Interest in features of our local environments that may promote better mental health and wellbeing continues to rise among decision makers. Our purpose was to highlight a selection of these challenges and some promising avenues for enhancing the quality of evidence.

An analysis of approximately 267, 000 people was used to test the local relative deprivation hypothesis, wherein the shortfall of a person's socioeconomic circumstances from their neighbours is said to impact negatively upon mental health. This case was used to anchor further discussion of challenges to identifying and interpreting genuine ‘place effects’ from spurious correlations.

A Median Odds Ratio of 1.29 computed via multilevel logistic regression showed that the odds of experiencing psychological distress (as measured by the Kessler score) varied by geographical area. Approximately 67% of this was attributed to a cross-classified measure of household income and neighbourhood deprivation. Compared to people on high incomes living in affluent neighbourhoods, the odds ratio of psychological distress for people on low incomes in affluent areas was 4.73 (95% confidence interval (95% CI) 4.39, 5.09), whereas that for people on low incomes in deprived areas was significantly higher at 5.83 (95% CI 5.41, 6.28).

While no evidence was found to support local relative deprivation hypothesis, the pattern suggests that more affluent areas may contain features that are conducive to better mental health. Selection of bespoke geographical boundaries, use of directed acyclic graphs and more evaluations of natural experiments are likely to be important in taking the field of enquiry onwards.

Standard acute psychiatric care in the UK is costly but problematic. Alternatives to standard in-patient wards exist, but little is known about their effectiveness, implementation and sustainability. This paper explores successful features and limitations of five residential alternative services in England and factors that facilitate or impede their initial and sustained implementation and success.

Semi-structured interviews about the functioning of six alternative services were conducted with 36 mental health professionals with good working knowledge of, and various connections with these services. A group interview with study researchers was also conducted. Data were analysed using thematic analysis.

One service did not show evidence of operating as an alternative and was excluded from further analysis. The remaining five alternatives are valued for providing a more holistic style of care than standard services that confers many perceived benefits. However, they are seen as less appropriate for compulsorily detained or highly disturbed patients, and as providing less comprehensive treatment packages than hospital settings. Factors identified as important to successful implementation and sustainability are: responding to known shortcomings in local acute care systems; balancing role clarity and adaptability; integration with other services; and awareness of the alternative among relevant local health-care providers.

Residential alternatives can play an important role in managing mental health crises. Their successful implementation and endurance depend on establishing and maintaining a valued position within local service systems. Findings contribute to bridging the gap between research evidence on the problems of standard acute care and delivering improved crisis management services.

There has been little research into the facilitated discharge (FD) function of Home Treatment Teams (HTTs). We aimed to explore and describe the prevalence and associations of FD and to estimate its effects on bed days during the index admission (length of stay corrected for ward leave) and on readmission.

Descriptive and regression analyses of data collected by South London and Maudsley NHS Foundation Trust on discharges from its general psychiatric wards, with multiple imputation of missing covariate values.

Overall, 29% of our sample of 7891 hospital admissions involved a FD. FD was associated with female gender, diagnosis of a severe mental illness, previous home treatment, having a longer previous admission, neither being discharged to a new address nor to a care home, having no other community team and having HoNOS item scores consistent with an active depressive or psychotic mental illness. In the regression analysis, FD was associated with 4.0 fewer bed days (95% confidence interval −6.7 to −1.3; p = 0.0004). There was no effect on readmission.

Our analysis provides some support for the effectiveness of FD in slightly reducing the time spent in hospital and suggests that this may be achieved without increasing the rate of readmission. Further studies in this area are important, especially given existing research that suggests that the introduction of HTTs in England and Wales was associated with little or no change in service utilisation.

Establishing the minimum clinically important difference (MCID) in functioning and cognition is essential to the interpretation of the research and clinical work conducted in bipolar disorders (BD). The present study aimed to estimate the MCID for the Functioning Assessment Short Test (FAST) and a battery of neuropsychological tests in BD.

Anchor-based and distributive methods were used to estimate the MCID for the FAST and cognition using data from a large, multicentre, observational cohort of individuals with BD. The FAST and cognition were linked with the Clinical Global Impressions Scale-Severity (CGI-S) and Global Assessment of Functioning (GAF) using an equipercentile method. The magnitude of the standard error measurement (s.e.m.) provided another estimate of the MCID.

