Diagnosis of prodromal Alzheimer's disease and Alzheimer's disease dementia in people with Down syndrome is a major challenge. The Cambridge Examination for Mental Disorders of Older People with Down's Syndrome and Others with Intellectual Disabilities (CAMDEX-DS) has been validated for diagnosing prodromal Alzheimer's disease and Alzheimer's disease dementia, but the diagnostic process lacks guidance.

To derive CAMDEX-DS informant interview threshold scores to enable accurate diagnosis of prodromal Alzheimer's disease and Alzheimer's disease dementia in adults with Down syndrome.

Psychiatrists classified participants with Down syndrome into no dementia, prodromal Alzheimer's disease and Alzheimer's disease dementia groups. Receiver operating characteristic analyses assessed the diagnostic accuracy of CAMDEX-DS informant interview-derived scores. Spearman partial correlations investigated associations between CAMDEX-DS scores, regional Aβ binding (positron emission tomography) and regional cortical thickness (magnetic resonance imaging).

Diagnostic performance of CAMDEX-DS total scores were high for Alzheimer's disease dementia (area under the curve (AUC), 0.998; 95% CI 0.953–0.999) and prodromal Alzheimer's disease (AUC = 0.954; 95% CI 0.887–0.982) when compared with healthy adults with Down syndrome. When compared with those with mental health conditions but no Alzheimer's disease, CAMDEX-DS Section B scores, denoting memory and orientation ability, accurately diagnosed Alzheimer's disease dementia (AUC = 0.958; 95% CI 0.892–0.984), but were unable to diagnose prodromal Alzheimer's disease. CAMDEX-DS total scores exhibited moderate correlations with cortical Aβ (r ~ 0.4 to 0.6, P ≤ 0.05) and thickness (r ~ −0.4 to −0.44, P ≤ 0.05) in specific regions.

CAMDEX-DS total score accurately diagnoses Alzheimer's disease dementia and prodromal Alzheimer's disease in healthy adults with Down syndrome.

Description of a model to improve care for patients with Medically Unexplained Symptoms (MUS) by small targeted investment and maximisation of existing resources.

Treatment of MUS presents several challenges including a lack of clarity on the best models of care and limited service provision. Patients typically present with a physical complaint to physical health outlets: here limited confidence in professionals around how to address these often leads to poor patient/doctor experience, inappropriate use of resources and repeated attendance. Evidence shows that integration of care, psychological interventions and upskilling physicians in interventions such as positive communication, can significantly improve outcomes. Psychiatric Liaison Teams (PLT) are positioned at the interface of mental and physical health services and can play a crucial role for these patients, when provided with the right skill-mix.

1FTE Clinical Psychologist specialising in MUS was integrated into the PLT. Pathways to triage between primary, secondary psychology and the new service were agreed, alongside channels of communication and supervision. The job plan included integrated sessions in Gastroenterology, Rheumatology and PLT. The activities included: assessments, formulations and discharges; brief psychological interventions; group sessions for patients; one-day long courses to GP trainees and physicians, and input in specialities MDTs. Clinical outcomes, numbers of patients seen and signposted, teaching sessions and simulation training delivered were collected.

Over 20 months the service was able to process 237 referrals, 35 were managed over the phone. Referral sources: Gastroenterology 32%, Rheumatology 37%, Psychiatric liaison 28%.

116 patients attended 315 face to face appointments and 21 phone contacts were made. Core-10 data show reduction from moderately severe to mild psychological distress in a sample of patients. 58% of patients were referred on for continuing care. The service ran 8 patient groups including sessions on pain management and joint sessions with Rheumatology. It ran 9 one-day long courses for GP and physician trainees, training a total of 120 doctors: feedback showed increased confidence in managing and recognising MUS. Attendances to Emergency Departments covered by Barking Havering and Redbridge and Bart's Health Trusts combined (5 sites) reduced by 22%, saving an estimated £19,200, while ambulance usage in the cohort dropped by 29%, saving an estimated £9072.

The integration of a specialist psychologist with a mix of educational, advisory and clinical role to a PLT can provide an effective and efficient stepped-up model to increase the provision of care for patients with MUS

Current first-line treatments for paediatric depression demonstrate mild-to-moderate effectiveness. This has spurred a growing body of literature on lifestyle recommendations pertaining to nutrition, sleep and exercise for treating paediatric depression.

