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Complex traumas are traumatic experiences that involve multiple interpersonal threats during childhood or adolescence, such as repeated abuse. These traumas are hypothesised to cause more severe psychopathology and poorer cognitive function than other non-complex traumas. However, empirical testing has been limited to clinical/convenience samples and cross-sectional designs.
To investigate psychopathology and cognitive function in young people exposed to complex, non-complex or no trauma, from a population-representative longitudinal cohort, and to consider the role of pre-existing vulnerabilities.
Participants were from the Environmental Risk Longitudinal Twin Study, a population-representative birth cohort of 2232 British children. At age 18 years (93% participation), we assessed lifetime exposure to complex and non-complex trauma, past-year psychopathology and current cognitive function. We also prospectively assessed early childhood vulnerabilities: internalising and externalising symptoms at 5 years of age, IQ at 5 years of age, family history of mental illness, family socioeconomic status and sex.
Participants exposed to complex trauma had more severe psychopathology and poorer cognitive function at 18 years of age, compared with both trauma-unexposed participants and those exposed to non-complex trauma. Early childhood vulnerabilities predicted risk of later complex trauma exposure, and largely explained associations of complex trauma with cognitive deficits, but not with psychopathology.
By conflating complex and non-complex traumas, current research and clinical practice underestimate the severity of psychopathology, cognitive deficits and pre-existing vulnerabilities linked with complex trauma. A better understanding of the mental health needs of people exposed to complex trauma could inform the development of new, more effective interventions.
The study aims to investigate attention deficit hyperactivity disorder (ADHD) symptoms, gastrointestinal (GI) symptoms, comorbid psychopathology and behaviour problems in children and adolescents with autism spectrum disorder (ASD).
Parents of 147 children and adolescents with ASD aged 6–18 years completed the Conners 3 Parent-Short Form, Gastrointestinal Symptom Inventory, Behavior Problems Inventory-Short Form and Autism Spectrum Disorder-Comorbid for Children.
Fifty-six per cent of children and adolescents had a comorbid diagnosis of ADHD, yet over 70% presented with clinically significant ADHD symptoms. Forty per cent of participants received a diagnosis of ADHD before ASD and 25.6% received a diagnosis of ASD first. Relationships were found between ADHD symptoms and comorbid psychopathology, GI symptoms, and behaviour problems.
The outcomes suggest that ADHD is being underestimated as a comorbid disorder of ASD. This may have implications on treatment and interventions for children and adolescents who have a diagnosis of both ASD and ADHD.
The current study aims to examine the prevalence rates and the relationship of symptoms of depression, anxiety, and comorbid depression/anxiety with neurocognitive performance in college athletes at baseline. We hypothesized a priori that the mood disturbance groups would perform worse than healthy controls, with the comorbid group performing worst overall.
Eight hundred and thirty-one (M = 620, F = 211) collegiate athletes completed a comprehensive neuropsychological test battery at baseline which included self-report measures of anxiety and depression. Athletes were separated into four groups [Healthy Control (HC) (n = 578), Depressive Symptoms Only (n = 137), Anxiety Symptoms Only (n = 54), and Comorbid Depressive/Anxiety Symptoms (n = 62)] based on their anxiety and depression scores. Athletes’ neurocognitive functioning was analyzed via Z score composites of Attention/Processing Speed and Memory.
One-way analysis of variance revealed that, compared to HC athletes, the comorbid group performed significantly worse on measures of Attention/Processing Speed but not Memory. However, those in the depressive symptoms only and anxiety symptoms only groups were not significantly different from one another or the HC group on neurocognitive outcomes. Chi-square analyses revealed that a significantly greater proportion of athletes in all three affective groups were neurocognitively impaired compared to the HC group.
These results demonstrate that collegiate athletes with comorbid depressive/anxiety symptoms should be identified, as their poorer cognitive performance at baseline could complicate post-concussion interpretation. Thus, assessing for mood disturbance at baseline is essential to obtain an accurate measurement of baseline functioning. Further, given the negative health outcomes associated with affective symptomatology, especially comorbidities, it is important to provide care as appropriate.
