Diagnosis of autism falls under the remit of psychiatry. Recognition that psychiatrists could be autistic is recent. Psychiatrists are the second largest specialty group in Autistic Doctors International, a peer support group for autistic doctors.

To explore the experiences of autistic psychiatrists in relation to recognising themselves and others as autistic.

This was a qualitative study using loosely structured interviews and an interpretive phenomenological analysis.

Eight autistic senior psychiatrists based in the UK participated. One had a childhood diagnosis, two had been diagnosed in adulthood and the remainder self-identified as autistic as adults. Recognition of autism followed diagnosis of their children or encounters with autistic patients. Barriers to self-recognition included lack of autism training, the deficit-based diagnostic criteria and stereotypical views of autism. Recognising that they were autistic led to the realisation that many colleagues were also likely to be autistic, particularly in neurodevelopmental psychiatry. All participants reported the ability to quickly recognise autistic patients and to develop a good rapport easily, once they were aware of their own autistic identity. Difficulties recognising patients as autistic occurred before self-recognition when they shared autistic characteristics and experiences. ‘If we don't recognise ourselves as autistic how on earth can we diagnose patients accurately?’

Autistic psychiatrists face multiple barriers to recognising that they are autistic. Lack of self-recognition may impede diagnostic accuracy with autistic patients. Self-recognition and disclosure by autistic psychiatrists may be facilitated by reframing the traditional deficit-based view of autism towards a neurodiversity-affirmative approach, with consequent benefits for autistic patients.

A significant rise in mental health disorders was expected during the COVID-19 pandemic. However, referrals to mental health services dropped for several months before rising to pre-pandemic levels.

To identify trajectories of incidence and risk factors for common mental disorders among the general population during 14 months of the COVID-19 pandemic, to inform potential mental health service needs.

A cohort of 33 703 adults in England in the University College London COVID-19 Social Study provided data from March 2020 to May 2021. Growth mixture modelling was used to identify trajectories based on the probability of participants reporting symptoms of depression (Patient Health Questionnaire-9) or anxiety (Generalised Anxiety Disorder-7) in the clinical range, for each month. Sociodemographic and personality-related characteristics associated with each trajectory class were explored.

Five trajectory classes were identified for depression and anxiety. Participants in the largest class (62%) were very unlikely to report clinically significant symptom levels. Other trajectories represented participants with a high likelihood of clinically significant symptoms throughout, early clinically significant symptoms that reduced over time, clinically significant symptoms that emerged as the pandemic unfolded and a moderate likelihood of clinically significant symptoms throughout. Females, younger adults, carers, those with existing mental health diagnoses, those that socialised frequently pre-pandemic and those with higher neuroticism scores were more likely to experience depression or anxiety.

Nearly 40% of participants followed trajectories indicating risk of clinically significant symptoms of depression or anxiety. The identified risk factors could inform public health interventions to target individuals at risk in future health emergencies.

Physician-assisted suicide (PAS) is typically associated with serious physical illnesses that are prevalent in palliative care. However, individuals with mental illnesses may also experience such severity that life becomes intolerable. In February 2020, the previous German law prohibiting PAS was repealed. Patients with severe mental illnesses are increasingly likely to approach physicians with requests for PAS.

To explore the ethical and moral perspectives of medical students and physicians when making individual decisions regarding PAS.

An anonymised digital survey was conducted among medical students and physicians in Germany. Participants were presented with a case vignette of a chronically depressed patient requesting PAS. Participants decided on PAS provision and assessed theoretical arguments. We employed generalised ordinal regression and qualitative analysis for data interpretation.

A total of N = 1478 participants completed the survey. Of these, n = 470 (32%) stated that they would refuse the request, whereas n = 582 (39%) would probably refuse, n = 375 (25%) would probably agree and n = 57 (4%) would definitely agree. Patient-centred arguments such as the right to self-determination increased the likelihood of consent. Concerns that PAS for chronically depressed patients might erode trust in the medical profession resulted in a decreased willingness to provide PAS.

Participants displayed relatively low willingness to consider PAS in the case of a chronically depressed patient. This study highlights the substantial influence of theoretical medical-ethical arguments and the broader public discourse, underscoring the necessity of an ethical discussion on PAS for mental illnesses.

