The need to ensure that research evidence is adopted by health systems and is informed by lived experience expertise has been increasingly recognised in mental health research. In the field of global mental health (GMH), though some progress has been made, the meaningful engagement of key stakeholders in research remains low. This editorial outlines recommendations to support the meaningful engagement of policy makers and people with lived or living experience of mental illness in GMH research. Recommendations include: increasing funding structures that are designed to support meaningful engagement; urging institutions to consider administrative structures that support engagement with lower resourced partners; promoting capacity development opportunities and resources to support researchers to promote meaningful engagement; developing research governance structures that include key stakeholders; and, taking steps to ensure the needs of diverse stakeholders are met through their engagement in research. Examples of good practice from these areas are provided. Though not an exhaustive list of recommendations, this editorial represents a call to the GMH research community to take a deliberate and proactive approach to prioritising meaningful stakeholder engagement in GMH research with the ultimate goal of improving accessible and appropriate mental health care.

The pathogenesis of bipolar disorder (BD) is to date not entirely clear. Classical genetic research showed that there is a contribution of genetic factors in BD, with high heritability. Twin studies, thanks to the fact that confounding factors as genetic background or family environment are shared, allow etiological inferences. In this work, we selected twin studies, which focus on the relationship between BD, genetic factors and brain structure, evaluated with magnetic resonance imaging. All the studies found differences in brain structure between BD patients and their co-twins, and also in respect to healthy controls. Genetic effects are predominant in white matter, except corpus callosum, while gray matter resulted more influenced by environment, or by the disease itself. All studies found no interactions between BD and shared environment between twins. Twin studies have been demonstrated to be useful in exploring BD pathogenesis and could be extremely effective at discriminating the neural mechanisms underlying BD.

Psychostimulants are the first choice medication in children with attention-deficit/hyperactivity disorder (ADHD). Despite the proven high efficacy of psychostimulants, at least in the short term, for ADHD core symptoms, concerns continue to be raised on their adverse effects, including putative increased risk of substance use disorders (SUDs). A recent multicentre, case–control, longitudinal, prospective, European study by Groenman and colleagues found that treatment with psychostimulants in children with ADHD lowered the risk of SUDs in adolescence. However, this finding is at odds with other recent evidence concluding that ADHD children with and without medication treatment history did not significantly differ on any subsequent SUDs rates. In the present paper, we discuss the study by Groenman and colleagues in view of its methodological strengths and limitations, and we suggest possible implications for day-to-day clinical practice.

Objective — To review the relevant literature on the effects of reductions in long stay beds on mental health services in the UK. Method — A selective literature review, with particular reference to research conducted by the author and colleagues at The Sainsbury Centre for Mental Health.Results — The evidence suggests that the effects of long stay bed reductions should be examined with regard to 'old' and 'new' long stay patients separately. While the 'old' long stay who have been most directly effected by these changes have generally fared well; the 'new' long stay have not. They are currently accumulating in acute inpatient units, often on general hospital sites, or are rotating in the 'revolving door' of acute inpatient care and inadequate community supports. Although it is clear that there is a shortage of acute beds especially in inner city areas many of the these beds are currently occupied by patients who would be better (and less expensively) cared for in community alternatives if these were available. The evidence suggests that it is possible to im-prove outcomes for this 'new' long stay group if specific kinds of housing, work and assertive community teams are provided. Conclusions — It is concluded that the effects of long stay bed reductions should be considered in a 'systems perspective'. Effective community services can be established, but in order to achieve effective substitution of one kind of service for another, there must be a well co-ordinated, clearly targeted, and technically efficient system. At the present time such services are rare. However, simply focusing on one element (e.g. beds) is unlikely to produce cost effective and efficient solutions.

This paper is concerned with issues in the routine measurement of quality of life in a mental health context. It is in three parts. In the first part the first author reviews briefly, lessons from a decade of experience in the use of data produced by routine measurement using the Colorado Client Assessment Record (CCAR) in the Mental Health Centre of Boulder County (MHCBC) in Colorado, USA. In the second part, the specific issues surrounding quality of life assessment as a routine outcome measure are considered. Evidence is presented to counter some of the commonly held beliefs about QoL measurement problems. Finally, general problems that affect QoL and all other routine measures are described and analysed using a framework devised by Peterson (1989).