Paediatric depression clinical practice guidelines (CPGs) were reviewed for quality and to catalogue recommendations on nutrition, sleep and exercise made by higher-quality CPGs.

Searches were conducted in Medline, EMBASE, PsycINFO, Web of Science and CINAHL, and grey literature CPGs databases for relevant CPGs. Eligible CPGs with a minimum or high-quality level, as determined by the Appraisal of Guidelines for Research and Evaluation, Second Edition instrument, were included if they were (a) paediatric; (b) CPGs, practice parameter or consensus or expert committee recommendations; (c) for depression; (d) the latest version and (e) lifestyle recommendations for nutrition, sleep or exercise. Key information extracted included author(s), language, year of publication, country, the institutional body issuing the CPG, target disorder, age group, lifestyle recommendation and the methods used to determine CPG lifestyle recommendations.

Ten paediatric CPGs for depression with a minimum or high-quality level contained recommendations on nutrition, sleep or exercise. Lifestyle recommendations were predominately qualitative, with quantitative details only outlined in two CPGs for exercise. Most recommendations were brief general statements, with 50% lacking supporting evidence from the literature.

Interest in lifestyle interventions for treatment in child and youth depression is growing. However, current CPG lifestyle recommendations for nutrition, sleep or exercise are based on expert opinion rather than clinical trials.

Acceptance and willingness to pay for the COVID-19 vaccine are unknown.

We compared attitudes toward COVID-19 vaccination in people suffering from depression or anxiety disorder and people without mental disorders, and their willingness to pay for it.

Adults with depression or anxiety disorder (n = 79) and healthy controls (n = 134) living in Chongqing, China, completed a cross-sectional study between 13 and 26 January 2021. We used a validated survey to assess eight aspects related to attitudes toward the COVID-19 vaccines. Psychiatric symptoms were assessed by the 21-item Depression, Anxiety and Stress Scale.

Seventy-six people with depression or anxiety disorder (96.2%) and 134 healthy controls (100%) reported willingness to receive the COVID-19 vaccine. A significantly higher proportion of people with depression or anxiety disorder (64.5%) were more willing to pay for the COVID-19 vaccine than healthy controls (38.1%) (P ≤ 0.001). After multivariate adjustment, severity of depression and anxiety was significantly associated with willingness to pay for COVID-19 vaccination among psychiatric patients (P = 0.048). Non-healthcare workers (P = 0.039), health insurance (P = 0.003), living with children (P = 0.006) and internalised stigma (P = 0.002) were significant factors associated with willingness to pay for COVID-19 vaccine in healthy controls.

To conclude, psychiatric patients in Chongqing, China, showed high acceptance and willingness to pay for the COVID-19 vaccine. Factors associated with willingness to pay for the COVID-19 vaccine differed between psychiatric patients and healthy controls.

Little is known about factors that influence discharge decision-making for people admitted to medium-secure services from prison, particularly for those who are returned to prison following treatment.

To explore the organisational influences on care pathways through medium-secure services for those admitted from prison.

We recruited 24 clinicians via purposive and snowball sampling; 13 shared their experiences via a focus group, and 11 shared their experiences via individual semi-structured interviews. A thematic analysis was conducted, producing three overarching themes: maintenance of throughput and service provision, class of two systems, and desirable and undesirable patients.

Data indicated external factors that direct and, at times, limit clinicians’ pathway decisions, including commissioning criteria and legal status under the Mental Health Act 1983 and within the criminal courts system (i.e. whether on remand or sentenced). These factors also influence how clinicians view the role and function of medium-secure services within the wider forensic mental health system, and therefore the types of patients that are deemed ‘appropriate’ for continued treatment when making discretionary pathway decisions.

There remains a deficit in adequate resources to meet the mental health needs of prisoners who are admitted to medium-secure services. To meet the clinical need of all admissions, criteria for prolonged treatment in medium-secure services needs to be reconsidered, and it is likely that provision for the medium-secure hospital estate will need to increase substantially if effective rehabilitation of those who transfer from prison is to take place.

Incidents of self-harm are common on psychiatric wards. There are a wide variety of therapeutic, social and environmental interventions that have shown some promise in reducing self-harm in in-patient settings, but there is no consensus on the most appropriate means of reducing and managing self-harm during in-patient admissions.