The prevalence of non-suicidal self-injury (NSSI) among adolescents underscores the importance of understanding the complex factors that drive this behaviour. Framed within broader constructs of emotional regulation theories, alexithymia and peer victimisation are thought to interact to influence NSSI behaviours.

This research addresses whether alexithymia and peer victimisation serve as risk factors for NSSI and, if so, how these factors interact with each other.

This quantitative study analysed data from 605 adolescents, using a range of validated self-report measures including the Toronto Alexithymia Scale. Statistical analyses including one-way analysis of variance, multiple regression and structural equation modelling were employed to scrutinise the relationships among the variables.

Alexithymia and peer victimisation significantly predicted NSSI behaviours. Specifically, the ‘difficulty in identifying feelings’ subscale of alexithymia emerged as a noteworthy predictor of NSSI (P < 0.001). Peer victimisation mediated the relationship between alexithymia and NSSI, explaining approximately 24.50% of alexithymia's total effect on NSSI. In addition, age was a significant predictor of NSSI, but gender and education years were not (P > 0.05). These relationships were found to be invariant across genders.

This study enriches our understanding of the interplay between alexithymia, peer victimisation and NSSI, particularly within the Chinese context. Its findings have significant implications for a rethinking of alexithymia's theoretical construct and interventions targeting emotional literacy and peer dynamics among adolescents. Future research could benefit from a longitudinal design to establish causality.

The COVID-19 pandemic initiated a mass switch to psychological therapy being delivered remotely, including at Anxiety UK, a national mental health charity. Understanding the impact of this forced switch could raise implications for the provision of psychological therapies going forwards.

To understand whether the forced switch to remote therapy had any impact on outcomes, and if certain groups should continue to be routinely offered certain delivery modalities in future.

Data were available for 2323 individuals who accessed Anxiety UK services between January 2019 and October 2021. Demographic data, baseline and discharge anxiety and depression symptoms, and mode of therapy delivery were available.

Regression models were built to model (a) the mode of therapy delivery received pre-pandemic using logistic regression, and (b) outcomes pre- and post-pandemic onset within demographic groups.

No statistically significant changes in baseline anxiety symptoms, demographics or outcomes were observed before and after the onset of the COVID-19 pandemic.

Pre-pandemic, males were more likely to receive online video therapy than telephone therapy (Relative Risk Ratio (RRR) 1.42, [1.01, 1.99]), while older clients were less likely to receive online video therapy (RRR 0.98, [0.97, 0.99]). However, no differences in outcomes were observed post-pandemic onset within these groups, with only the number of sessions of therapy being a significant predictor of outcomes.

Anxiety UK services remained effective throughout the pandemic. We observed no evidence that any demographic group had worse outcomes following the forced switch to remote therapy.

The review explored differences in sources of referrals and utilisation of child and adolescent mental health services (CAMHS) among children and young people (CYP) of black ethnicity compared with other ethnicities. We also explored international differences.

We searched MEDLINE (through Ovid), PsycINFO, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Web of Science using a priori defined search terms to identify relevant records. We used the “Population, Exposure, and Outcome” (PEO) framework to define search terms. Pairs of authors assessed papers for inclusion, extracted the data and conducted quality assessment. The systematic review was pre-registered with PROSPERO (CRD42021249619).

We identified 110 studies which all had quantitative design. The results indicate that compared with other ethnic groups, CYP of black ethnicity were less likely to be screened for mental disorders, and more likely to be referred by non-voluntary sources such as social/child welfare services and juvenile justice systems. CYP of black ethnicity were also less likely to utilise all types and levels of mental health services with the exception of school-based services. CYP of black ethnicity were less likely to access psychological intervention or to be prescribed psychotropic medications. Also, CYP of black ethnicity were more likely to experience coercive treatments, and to receive poorer quality of care. These findings were similar across different countries.

CYP of black ethnicity experience significant disadvantages across their care journeys through CAMHS. Addressing the drivers for these disadvantages is crucial for improving access to care for this group.

The COVID-19 pandemic significantly impacted the mental health of adults with intellectual and developmental disabilities (IDD). During this period of uncertainty and need for up-to-date information, various virtual training programmes demonstrated the role of tele-mentoring programmes.

