (65.4%; 95% CI, 44.3–82.8) or qSOFA ≥ 2 (38.4; 95% CI, 20.2–59.4).

Frailty is a highly prevalent prognostic factor that can be used to risk-stratify older ED patients with suspected infection. ED clinicians should consider screening for frailty to optimize disposition in this population.

There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.

Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.

Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.

Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.

Excessive cortical cerebrospinal fluid (CSF) has been acknowledged as a possible marker of a gray matter loss. This excess in schizophrenia is found predominantly in the prefrontal and temporal regions. We hypothesized that the poorer global outcome and treatment response in males with schizophrenia are related to a greater cortical volume loss as compared to females.

In order to test this hypothesis we have used magnetic resonance imaging (MRI) to study the cortical (prefrontal, temporal, and hemispheric) CSF values in a group of 85 patients with schizophrenia, of whom 56 were males and 29, females. We calculated the residual values of CSF in the patients based on the data pertaining to 45 control subjects and linear regression, from which the normal effects of age and intracranial volume were discounted. These residual scores constitute a quantitative measurement of the excess of CSF due to the disease.

Males, but not females, presented a trend-level significant excess of left prefrontal CSF. The prefrontal and temporal residual values were significantly associated with illness duration in males, but not in females.

These results conform to the worse outcome and the higher severity of structural abnormalities generally found in schizophrenia in male subjects.

Our data support the hypothesis of accelerated prefrontal cortical loss in males, but not in females with schizophrenia.

Little evidence exists about suicidal acts in eating disorders and its relation with personality. We explored the prevalence of lifetime suicide attempts (SA) in women with bulimia nervosa (BN), and compared eating disorder symptoms, general psychopathology, impulsivity and personality between individuals who had and had not attempted suicide. We also determined the variables that better correlate with of SA.

Five hundred sixty-six BN outpatients (417 BN purging, 47 BN non-purging and 102 subthreshold BN) participated in the study.

Lifetime prevalence of suicide attempts was 26.9%. BN subtype was not associated with lifetime SA (p = 0.36). Suicide attempters exhibited higher rates on eating symptomatology, general psychopathology, impulsive behaviors, more frequent history of childhood obesity and parental alcohol abuse (p < 0.004). Suicide attempters exhibited higher scores on harm avoidance and lower on self-directedness, reward dependence and cooperativeness (p < 0.002). The most strongly correlated variables with SA were: lower education, minimum BMI, previous eating disorder treatment, low self-directedness, and familial history of alcohol abuse (p < 0.006).

Our results support the notion that internalizing personality traits combined with impulsivity may increase the probability of suicidal behaviors in these patients. Future research may increase our understanding of the role of suicidality to work towards rational prevention of suicidal attempts.

Comorbidity has been defined as the coexistence of somatic and psychiatric diseases with diferent physiopatology in the same person, and it can appear simultaneously to the schizophrenia or during the patient's lifetime. There are two types of comorbidity: episodical or taking place during the lifetime of the patient. We can diffferenciate between comorbidity itself (in cluster, dependent or associated) to the so-called pseudo-comorbidity. Besides, comorbidity has been classified as a co-syndrome and it is considered a prognosis indicator of this disease, which can determine an increase in the rates related to relapses, worse response to treatment, less capacity to cope with social situations, and suicide in patients suffering from schizophrenia.

177 schizophrenic patients were assessed for affective symptoms and suicide behaviour. 24.3% were suffered for depression. 35% had a previous record of autolytic attempts. The rate of suicide history were higher among depressed schizophrenics (50%) than non-depressed schizophrenics (20%) (p<0,05).

We point out the clinic importance of suicide in schizophrenic patients suffering from depression. Moreover, the study shows the necessity to carry out longitudinal studies to recognize indicators of depression in advance and establish the diagnosis of depression, and, also, to acknowledge the importance of the gender factor in the depression of schizophrenic patients.

Empathy is critical to the development of professionalism in medical students, but evidence suggests that empathy actually declines over the course of undergraduate medical education.

Improving medical student empathy by encouraging students to think about the person behind the illness.

Two interventions were studied. From December 2015 until November 2016, a fourth year psychiatry medical student book club was conducted. Students were asked to read an autobiography of a lived experience of psychosis. The old age simulation suit aims to simulate the sensory and physical impairments faced by older adults with age related illnesses. A training session provided a transient experience of old age for the students.

Forty-four students completed the feedback on the book club. Twenty-eight (64%) stated that they strongly agreed with the statement ‘the book club encouraged me to consider the person behind the illness’. Thirty-nine (89%) stated that after attending the book club their empathy towards people with mental health problems had increased. Eleven students completed full feedback following the old age simulation session. Empathy statements relating to living in an ageing body improved from the pre-test median score of 4 (range 1–7) to a median score of 6 (range 2–8) post-teaching session. Empathy statements focusing on sensory and physical impairments had pre-test score median of 3 (range 1–7) and post-test median 8 (range 3–9).

Feedback from these sessions has demonstrated that with a little creativity, empathy training can be delivered to medical students with a positive impact.