This study aimed to establish rates and gender patterns of 25 comorbidities in 1912 children (72% male) with a neurological disorder and a comparison group (n = 40 718, 45% male) from a large clinical records data-set in child mental health services in the UK with clinician-recorded data on neurological and psychological conditions. Obsessive–compulsive disorder, oppositional defiant/conduct disorders, autism spectrum disorders and intellectual disabilities (also known in UK health services as learning disabilities) occurred significantly more often in both boys and girls with neurological disorders than in the comparison group. Girls with neurological disorders showed a ‘male-typic’ comorbidity profile.
Prior research has identified behavioural health outcomes as key sequelae to combat deployment. However, relatively little is known about differential patterns of change in depression or generalised anxiety linked to deployment to a combat zone. In this paper, we add to the existing trajectory literature and examine key predictive factors of behavioural health risk.
The primary aim is to leverage growth mixture modelling to ascertain trajectories of psychological distress, operationalised as a coherent construct combining depression and generalised anxiety, and to identify factors that differentiate adaptive and maladaptive patterns of change.
Data were collected from a brigade combat team prior to a combat deployment to Afghanistan, during deployment, at immediate re-integration and approximately 2–3 months thereafter. The main outcome was measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS).
Three latent trajectories were identified: a low–stable trajectory, a declining trajectory and a rising trajectory. Most individuals aligned with the low–stable trajectory. A conditional model using covariates measured during deployment showed that the low–stable trajectory differed consistently from the remaining trajectories on self-reported loneliness and non-combat deployment stressors.
The examination of differential patterns of adaptation, to identify individuals at higher risk, is critical for the efficient targeting of resources. Our findings further indicate that loneliness may be a useful leverage point for clinical and organisational intervention.
Familial co-aggregation studies of eating disorders (EDs) and schizophrenia reveal shared genetic and environment factors, yet their etiological and clinical relationship remains unclear. We evaluate the influence of schizophrenia family history on clinical outcomes of EDs.
We conducted a cohort evaluation of the association between family history of schizophrenia and ED clinical features, psychiatric comorbidities, and somatic and mental health burden in individuals born in Sweden 1977–2003 with anorexia nervosa (AN) or other EDs (OED: bulimia nervosa, binge-eating disorder, and ED not otherwise specified).
Of 12 424 individuals with AN and 20 716 individuals with OED, 599 (4.8%) and 1118 (5.4%), respectively, had a family history of schizophrenia (in up to third-degree relatives). Among individuals with AN, schizophrenia in first-degree relatives was significantly associated with increased comorbid attention-deficit/hyperactivity disorder (ADHD) [HR(95% CI) 2.26 (1.27–3.99)], substance abuse disorder (SUD) [HR (95% CI) 1.93 (1.25–2.98)], and anxiety disorders [HR (95% CI) 1.47 (1.08–2.01)], but higher lowest illness-associated body mass index (BMI) [1.14 kg/m2, 95% CI (0.19–2.10)]. Schizophrenia in any relative (up to third-degree) in AN was significantly associated with higher somatic and mental health burden, but lower ED psychopathology scores [−0.29, 95% CI (−0.54 to −0.04)]. Schizophrenia in first-degree relatives in individuals with OED was significantly associated with increased comorbid ADHD, obsessive-compulsive disorder, SUD, anxiety disorders, somatic and mental health burden, and suicide attempts.
We observed different patterns of ED-related outcomes, psychiatric comorbidity, and illness burden in individuals with EDs with and without family histories of schizophrenia and provide new insights into the diverse manifestations of EDs.
The unprecedented occurrence of a global pandemic is accompanied by both physical and psychological burdens that may impair quality of life. Research relating to COVID-19 aims to determine the effects of the pandemic on vulnerable populations who are at high risk of developing negative health or psychosocial outcomes. Having an ongoing medical condition during a pandemic may lead to greater psychological distress. Increased psychological distress may be due to preventative public health measures (e.g. lockdown), having an ongoing medical condition, or a combination of these factors.
This study analyses data from an online cross-sectional national survey of adults in Ireland and investigates the relationship between comorbidity and psychological distress. Those with a medical condition (n = 128) were compared to a control group without a medical condition (n = 128) and matched according to age, gender, annual income, education, and work status during COVID-19. Participants and data were obtained during the first public lockdown in Ireland (27 March 2020–8 June 2020).