The aim of this paper is to describe the educational evaluation of the National Extension for Community Healthcare Outcomes – Adults with Intellectual and Developmental Disabilities (ECHO-AIDD), a programme for service providers working with adults with IDD during COVID-19.

The programme consisted of six sessions, conducted weekly, over two cycles. Each session included didactic teaching by hub team members, COVID-19 news updates, wellness check-ins and a brief mindfulness activity, followed by a 30 to 45 min case-based discussion. The hub structure had an inter-professional approach to team expertise. Those with lived experience were an integral part of the content experts’ hub. Pre-, post- and follow-up evaluation data were collected.

Care providers from health and social care sectors (n = 230) participated in the programme. High levels of engagement and satisfaction were reported. Self-efficacy ratings improved from pre- to post-, and were maintained at 8-week follow-up; improvement from pre- to post- was significant (P < 0.0001).

Exposure to National ECHO-AIDD educational intervention led to improvement in perceived competencies. This study also shows the valuable role of people with lived experience in fostering adaptive expertise in learners. The outreach and scalability support the feasibility of building a national virtual community of practice for IDD service providers. Future studies should focus on studying the impact of these programmes on the health outcomes of people with IDD.

Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care.

To explore patient and carer experiences of receiving the ECHOMANTRA intervention.

This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts.

Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability.

Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

Psychoeducation is a common element in psychological interventions for youth depression and anxiety, but evidence about its use with youth perinatally is limited.

This review aims to understand outcomes and mechanisms of psychoeducation for the indicated prevention and treatment of perinatal depression and anxiety in youth.

For this review, we synthesised published quantitative and qualitative evidence. Seven databases (ASSIA, Medline, PubMed, PsycINFO, PsycArticles, Scopus and Web of Science) were searched for studies published before 10 August 2021. We also had consultations with a youth advisory group (N = 12).

In total, 20 studies met the inclusion criteria. Seven quantitative studies examined multicomponent interventions that included psychoeducation, and one study evaluated psychoeducation as a standalone intervention for postnatal depression. Multicomponent interventions showed significant effects on postnatal depression in two out of six studies, as well as being effective at reducing prenatal anxiety in one study. Standalone psychoeducation for postnatal depression was also effective in one study. Evidence from 12 qualitative studies, corroborated by commentaries from the youth advisory group, suggested that psychoeducation could increase knowledge about symptoms, generate awareness of relevant services and enhance coping.

Psychoeducation may be an important foundational ingredient of interventions for perinatal depression and, potentially, anxiety in adolescents and young adults through stimulating help-seeking and self-care.

Neuroimaging studies suggest alterations in prefrontal cortex (PFC) activity in healthy adults under stress. Adolescents with non-suicidal self-injury (NSSI) report difficulties in stress and emotion regulation, which may be dependent on their level of borderline personality disorder (BPD).

The aim was to examine alterations in the PFC in adolescents with NSSI during stress.

Adolescents (13–17 years) engaging in non-suicidal self-injury (n = 30) and matched healthy controls (n = 29) performed a task with low cognitive demand and the Trier Social Stress Test (TSST). Mean PFC oxygenation across the PFC was measured with an eight-channel near-infrared spectroscopy system. Alongside self-reports on affect, dissociation and stress, BPD pathology was assessed via clinical interviews.

Mixed linear-effect models revealed a significant effect of time on PFC oxygenation and a significant time×group interaction, indicating increased PFC activity in patients engaging in NSSI at the beginning of the TSST compared with healthy controls. Greater BPD symptoms overall were associated with an increase in PFC oxygenation during stress. In exploratory analyses, mixed models addressing changes in PFC connectivity over time as a function of BPD symptoms were significant only for the left PFC.

Results indicate differences in the neural stress response in adolescents with NSSI in line with classic neuroimaging findings in adults with BPD. The link between PFC oxygenation and measures of BPD symptoms emphasises the need to further investigate adolescent risk-taking and self-harm across the spectrum of BPD, and maybe overall personality pathology, and could aid in the development of tailored therapeutic interventions.