The importance of measuring the quality of mental health care is widely recognized. A number of factors should be considered when constructing mental health quality indicators including the aspects of care to be measured; translation of quality measurement concepts into indicators that can be measured; pilot-testing, analysis and display of measures; and maintaining effectiveness of performance measures and policies over time. The impetus to measure quality in mental health care may be dampened by the innumerable challenges inherent in this worthwhile endeavour. In particular, many countries lack adequate quality measurement infrastructure. Challenges may be overcome to a certain extent by international collaboration. While cross-country co-operation can also introduce additional complexities; its benefits usually outweigh the costs. Quality indicators can have many uses but of utmost importance is that quality measurement in mental health care subsequently results in quality improvements.

Objectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.

Aims – Evidence from the literature show that patients affected by psychosis rarely are informed about their diagnosis and/or involved in the decision making process regarding the therapeutic program. The aim of the present study is to investigate psychiatrists' clinical experiences, beliefs and attitudes towards communicating the diagnosis to patients affected by psychosis. Method – Three focus groups were conducted with 28 psychiatrists of different levels of expertise (10 senior psychiatrists and 18 psychiatrists in training), all working at the South-Verona Community-based Mental Health Service. The group discussions were audiotaped and transcribed. The authors derived different thematic categories which were used by two raters to classify all contributions of the psychiatrists. Results – The main themes of interest which emerged were: experience with the communication of the diagnosis of psychosis and main communication strategies used; obstacles and personal difficulties in giving such information. Conclusions – In the psychiatric setting the disclosure of the diagnosis of psychosis implies different clinical and ethical issues and is felt as highly problematic. These findings suggest a need of psychiatrists to involve the psychotic patient in the information giving process in order to learn his/her informative needs which are the starting point for individually tailored information.

The authors have no potential conflict of interest related to the subject of the paper. No economic support has been received for this study.

Aims — This aim of this paper is to discuss a consumer -therapist co-run pilot group on self-injury held at an American college. Deliberate self-injury has come to be a common phenomenon in schools and colleges. However the treatment and understanding of self-injury still remains a challenge. Most people who self-injure remain hidden in society and do not seek therapy, due to the shame-filled stereotypes and misconceptions that surround self-injury. Group therapy has been discussed as ineffective by many in the mental health field while individual treatment has been controversial for decades. Method — The paper will discuss how this group treatment was informed by consumer empowerment philosophy and how consumer and therapist facilitators worked together to turn it into a healing experience. Results — This group was indeed challenging but confirmed that consumer- run programs are able to function as a catalyst to facilitate healing. It confirmed that breaking away from traditional models that allocate all power and hope for change to professionals might not only be an important step but, in cases such as treatment of self-injury, a necessity.

Declaration of Interest: none.

Although we have gained enormous insights into neurobiological and psychological underpinnings of bipolar disorder (BD) symptoms, our knowledge concerning pathogenic mechanisms initiating recurrent affective episodes is still fragmentary. Previous research has highlighted the role of significant life events and social rhythm in recurrent episodes of mania and depression. However, most studies share the drawback of retrospective self-report data, which are prone to recall biases and limited introspective abilities. Therefore, more objective data, such as neuropsychological and neurobiological measures are needed to further unravel the pathogenic mechanisms of the dynamics of bipolar disorder. Previous research has highlighted disturbed emotional reactivity as well as impaired emotion regulation and impulse control as major behavioural characteristics of BD and aberrancies in prefrontal–limbic–striatal networks that have been proposed to be the correlates of these behavioural alterations. However, longitudinal studies assessing these neural and behavioural alterations are rare. Future research should therefore adopt prospective study designs including behavioural and neuroimaging measures underlying cognitive, emotional and motivational deficits in bipolar disorder. Particularly, these measures should be collected continuously at multiple time points as implemented in modern ambulatory assessment tools.