Individuals with existing medical conditions reported significantly higher levels of anxiety (p < .01) and felt less gratitude (p ≤ .001). Exploratory analysis indicated that anxiety levels were significantly associated with illness perceptions specific to COVID-19. Post hoc analysis revealed that psychological well-being was not significantly related to condition type (e.g. respiratory disorders).
This research supports individualised supports for people with ongoing medical conditions during the COVID-19 pandemic, and has implications for the consideration of follow-up care specifically for mental health. Findings may also inform future public health policies and post-vaccine support strategies for vulnerable populations.
In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15–20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics.
To investigate the attitudes and experiences regarding smoke-free policies among managers and staff involved in the implementation processes of smoke-free psychiatric clinics at hospitals in Malmö (Sweden) and Barcelona (Spain).
We used a qualitative methodology, with 15 semi-structured interviews. The interviews were conducted with each participant individually, and were subsequently transcribed. The data were analysed with systematic text condensation.
There were notable differences in how the smoke-free policies were carried out and experienced, and attitudes regarding the policy changes differed in the two settings. Key differences were the views on the right to smoke in compulsory care and to stay in smoke-free surroundings supported by smoking cessation intervention; the prioritisation of staff facilitation of smoking breaks; and views on smoking and smoke-free psychiatry. In contrast, participants agreed on the importance of staff education and management support. A smoking ban by law and belonging to a network of smoke-free hospitals were also relevant.
Staff education, and support from staff and management for the patients’ right to stay in smoke-free surroundings, facilitated successful implementation of smoke-free policies in the psychiatric clinics, whereas supporting the right to smoke was a barrier.
Psychiatric comorbidity is common in binge-eating disorder (BED) but effects on treatment outcomes are unknown. The current study aimed to determine whether psychiatric comorbidity predicted or moderated BED treatment outcomes.
In total, 636 adults with BED in randomized-controlled trials (RCTs) were assessed prior, throughout, and posttreatment by doctoral research-clinicians using reliably-administered semi-structured interviews, self-report measures, and measured weight. Data were aggregated from RCTs testing cognitive-behavioral therapy, behavioral weight loss, multi-modal (combined pharmacological plus cognitive-behavioral/behavioral), and/or control conditions. Intent-to-treat analyses (all available data) tested comorbidity (mood, anxiety, ‘any disorder’ separately) as predictors and moderators of outcomes. Mixed-effects models tested comorbidity effects on binge-eating frequency, global eating-disorder psychopathology, and weight. Generalized estimating equation models tested binge-eating remission (zero binge-eating episodes during the past month; missing data imputed as failure).
Overall, 41% of patients had current psychiatric comorbidity; 22% had mood and 23% had anxiety disorders. Psychiatric comorbidity did not significantly moderate the outcomes of specific treatments. Psychiatric comorbidity predicted worse eating-disorder psychopathology and higher binge-eating frequency across all treatments and timepoints. Patients with mood comorbidity were significantly less likely to remit than those without mood disorders (30% v. 41%). Psychiatric comorbidity neither predicted nor moderated weight loss.
Psychiatric comorbidity was associated with more severe BED psychopathology throughout treatment but did not moderate outcomes. Findings highlight the need to improve treatments for BED with psychiatric comorbidities but challenge perspectives that combining existing psychological and pharmacological interventions is warranted. Treatment research must identify more effective interventions for BED overall and for patients with comorbidities.
To evaluate outcomes in patients with Turner Syndrome, especially those with cardiac conditions, compared to those without Turner syndrome.
Retrospective cohort study utilising hospitalisation data from 2006 to 2012. Conditional logistic regression models are used to analyse outcomes of interest: all-cause mortality, increased length of stay, and discharge to home.
We identified 2978 women with Turner syndrome, matched to 11,912 controls by primary diagnosis.