In schizophrenia, disorganisation and impoverished mental activity (as described in the classical descriptions by Kraepelin and Bleuler) together with impaired cognitive function, predict persisting functional impairment (Liddle, 2019). We propose that in schizophrenia, four ‘classical’ features (disorganisation, impoverished mental activity, cognitive dysfunction, and impaired role-functioning) arise from a shared pathophysiological process that increases risk of persisting functional impairment. We also propose that this shared process creates a risk of subsequent episodic reality distortion (delusions and hallucinations). In the current work, we investigate whether a single latent variable accounts for the shared variance in the four ‘classical’ features. We also investigate whether the severity of this latent variable based on assessment of long-standing classical symptoms predicts severity of current reality distortion.

We performed maximum likelihood factor analysis of disorganisation, impoverishment, cognition and role-function in three separate samples of patients (n = 54, n = 128, n = 64) with DSM diagnosed schizophrenia, schizo-affective disorder or bipolar disorder. In the first two samples, we quantified current disorganisation and impoverished mental activity using the Positive and Negative Syndrome Scale (PANSS). In the third, we scored persistent disorganisation and impoverished mental activity according to Symptoms & Signs of Psychosis Illness (SSPI) based on systematic examination of case records. We assessed cognition using the Digit Symbol Substitution Test (DSST) and role-function using the Social & Occupational functioning scale (in two studies) and the Personal & Social Performance scale (in one study). We quantified current reality distortion by summing SSPI scores for current delusions and hallucinations.

In each of the three studies, a single latent variable accounted for more than 50% of variance. Loadings were similar whether current or persistent symptoms were used. The latent variable derived from persistent symptom scores correlated significantly with current reality distortion.

This series of studies provide further evidence that disorganisation, impoverished mental activity, cognitive impairment and impaired role function share substantial variance, consistent with the proposal that they reflect a core pathophysiological process underlying ‘classical’ schizophrenia. Furthermore, our findings are consistent with the hypothesis that over time, this pathophysiological process increases the risk of episodic reality distortion. However, these were all cross-sectional studies, and need to be confirmed using longitudinal data. Our findings have potential clinical and research implications including development of a custom-made clinical tool to quantify the core deficit as well as investigating targeted interventions employing medication or neuromodulation.

Previous pandemics have had negative effects on mental health, but there are few data on children and adolescents who were receiving ongoing psychiatric treatment.

To study changes in emotions and clinical state, and their predictors, during the COVID-19 pandemic in France.

We administered (by interview) the baseline Youth Self-Report version of the CoRonavIruS Health Impact Survey v0.3 (CRISIS, French translation) to 123 adolescent patients and the Parent/Caregiver version to evaluate 99 child patients before and during the first ‘lockdown’. For 139 of these patients who received ongoing treatment in our centre, treating physicians retrospectively completed longitudinal global ratings for five time periods, masked to CRISIS ratings.

The main outcome measure was the sum of eight mood state items, which formed a single factor in each age group. Overall, this score improved for each age group during the first lockdown. Clinician ratings modestly supported this result in patients without intellectual disability or autism spectrum disorder. Improvement of mood states was significantly associated with perceived improvement in family relationships in both age groups.

Consistent with previous studies of clinical cohorts, our patients had diverse responses during the pandemic. Several factors may have contributed to the finding of improvement in some individuals during the first lockdown, including the degree of family support or conflict, stress reduction owing to isolation, limitations of the outcome measures and/or possible selection bias. Ongoing treatment may have had a protective effect. Clinically, during crises additional support may be needed by families who experience increased conflict or who care for children with intellectual disability.

Medication, combined with environmental and psychosocial support, can mitigate adverse outcomes in attention-deficit hyperactivity disorder (ADHD). There is a need for research into regional and national prescription volumes and patterns, especially among adults.

This study analysed prescribing patterns for medications commonly used to treat ADHD in adolescents and adults.

Data was extracted from the NHS Scotland Prescribing Information System on prescriptions for 7806 adolescents (aged 10–19 years) and 4998 adults (aged 20–59 years) in 2019. This included medications listed under Section 4.4 of the British National Formulary. We explored 2019 prescription patterns across different regions and estimated ADHD prevalence levels. Additionally, we assessed changes in dispensed prescriptions, defined daily dose and costs, compared with figures from 2010.