To review interventions used to reduce self-harm and suicide attempts on adolescent and adult psychiatric in-patient wards.

A systematic literature search was conducted between 14 March 2019 and 25 January 2021 using PsycINFO and Medline (PROSPERO ID: CRD42019129046). A total of 23 papers were identified for full review.

Interventions fell into two categories, therapeutic interventions given to individual patients and organisational interventions aimed at improving patient–staff communication and the overall ward milieu. Dialectical behaviour therapy was the most frequently implemented and effective therapeutic intervention, with seven of eight studies showing some benefit. Three of the six ward-based interventions reduced self-harm. Two studies that used a combined therapeutic and ward-based approach significantly reduced self-harm on the wards. The quality of the studies was highly variable, and some interventions were poorly described. There was no indication of harmful impact of any of the approaches reported in this review.

A number of approaches show some promise in reducing self-harm, but the evidence is not strong enough to recommend any particular approach. Current evidence remains weak overall but provides a foundation for a more robust programme of research aimed at providing a more substantial evidence base for this neglected problem on wards.

Emotional cognition and effective interpretation of affective information is an important factor in social interactions and everyday functioning, and difficulties in these areas may contribute to aetiology and maintenance of mental health conditions. In younger people with depression and anxiety, research suggests significant alterations in behavioural and brain activation aspects of emotion processing, with a tendency to appraise neutral stimuli as negative and attend preferentially to negative stimuli. However, in ageing, research suggests that emotion processing becomes subject to a ‘positivity effect’, whereby older people attend more to positive than negative stimuli.

This review examines data from studies of emotion processing in Late-Life Depression and Late-Life Anxiety to attempt to understand the significance of emotion processing variations in these conditions, and their interaction with changes in emotion processing that occur with ageing.

We conducted a systematic review following PRISMA guidelines. Articles that used an emotion-based processing task, examined older persons with depression or an anxiety disorder and included a healthy control group were included.

In Late-Life Depression, there is little consistent behavioural evidence of impaired emotion processing, but there is evidence of altered brain circuitry during these processes. In Late-Life Anxiety and Post-Traumatic Stress disorder, there is evidence of interference with processing of negative or threat-related words.

How these findings fit with the positivity bias of ageing is not clear. Future research is required in larger groups, further examining the interaction between illness and age and the significance of age at disease onset.

The coronavirus disease 2019 (COVID-19) outbreak has become a pandemic. Obstetricians and midwives, among other medical staff, are tackling COVID-19 and are under immense psychological stress.

We aimed to survey the mental health of non-infectious disease specialist staff, specifically obstetricians and midwives, working in officially designated hospitals treating patients with COVID-19.

A nationwide online survey was conducted from 7 March to 17 March 2020 investigating the mental health of obstetricians and midwives (who were not themselves infected with COVID-19) working in hospitals treating patients with COVID-19. We used the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder (GAD-7) scale and the 7-item Insomnia Severity Index (ISI) to assess their symptoms of depression, anxiety and insomnia.

A total of 885 (41.6%), 609 (28.6%) and 729 (34.3%) obstetricians and midwives reported depression (PHQ-9 ≥ 5), anxiety (GAD-7 ≥ 5) and insomnia (ISI ≥ 8), respectively, during the COVID-19 pandemic. Regardless of whether or not they had direct contact with patients with COVID-19, obstetricians and midwives were more likely to report mild and moderate depression and anxiety during the COVID-19 pandemic when compared with before the pandemic. Those who had direct contact with patients with COVID-19 were more likely to report depression and insomnia than those who did not. Those who had sufficient protective equipment or training were less likely to report depression, anxiety and insomnia than those who did not.

Our data suggest that non-infectious disease specialist staff have experienced varying, but increased levels of depression, anxiety and insomnia during this COVID-19 pandemic, which could be reduced by sufficient levels of protective equipment and occupational COVID-19 workplace training.

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.

Negative or adverse effects of psychological treatments are increasingly a focus of psychotherapy research. Yet, we still know little about the prevalence of these effects.

Starting from a representative national sample, the prevalence of negative effects and malpractice was determined in a subsample of individuals reporting psychotherapy currently or during the past 6 years.