Patients with Turner syndrome were more likely to experience inpatient mortality (odds ratio 1.44, 95% confidence interval 1.02–2.02, p = 0.04) and increased length of stay (OR 1.31, CI 1.18–1.46, p = 0.03) than primary diagnosis matched controls, after adjusting for age, race, insurance status, and Charlson comorbidity index. Patients with Turner syndrome were 32% less likely to be discharged to home (OR 0.68, CI 0.60–0.78, p < 0.001). When restricting the sample of patients to those admitted with a cardiac diagnosis, the likelihood of mortality (OR 3.10, CI 1.27–7.57, p = 0.01) and prolonged length of stay (OR 1.42, CI 1.03–1.95, p = 0.03) further increased, while the likelihood of discharge to home further decreased (OR 0.55, CI 0.38–0.80, p = 0.001) in Turner syndrome compared to primary diagnosis matched controls. Specifically, patients with congenital heart disease were more likely to have prolonged length of stay (OR: 1.53, CI 1.18–2.00, p = 0.002), but not increased mortality or decreased discharge to home.
Hospitalised women with Turner syndrome carry a higher risk of adverse outcomes even when presenting otherwise similarly as controls, an important consideration for those treating them in these settings.
Psychiatric disorders overlap substantially at the genetic level, with family-based methods long pointing toward transdiagnostic risk pathways. Psychiatric genomics has progressed rapidly in the last decade, shedding light on the biological makeup of cross-disorder risk at multiple levels of analysis. Over a hundred genetic variants have been identified that affect multiple disorders, with many more to be uncovered as sample sizes continue to grow. Cross-disorder mechanistic studies build on these findings to cluster transdiagnostic variants into meaningful categories, including in what tissues or when in development these variants are expressed. At the upper-most level, methods have been developed to estimate the overall shared genetic signal across pairs of traits (i.e. single-nucleotide polymorphism-based genetic correlations) and subsequently model these relationships to identify overarching, genomic risk factors. These factors can subsequently be associated with external traits (e.g. functional imaging phenotypes) to begin to understand the makeup of these transdiagnostic risk factors. As psychiatric genomic efforts continue to expand, we can begin to gain even greater insight by including more fine-grained phenotypes (i.e. symptom-level data) and explicitly considering the environment. The culmination of these efforts will help to inform bottom-up revisions of our current nosology.
Depression in first-episode psychosis (FEP) is highly prevalent and associated with poor outcomes; it has become increasingly recognised and adopted in national and international guidelines for psychosis. Using a 26-item questionnaire, this study aimed to explore if this shift has led to greater recognition among UK psychiatrists, and more effective management of depression in FEP.
Of the 297 respondents, 54.4% observed depression occurring in chronic psychosis, with the least number of respondents (17.7%) identifying depression occurring frequently during FEP. Although there was reasonable agreement in the use of antidepressants as a first-line treatment for depression (70% prescribing antidepressants), there was uncertainty around assessing depression and delineating from psychosis symptoms, and particularly negative symptoms.
Evidence-based treatments for comorbid depression in psychosis will lead to clearer national guidelines, allowing for optimal management of depression in early psychosis, potentially leading to improved outcomes for these individuals.
An article in BJPsych Advances on the topic of dissociative identity disorder gave rise to a number of linked commentaries and a vigorous eLetter debate. This commentary, by the Editor, points out the journal's role as a CPD journal and clarifies its position on the publication of reviews and opinion pieces on controversial topics.
To evaluate otorhinolaryngological manifestations of coronavirus disease 2019 infection and the time required for their resolution.
A prospective analysis was conducted of coronavirus disease 2019 patients presenting from 1 April 2020 to 30 July 2020. The otorhinolaryngological manifestations were evaluated based on patient history. The time required for symptom resolution was evaluated separately for intensive care unit and non-intensive care unit patients.
A total of 600 patients were included in the study; 13.3 per cent required the intensive care unit and 2.2 per cent expired. The otorhinolaryngological manifestations were: sore throat (88 per cent), fever (78.8 per cent), anosmia or hyposmia (63.6 per cent), ageusia or hypogeusia (63.5 per cent), rhinorrhoea (51.3 per cent), nasal obstruction (33.5 per cent), sneezing (30.3 per cent), and breathing difficulty (18.6 per cent). The time required for symptom resolution was longest for breathing difficulty (23.6 days for intensive care unit and 8.2 days for non-intensive care unit patients).
Otorhinolaryngological symptoms are one of the main presentations of coronavirus disease 2019 infection. The increased prevalence of medical co-morbidities in patients requiring intensive care unit and in deceased patients is also highlighted.