In total, 570 participants were followed for 2 years. Cross-sectional CGI-S and GAF scores were linked to a threshold ⩽7 on the FAST for functional remission. The MCID for the FAST equalled 8- or 9-points change from baseline using the CGI-S and GAF. One s.e.m. on the FAST corresponded to 7.6-points change from baseline. Cognitive variables insufficiently correlated with anchor variables (all ρ <0.3). One s.e.m. for cognitive variables corresponded to a range of 0.45 to 0.93-s.d. change from baseline.

These findings support the value of the estimated MCID for the FAST and cognition and may be a useful tool to evaluate cognitive and functional remediation effects and improve patient functional outcomes in BD. The CGI-S and GAF were inappropriate anchors for cognition. Further studies may use performance-based measures of functioning instead.

People with severe mental illness (SMI) have a greater risk of dying from colorectal cancer (CRC), even though the incidence is lower or similar to that of the general population This pattern is unlikely to be solely explained by lifestyle factors, while the role of differences in cancer healthcare access or treatment is uncertain

We undertook a systematic review and meta-analysis on access to guideline-appropriate care following CRC diagnosis in people with SMI including the receipt of surgery, chemo- or radiotherapy. We searched for full-text articles indexed by PubMed, EMBASE, PsychInfo and CINAHL that compared CRC treatment in those with and without pre-existing SMI (schizophrenia, schizoaffective, bipolar and major affective disorders). Designs included cohort or population-based case–control designs.

There were ten studies (sample size = 3501–591 561). People with SMI had a reduced likelihood of surgery (RR = 0.90, 95% CI 0.92–0.97; p = 0.005; k = 4). Meta-analyses were not possible for the other outcomes but in results from individual studies, people with SMI were less likely to receive radiotherapy, chemotherapy or sphincter-sparing procedures. The disparity in care was greatest for those who had been psychiatric inpatients.

People with SMI, including both psychotic and affective disorders, receive less CRC care than the general population. This might contribute to higher case-fatality rates for an illness where the incidence is no higher than that of the general population. The reasons for this require further investigation, as does the extent to which differences in treatment access or quality contribute to excess CRC mortality in people with SMI.

There is a lack of mental health promotion and treatment services targeting HIV-positive men who have sex with men (HIVMSM) in China. The aim of this study was to evaluate the mental health promotion efficacy of an online intervention that combined Three Good Things (TGT) with electronic social networking (TGT-SN) and an intervention that used TGT only (TGT-only), compared with a control group.

We conducted a randomised controlled trial among HIVMSM in Chengdu, China. The participants were randomly assigned to the TGT-SN, TGT-only, and control groups. The participants in the TGT-SN group were divided into five social network groups and asked to post brief messages to the group about three good things that they had experienced and for which they felt grateful. The participants in the TGT-only group were only required to write down their three good things daily without sharing them with others. The control group received information about mental health promotion once a week for a month. The primary outcome was probable depression. Secondary outcomes were anxiety, positive and negative affect, gratitude, happiness and social support. These outcomes were assessed at baseline, 1, 3, 6 and 12 months after the intervention. Repeated-measures analyses were conducted using generalised estimation equations. The study was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-13003252).

Between June 2013 and May 2015, 404 participants were enrolled and randomly assigned to either the TGT-SN (n = 129), TGT-only (n = 139) or control group (n = 136). The main effects of TGT-SN (adjusted odds ratio (aOR) = 0.75, 95% CI 0.52–1.09; p = 0.131) and TGT-only (aOR = 0.83, 95% CI 0.57–1.21; p = 0.332) in reducing depression were statistically non-significant. The participants of the TGT-SN group showed significantly lower anxiety symptoms (aOR = 0.62, 95% CI 0.43–0.89; p = 0.009) and negative affect (β = −1.62, 95% CI 2.98 to −0.26; p = 0.019) over time compared with those of the control group. No significant main effect was found for any secondary outcomes for the TGT-only group.

The novel intervention combining the TGT exercise with electronic social networking was found effective in reducing anxiety and negative affect among HIVMSM.

To identify the predictors of psychotropic medication use and to determine rates and patterns of use in Northern Ireland (NI) among the general population and various subgroups.

Analysis of data from the NI Study of Health and Stress, a representative household survey undertaken between 2004 and 2008 with 4340 individuals. Respondents were asked about prescribed psychotropic medication use in the previous 12 months along with a series of demographic questions and items regarding experience of traumatic life events. Mental health disorders were assessed using the World Health Organization's Composite International Diagnostic Interview.