The authors have not supplied their declaration of competing interest.

North East London NHS Foundation Trust (NELFT) provides an extensive range of integrated community and mental health services for people living in London serving a population of 1.5 million people. With an annual budget of £325 million NELFT is one of the largest community service providers in the United Kingdom (UK). NELFT is responsible for the education and training of the entire workforce and in August 2016, it employed a nurse fellow to work with the medical education fellows so it could focus on multidisciplinary team (MDT) teaching.

• (1) Providing MDT teaching by delivered by a MDT medical education team.

• (2) Improving the training experience of all trainees, nurses and allied health professionals in NELFT.

• (3) Improving physical health knowledge for mental health staff.

• (4) Improving mental health knowledge of physical health staff.

Two psychiatrists and one nurse manager worked together on joint projects to deliver the MDT teaching. Teaching sessions where at least one psychiatrist and nurse manager delivered teaching on serious incidents affecting patient care, identification and management of sepsis in community settings and empathy training using an old age simulation suit.

Multiple teaching sessions were delivered to MDTs within the Trust. Staffs were receptive to learning in MDTs rather than traditional splits according to professions. Due to the success of this teaching and the reputation of the medical education team, neighboring Trusts have expressed an interest in working in partnership with the team to further enhance teaching and learning in acute and community settings.

The authors have not supplied their declaration of competing interest.

Poor adherence to treatment is one of the main problems in health care to psychiatric patients. The second-generation antipsychotics, and the subsequent emergence of the depot forms (long acting formulations) have facilitated this aspect, increasing the time to clinical relapse in patients with schizophrenia.

Determine the time to relapse in a clinical sample of patients diagnosed with schizophrenia treated with paliperidone palmitate over 3 years. Other objectives include the possible reduction in hospital admissions, as well as the possible reduction of psychiatric emergency visits, concomitant medication (benzodiazepines and Biperiden) and the possible increase in drug monotherapy.

This is a study with a sample of 101 patients with schizophrenia who had started treatment with PP (consecutive sampling). Quantified variables in the 12 months prior to the change of PP treatment with variables at 6, 12, 24 and 36 months after initiation of treatment with PP were compared.

At the end of the tracking, 72.22% (73 patients) remained clinically stable, with adequate adherence to treatment and there have been no clinical relapses. It has obtained a statistically significant reduction in the use of concomitant medication, emergency room visits and the average duration of revenues, with no clinical relapse should occur in patients of the sample in the second and third year.

The authors have not supplied their declaration of competing interest.

Role-playing scenarios are widely used in psychiatry education, both as a means of assessment and for teaching various clinical skills. But can you get as much from them by learning vicariously as an observer? Fourth-year medical students from Queen Mary University of London were invited to a psychiatry practice OSCE (objective structured clinical examination), shortly before end of year exams. We created 96 places, approximately 40% of the year, but to maximize numbers students also rotated through the six-station OSCE circuit in pairs. For each scenario students alternated either undertaking the OSCE task or observing.

We sought to identify if there was a significant difference in student experience depending on whether they were the ‘candidate’ or ‘observer’. Students were asked to rate their learning experience in each station on a five-point Likert scale and this was analyzed using an ordinal logistic regression model.

While students rated their experiences as ‘observers’ marginally lower than that of ‘candidates’, we found no statistically significant difference (OR = 0.629, P = 0.093). Practice OSCEs took place over six half-days with different facilitators and role-players, but we identified no interaction from these factors. For one station on depression, we found a statistically significant interaction in which ‘candidates’ rather than ‘observers’ rated better experiences (P = 0.032).

Observation by learners is frequently used within simulated clinical scenarios and may have a number of potential advantages. However, while unable to examine the direct impact on knowledge or skills, we found no significant difference in student-reported experiences between ‘candidate’ and ‘observer’ positions.

The authors have not supplied their declaration of competing interest.

About one in 20 attendances at emergency departments (EDs) in the UK relate to mental health, yet recent work has shown that a majority of people presenting with mental health crises do not report positive experiences (Care Quality Commission, 2015). Although there are many reasons for this, one may be a lack of mental health training for staff working in EDs. In response to this, a new training module for multi-professional ED staff was developed.

We aimed to assess the impact of this new module on clinicians’ confidence in managing mental health presentations. Thirty-eight ED doctors and nurses across two centers were asked to complete surveys before and after receiving training.

Following training, we found improvements in confidence in each of five domains explored: assessing self-harm; managing someone with personality difficulties; assessing psychotic symptoms; distinguishing between physical and psychotic symptoms; and, managing psychotic symptoms. These improvements were seen for clinicians across both centers.

The results show that training can help to improve confidence around mental health. This is particularly important given that before the training was developed a survey of local ED doctors had shown that 31% felt under-confident in managing mental health conditions. Since developing the training, it has been further enhanced at the request of local EDs to include video-based scenarios. We continue to assess its impact in improving the confidence of ED clinicians (as well as their knowledge, skills and attitudes towards mental health), and ultimately the benefit to patients experiencing mental health crises.

The authors have not supplied their declaration of competing interest.