The distressing reality that mental healthcare for children and young people in acute trust settings in the UK is woefully underprovided is not news. But with acute trust debts being written off, hospital trusts and commissioners of services have a timely opportunity to address this age- and condition-based discrimination.
Delivering a just service for under-18s depends on attitude, resources and adequate knowledge of the tasks involved. This article aims to describe the current landscape, summarise the arguments for better integrating mental healthcare into physical healthcare settings, articulate the tasks involved and the challenges for commissioning and providing, and finally share examples of current service models across the country.
Ultimately, commissioning and provider choices will be constrained by resource pressures, but this article aims to underscore why commissioning and providing a portmanteau ‘no wrong door’ hospital service for children, young people and families is worth the headache of thinking outside old commissioning and provider boxes.
During psychotherapy some patients experience large symptom improvements between sessions, termed sudden gains. Most commonly, sudden gains are observed during treatment for depression (40–50% of participants), but these are occasionally also observed in treatment for anxiety (15–20%). This study investigated the impact of comorbid depression on sudden gains in a primary anxiety sample. It was hypothesised that sudden gains would occur more frequently in participants with anxiety and comorbid depression than anxiety-only participants. The sample consisted of 58 adults who participated in a 12-week transdiagnostic cognitive-behavioural therapy (tCBT) programme. Sudden gains were more frequent in the comorbid depression group than in the anxiety-only group. Sudden gains may be predominantly a function of depressive disorders, which supports the higher rates seen in depressive disorders compared with anxiety disorders. Future research should endeavour to replicate these findings, as this was the first study designed to specifically investigate comorbidity in sudden gains.
Investigating obstetric near misses (life-threatening obstetric complications) provides crucial information to prevent maternal mortality and morbidity.
To investigate the rate and type of obstetric near misses among women with serious mental illness (SMI).
We conducted a historical cohort study, using de-identified electronic mental health records linked with maternity data from Hospital Episode Statistics. The English Maternal Morbidity Outcome Indicator was used to identify obstetric near misses at the time of delivery in two cohorts: (1) exposed cohort – all women with a live or still birth in 2007–2016, and a history of secondary mental healthcare before delivery in south-east London (n = 13 570); (2) unexposed cohort – all women with a live or still birth in 2007–2016, resident within south-east London, with no history of mental healthcare before delivery (n = 223 274).
The rate of obstetric near misses was 884.3/100 000 (95% CI 733.2–1057.4) maternities in the exposed group compared with 575.1/100 000 (95% CI 544.0–607.4) maternities in the unexposed group (adjusted odds ratio 1.6, 95% CI 1.3–2.0, P < 0.001). Highest risks were for acute renal failure (adjusted odds ratio 2.1, 95% CI 1.1–3.8, P = 0.022); cardiac arrest, failure or infarction (adjusted odds ratio 2.3, 95% CI 1.1–4.8, P = 0.028); and obstetric embolism (adjusted odds ratio 3.1, 95% CI 1.6–5.8, P < 0.001).
Findings emphasise the importance of integrated physical and mental healthcare before and during pregnancy for women with SMI.
Mental health (MH) service users have increased prevalence of chronic physical conditions such as cardio-respiratory diseases and diabetes. Potentially Preventable Hospitalisations (PPH) for physical health conditions are an indicator of health service access, integration and effectiveness, and are elevated in long term studies of people with MH conditions. We aimed to examine whether PPH rates were elevated in MH service users over a 12-month follow-up period more suitable for routine health indicator reporting. We also examined whether MH service users had increased PPH rates at a younger age, potentially reflecting the younger onset of chronic physical conditions.
A population-wide data linkage in New South Wales (NSW), Australia, population 7.8 million. PPH rates in 178 009 people using community MH services in 2016–2017 were compared to population rates. Primary outcomes were crude and age- and disadvantage-standardised annual PPH episode rate (episodes per 100 000 population), PPH day rate (hospital days per 100 000) and adjusted incidence rate ratios (AIRR).