Females, individuals aged 50–64 years old, those who were previously married, and those who had experienced a traumatic lifetime event were more likely to have taken any psychotropic medication. Use of any psychotropic medication in the population in the previous 12 months was 14.9%. Use among individuals who met the criteria for a 12-month mental health disorder was 38.5%. Almost one in ten individuals (9.4%) had taken an antidepressant.

Compared with other countries, NI has high proportions of individuals using psychotropic medication in both the general population and those who met the criteria for a 12-month mental disorder. However, these results still suggest possible under treatment of mental disorders in the country. In addition, rates of use in those with no disorder are relatively high. The predictors of medication use are similar to findings in other countries. Possible research and policy implications are discussed.

Compared with the general population, individuals with schizophrenia have a higher risk of periodontal disease, which can potentially reduce their life expectancy. However, evidence for the early development of periodontal disease in schizophrenia is scant. The current study investigated risk factors for periodontal disease in patients newly diagnosed with schizophrenia.

We identified a population-based cohort of patients in Taiwan with newly diagnosed schizophrenia who developed periodontal disease within 1 year of their schizophrenia diagnosis. Treatment with antipsychotics and other medications was categorised according to medication type and duration, and the association between medication use and the treated periodontal disease was assessed through logistic regression.

Among 3610 patients with newly diagnosed schizophrenia, 2373 (65.7%) had an incidence of treated periodontal disease during the 1-year follow-up. Female sex (adjusted odds ratios [OR] 1.40; 95% confidence interval [CI] 1.20–1.63); young age (adjusted OR 0.99; 95% CI 0.98–0.99); a 2-year history of periodontal disease (adjusted OR 2.45; 95% CI 1.84–3.26); high income level (adjusted OR 2.24; 95% CI 1.64–3.06) and exposure to first-generation (adjusted OR 1.89; 95% CI 1.54–2.32) and secondary-generation (adjusted OR 1.33; 95% CI 1.11–1.58) antipsychotics, anticholinergics (adjusted OR 1.24; 95% CI 1.03–1.50) and antihypertensives (adjusted OR 1.91; 95% CI 1.64–2.23) were independent risk factors for periodontal disease. Hyposalivation – an adverse effect of first-generation antipsychotics (FGAs) (adjusted OR 2.00; 95% CI 1.63–2.45), anticholinergics (adjusted OR 1.27; 95% CI 1.05–1.53) and antihypertensives (adjusted OR 1.90; 95% CI 1.63–2.22) – was associated with increased risk of periodontal disease. Therefore, hypersalivation due to FGA use (adjusted OR 0.72; 95% CI 0.59–0.88) was considered a protective factor.

The current study highlights that early prevention of periodontal disease in individuals with schizophrenia is crucial. Along with paying more attention to the development of periodontal disease, assessing oral health regularly, helping with oral hygiene, and lowering consumption of sugary drinks and tobacco, emphasis should also be given by physicians to reduce the prescription of antipsychotics to the extent possible under efficacious pharmacotherapy for schizophrenia.

The European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) produce guidelines for the design of pivotal psychiatric drug trials used in new drug applications. It is unknown who are involved in the guideline development and what specific trial design recommendations they give.

Cross-sectional study of EMA Clinical Efficacy and Safety Guidelines and FDA Guidance Documents. Study outcomes: (1) guideline committee members and declared conflicts of interest; (2) guideline development and organisation of commenting phases; (3) categorisation of stakeholders who comment on draft and final guidelines according to conflicts of interest (‘industry’, ‘not-industry but with industry-related conflicts’, ‘independent’, ‘unclear’); and (4) trial design recommendations (trial duration, psychiatric comorbidity, ‘enriched design’, efficacy outcomes, comparator choice). Protocol registration https://doi.org/10.1101/2020.01.22.20018499 (27 January 2020).