Out of an initial representative sample of 5562 individuals, 244 were determined to have had psychotherapy within the past 6 years. Besides answering questions related to treatment, its effects and the therapists, patients filled out the Negative Effects Questionnaire, items of the Inventory of Negative Effects of Psychotherapy reflecting malpractice and the Helping Alliance Questionnaire, and rated psychotherapeutic changes in different areas.

Rates of positive changes related to therapy varied between 26.6% (relationship to parents) and 67.7% (improvement in depressed mood). Deteriorations were most commonly related to physical well-being (13.1%), ability to work (13.1%) and vitality (11.1%). Although patients generally reported a positive helping alliance, many of them reported high rates of negative effects (though not always linked to treatment). This was especially true of the experience of unpleasant memories (57.8%), unpleasant feelings (30.3%) and a lack of understanding of the treatment/therapist (19.3/18.4%). Indicators of malpractice were less common, with the exception that 16.8% felt violated by statements of their therapist.

This study helps to better estimate aspects of negative effects in psychotherapy ranging from deteriorations, specific effects and issues of malpractice that should be replicated and specified in future studies.

1.To generate a Natural Language Processing (NLP) application that can identify mentions of perinatal self-harm among electronic healthcare records (EHRs)

2.To use this application to estimate the prevalence of perinatal self-harm within a data-linkage cohort of women accessing secondary mental healthcare during the perinatal period.

Data source: the Clinical Record Interactive Search system. This is a database of de-identified EHRs of secondary mental healthcare service-users at South London and Maudsley NHS Foundation Trust (SLaM). CRIS has pre-existing ethical approval via the Oxfordshire Research Ethics Committee C (ref 18/SC/0372) and this project was approved by the CRIS Oversight Committee (16-069). After developing a list of synonyms for self-harm and piloting coding rules, a gold standard dataset of EHRs was manually coded using Extensible Human Oracle Suite of Tools (eHOST) software. An NLP application to detect perinatal self-harm was then developed using several layers of linguistic processing based on the spaCy NLP library for Python. Evaluation of mention-level performance was done according to the attributes of mentions the application was designed to identify (span, status, temporality and polarity), by comparing application performance against the gold standard dataset. Performance was described as precision, recall, F-score and Cohen's kappa. Most service-users had more than one EHR in their period of perinatal service use. Performance was therefore also measured at “service-user level” with additional performance metrics of likelihood ratios and post-test probabilities. Linkage with the Hospital Episode Statistics datacase allowed creation of a cohort of women who accessed SLaM during the perinatal period. By deploying the application on the EHRs of the women in the cohort, we were able to estimate the prevalence of perinatal self-harm.

Mention-level performance: micro-averaged F-score, precision and recall for span, polarity and temporality all >0.8. Kappa for status 0.68, temporality 0.62, polarity 0.91. Service-user level performance: F-score, precision, recall all 0.69, overall F-score 0.81, positive likelihood ratio 9.4 (4.8–19), post-test probability 68.9% (95%CI 53–82).

Cohort prevalence of self-harm in pregnancy was 15.3% (95% CI 14.3–16.3); self-harm in the postnatal year was 19.7% (95% CI 18.6–20.8). Only a very small proportion of women self-harmed in both pregnancy and the postnatal year (3.9%, 95% CI 3.3–4.4).

NLP can be used to identify perinatal self-harm within EHRs. The hardest attribute to classify was temporality. This is in line with the wider literature indicating temporality as a notoriously difficult problem in NLP. As a result, the application probably over-estimates prevalence, to a degree. However, overall performance, given the difficulty of the task, is good.

Bearing in mind the limitations, our findings suggest that self-harm is likely to be relatively common in women accessing secondary mental healthcare during the perinatal period.

Funding: KA is funded by a National Institute for Health Research Doctoral Research Fellowship (NIHR-DRF-2016-09-042). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. RD is funded by a Clinician Scientist Fellowship (research project e-HOST-IT) from the Health Foundation in partnership with the Academy of Medical Sciences which also party funds AB. AB's work was also part supported by Health Data Research UK, an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities, as well as the Maudsley Charity.

Acknowledgements: Professor Louise M Howard, who originally suggested using NLP to identify perinatal self-harm in EHRs. Professor Howard is the primary supervisor of KA's Fellowship.

The UK went into nationwide lockdown on 24 March 2020, in response to COVID-19. The direct psychiatric effects of this are relatively unknown.