MH service users had higher rates of PPH admission (AIRR 3.6, 95% CI 3.5–3.6) and a larger number of hospital days (AIRR 5.2, 95% CI 5.2–5.3) than other NSW residents due to increased likelihood of admission, more admissions per person and longer length of stay. Increases were greatest for vaccine-preventable conditions (AIRR 4.7, 95% CI 4.5–5.0), and chronic conditions (AIRR 3.7, 95% CI 3.6–3.7). The highest number of admissions and relative risks were for respiratory and metabolic conditions, including chronic obstructive airways disease (AIRR 5.8, 95% CI 5.5–6.0) and diabetic complications (AIRR 5.4, 95% CI 5.1–5.8). One-quarter of excess potentially preventable bed days in MH service users were due to vaccine-related conditions, including vaccine-preventable respiratory illness. Age-related increases in risk occurred earlier in MH service users, particularly for chronic and vaccine-preventable conditions. PPH rates in MH service users aged 20–29 were similar to population rates of people aged 60 and over. These substantial differences were not explained by socio-economic disadvantage.
PPHs for physical health conditions are substantially increased in people with MH conditions. Short term (12-month) PPH rates may be a useful lead indicator of increased physical morbidity and less accessible, integrated or effective health care. High hospitalisation rates for vaccine-preventable respiratory infections and hepatitis underline the importance of vaccination in MH service users and suggests potential benefits of prioritising this group for COVID-19 vaccination.
Psychiatric disorders are very common in patients affected by Parkinson’s disease (PD). However, comorbidity with Bipolar Spectrum disorders is understudied. The aim of this study is to explore the clinical correlates of PD associated with Bipolar Spectrum disorders.
One hundred PD patients were screened for psychiatric comorbidities, cognitive profile, motor, and non-motor symptoms. The sample was divided into three groups: PD-patients with Bipolar Spectrum disorders (bipolar disorder type I, type II, and spontaneous or induced hypomania; N = 32), PD-patients with others psychiatric comorbidities (N = 39), PD-patients without psychiatric comorbidities (N = 29). Clinical features were compared among the groups using analysis of variance and chi-square test. A logistic regression was performed to evaluate the association between Bipolar Spectrum disorders and early onset of PD (≤50 years) controlling for lifetime antipsychotic use.
In comparison with PD patients with and without other psychiatric comorbidity, subjects affected by Bipolar Spectrum disorders were younger, showed more frequently an early onset PD, reported more involuntary movements and a higher rate of impulse control disorders and compulsive behaviors. No differences were observed in indexes of exposure to dopamine agonist treatments. The early onset of PD was predicted by Bipolar Spectrum comorbidity, independently from lifetime antipsychotic use.
Bipolar Spectrum disorders are common in early onset PD. The presence of bipolar comorbidity could identify a particular subtype of PD, showing higher rates of neurological and psychiatric complications and deserving further investigation.
Meta-analyses show efficacy of mindfulness-based cognitive therapy (MBCT) in terms of relapse prevention and depressive symptom reduction in patients with major depressive disorder (MDD). However, most studies have been conducted in controlled research settings.
We aimed to investigate the effectiveness of MBCT in patients with MDD presenting in real-world clinical practice. Moreover, we assessed whether guideline recommendations for MBCT allocation in regard to recurrence and remission status of MDD hold in clinical practice.
This study assessed a naturalistic cohort of patients with (recurrent) MDD, either current or in remission (n = 765), who received MBCT in a university hospital out-patient clinic in The Netherlands. Outcome measures were self-reported depressive symptoms, worry, mindfulness skills and self-compassion. Predictors were MDD recurrence and remission status, and clinical and sociodemographic variables. Outcome and predictor analyses were conducted with linear regression.
MBCT adherence was high (94%). Patients with a lower level of education had a higher chance of non-adherence. Attending more sessions positively influenced improvement in depressive symptoms. Depressive symptoms significantly reduced from pre- to post-MBCT (Δ mean = 7.7, 95%CI = 7.0–8.5, Cohen's d = 0.75). Improvement of depressive symptoms was independent from MDD recurrence and remission status. Unemployed patients showed less favourable outcomes. Worry, mindfulness skills and self-compassion all significantly improved. These improvements were related to changes in depressive symptoms.
Previous efficacy results in controlled research settings are maintained in clinical practice. Results illustrate that MBCT is effective in routine clinical practice for patients suffering from MDD, irrespective of MDD recurrence and remission status.