We included 13 EMA and five FDA guidelines covering 15 psychiatric indications. Eleven months after submission, the EMA had not processed our request regarding committee member disclosures. FDA offices draft the Guidance Documents, but the Agency is not in possession of employee conflicts of interest declarations because FDA employees generally may not hold financial interests (although some employees may hold interests up to $15,000). The EMA and FDA guideline development phases are similar; drafts and final versions are publicly announced and everybody can submit comments. Seventy stakeholders commented on ten guidelines: 38 (54%) ‘industry’, 18 (26%) ‘not-industry but with industry-related conflicts’, six (9%) ‘independent’ and eight (11%) ‘unclear’. They submitted 1014 comments: 640 (68%) ‘industry’, 243 (26%) ‘not-industry but with industry-related conflicts’, 44 (5%) ‘independent’ and 20 (2%) ‘unclear’ (67 could not be assigned to a specific stakeholder). The recommended designs were generally for trials of short duration; with restricted trial populations; allowing previous exposure to the drug; and often recommending rating scale efficacy outcomes. EMA mainly recommended three arm designs (both placebo and active comparators), whereas FDA mainly recommended placebo-controlled designs. There were also other important differences and FDA's recommendations regarding the exclusion of psychiatric comorbidity seemed less restrictive.

The EMA and FDA clinical research guidelines for psychiatric pivotal trials recommend designs that tend to have limited generalisability. Independent and non-conflicted stakeholders are underrepresented in the guideline development. It seems warranted with more active involvement of scientists and independent organisations without conflicts of interest in the guideline development process.

Gene x environment (G×E) interactions, i.e. genetic modulation of the sensitivity to environmental factors and/or environmental control of the gene expression, have not been reliably established regarding aetiology of psychotic disorders. Moreover, recent studies have shown associations between the polygenic risk scores for schizophrenia (PRS-SZ) and some risk factors of psychotic disorders, challenging the traditional gene v. environment dichotomy. In the present article, we studied the role of GxE interaction between psychosocial stressors (childhood trauma, stressful life-events, self-reported discrimination experiences and low social capital) and the PRS-SZ on subclinical psychosis in a population-based sample.

Data were drawn from the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study, in which subjects without psychotic disorders were included in six countries. The sample was restricted to European descendant subjects (n = 706). Subclinical dimensions of psychosis (positive, negative, and depressive) were measured by the Community Assessment of Psychic Experiences (CAPE) scale. Associations between the PRS-SZ and the psychosocial stressors were tested. For each dimension, the interactions between genes and environment were assessed using linear models and comparing explained variances of ‘Genetic’ models (solely fitted with PRS-SZ), ‘Environmental’ models (solely fitted with each environmental stressor), ‘Independent’ models (with PRS-SZ and each environmental factor), and ‘Interaction’ models (Independent models plus an interaction term between the PRS-SZ and each environmental factor). Likelihood ration tests (LRT) compared the fit of the different models.

There were no genes-environment associations. PRS-SZ was associated with positive dimensions (β = 0.092, R2 = 7.50%), and most psychosocial stressors were associated with all three subclinical psychotic dimensions (except social capital and positive dimension). Concerning the positive dimension, Independent models fitted better than Environmental and Genetic models. No significant GxE interaction was observed for any dimension.

This study in subjects without psychotic disorders suggests that (i) the aetiological continuum hypothesis could concern particularly the positive dimension of subclinical psychosis, (ii) genetic and environmental factors have independent effects on the level of this positive dimension, (iii) and that interactions between genetic and individual environmental factors could not be identified in this sample.

Heterogeneity of schizophrenia is known to be reflected in neuropsychological functioning of patients, but its expression in relatives is understudied. This study aims at exploring relationship between executive functioning and clinical profiles of first-degree relatives of patients who are classified as having or not having the deficit subtype of schizophrenia (DSRELs v. non-DSRELs), with the prediction of greater executive impairment in DSRELs.

DSRELs (n = 15) and non-DSRELs (n = 40) were compared with community controls (CCs, n = 55) on executive functioning measured by the Wisconsin Card Sorting Test (WCST) and the phonemic verbal fluency (PVF), and clinical measures. Effects of psychopathology and intelligence quotient (IQ) measures were investigated to determine their association with executive performance.

DSRELs showed more executive dysfunction on WCST and poorer social functioning than CCs and more severe negative symptoms than non-DSRELs. Differences on WCST-categories achieved (WCST-CA) remained significant after adjustment for clinical confounders and IQ. WCST-CA was associated with apathy and paranoid ideation only within the DSREL subgroup.

Executive functioning and negative symptoms are severely impaired in first-degree relatives of deficit syndrome patients, thus suggesting that some neurocognitive deficits in patients may be transmitted within families according to the pathophysiology of the probands.