We examined whether the first UK lockdown changed the demographics of patients admitted to psychiatric hospitals (to include gender, legality, route of admission and diagnoses), independent of seasonal variation..

We conducted an anonymous review of psychiatric admissions aged ≥18 years in the 6-month period after the announcement of the first UK lockdown (March to August 2020), and in the previous year (March to August 2019), in Kent and Medway NHS and Social Care Partnership Trust in-patient facilities. The number of admissions were compared, along with factors that may help to explain the psychological effects of national lockdown.

There was no significant increase in total number of admissions or the gender percentage. However, there was a 11.8% increase in formal sectioning under the Mental Health Act 1983. This increase was sustained and statistically significant across all 6 months. A sustained decrease in admissions via the crisis team was also observed as being statistically significant. Separate diagnoses saw changes in percentage of admissions between March and May. The most statistically significant was schizophrenia admissions for men in April (18.7%), and women in March (18.4%).

Our findings highlight the effect of COVID-19 on the legal status of psychiatric admissions, and emphasise the importance of having a robust, adaptable and open psychiatric service that caters to the ongoing needs of patients, regardless of government restrictions.

People who have suffered the loss of a loved one may subsequently report sensory experiences of the deceased (termed ‘after-death communications’, or ADCs). Such encounters are common and can be a source of comfort to the bereaved. Nevertheless, there has been limited empirical investigation of this phenomenon, and consequently mental health professionals feel ill-equipped to support those who disclose them.

To map the phenomenology of ADCs, and identify covariates and effects upon the recipient.

We conducted an online mixed-methods survey comprising 194 items about all aspects of ADCs. A purposive sample of 1004 respondents across three language groups (English, French and Spanish) completed the survey.

The most common form of ADC was during sleep, but large numbers of cases involved sensory modalities of touch, sight, hearing, smell and sense of presence that externalised the phenomenon for the recipient. Variations in incidence with participant gender and language group suggest a psychosocial component. ADCs were typically regarded by the participant as deeply meaningful and comforting. Respondents reported significant increases in their sense of spirituality, but not religiosity.

ADCs are a common feature of bereavement that occur unexpectedly, and are independent of any underlying pathology or psychological need. For the person experiencing the hallucination, they are important and meaningful events that they interpret in terms of continuing bonds with the deceased. This adaptive outcome may be stymied where mental health professionals trivialise or pathologise disclosures about ADCs.

To compare the feasibility and acceptability of delivering a simulation-based learning (SBL) programme for Junior Doctors virtually versus face to face.

The Nottinghamshire Healthcare Simulation Centre has been delivering a SBL programme for Foundation Year 2 doctors on behalf of Health Education East Midlands for the past three years. Since face to face teaching was not possible during the COVID-19 pandemic the programme was delivered online using the same content and format as for prior cohorts. Feedback questionnaires from 128 face to face participants (F2F) and 133 virtual participants (V) were compared.

There was a decrease in Likert scale ratings across all domains in the virtual group. This was most apparent when examining the ‘strongly agreed’ responses: the venue/remote format was suitable for the session 34% decrease, the course length was appropriate 24% decrease, the pace of the course was appropriate 20% decrease, the simulation was helpful and relevant 15% decrease, the content of the course was organised and easy to follow 13% decrease, the learning objectives were met 10% decrease, the presenters were engaging 6% decrease, the trainers were well prepared 3% decrease. The virtual group included responses in the ‘strongly disagree’ and ‘disagree’ categories relating to the virtual format, length and pace, which did not occur in any domain for the F2F group.

Combining the ‘strongly agree’ and ‘agree’ statements also showed a decrease in satisfaction with 72.5% of responses falling into this category for the V group and 88.3% for the F2F group. Fewer participants in the V group would recommend the course to a colleague (98% V vs 99% F2F).

Providing the SBL programme using an online format was feasible while also being acceptable to most participants. However, participants did not rate this experience as highly as face to face teaching. The largest decreases in satisfaction were in areas related to the virtual format. An interesting finding is that participants rated the pace and length of the online course as less agreeable, despite the content and scheduling being the same as for the face to face group.

Based on these findings face to face teaching should resume when practicable. In the meantime, the virtual delivery may be improved if the course length was reduced. Analysis of qualitative feedback may provide insights into why participants did not rate the virtual simulation as highly as the face to face equivalent.