Between 2010 and 2019, prescriptions for ADHD medications increased (dispensed prescriptions +233.2%, defined daily dose +234.9%, cost +216.6%). Despite these increases, analysis indicated that in 2019, considering a 5% estimated ADHD prevalence among adolescents, 73% were not prescribed medication, increasing to 81% at a 7% estimated prevalence. Similarly, among adults with a 2% estimated prevalence, 91% were not prescribed medication, rising to 96% at a 4% estimated prevalence. Regional disparities were evident, with 41–96% of adolescents and 85–100% of adults, based on ADHD prevalence estimates, not receiving a prescription, depending on area.

Although prescription rates for ADHD medication have increased over time, the data do not indicate excessive use of medication. Instead, they suggest that for some groups there is a lower use of medication compared with expected prevalence figures, especially among adults.

Carers of people who are involuntarily admitted to hospital report feeling isolated and unsupported by services. The Independent Review of the Mental Health Act (MHA) recommended that carers be supported. However, no research has directly explored what type of support carers would find most helpful when a relative/friend is involuntary admitted.

To explore carers’ experiences and views around the support they want to receive when their relative/friend is involuntarily admitted under the MHA.

A total of 22 one-to-one interviews with carers were conducted online at three sites across England. Audio recordings of the interviews were transcribed, and data were analysed with thematic analysis.

Four main themes were identified: (a) heterogeneity in the current support for carers, (b) information about mental health and mental health services, (c) continuous support, and (d) peer support and guidance. Carers reported receiving support from professionals, peers and relatives, but this was unstructured, and the extent of support varied across carers. Carers reported wanting more information about mental health services, and for this information to be consistent. Carers also reported wanting emotional support from a single, continuous person, helping them establish a more personal and sincere connection. Peers were also identified as important in the provision of carer support, allowing carers to feel reassured and understood in their experience.

The support received by carers is currently unstructured. To meet the MHA review recommendations, carers of patients who are involuntarily admitted should be allocated a named contact person, ideally with lived experience, to offer information and personal continuity of support.

Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa.

This study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services.

We compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38).

Autism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety.

The presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.

To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults.

Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013.

This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice.

Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered.

Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

Childhood maltreatment and peer victimisation are common sources of early-life interpersonal stress. Childhood maltreatment is associated with atypical frontolimbic emotion processing and regulation, and increased vulnerability for self-harm/suicide. However, few studies have compared the neurofunctional correlates between caregiver- versus peer-inflicted mistreatment.

We compared the alterations of neurofunctional correlates of facial emotion processing in youths exposed to childhood maltreatment or peer victimisation, and explored their associations with self-harm.

Functional magnetic resonance imaging data were collected from 114 age- and gender-matched youths (39 childhood maltreatment, 37 peer victimisation and 38 controls) during an emotion discrimination task. Region-of-interest (amygdala, insula) and whole-brain analyses were conducted.

Groups differed significantly during disgust processing only. Both groups had lower activation in the right amygdala and bilateral posterior insula than controls; left insular underactivation was furthermore related to increased self-harm in maltreated youths. Compared with controls, at the whole-brain level, both groups also had underactivation in a cluster of bilateral limbic-thalamic-striatal, precuneus/posterior cingulate, temporal, fusiform/lingual and cerebellar regions, which was negatively associated with emotional problems in controls, as well as a cluster of somatosensory regions associated with increased self-harm in maltreated youths.

Early-life interpersonal stress from caregivers or peers is associated with common underactivation of limbic-thalamic-striatal, precuneus/posterior cingulate and somatosensory regions during disgust processing. The hypoactivation of key emotion and sensory processing and self-referential brain regions could be a potential suppressive mechanism to cope with the aversive emotion; however, it may also entail increased risk of affective psychopathology in seemingly healthy youths.

People with intellectual disability (PwID) and epilepsy have increased premature and potentially preventable mortality. This is related to a lack of equitable access to appropriate care. The Step Together guidance and toolkit, developed with patient, clinical, charity and commissioning stakeholders, allows evaluation and benchmarking of essential epilepsy service provision for PwID in eight key domains, at a care system level.

To evaluate care provisions for adult PwID and epilepsy at a system level in the 11 integrated care systems (ICSs) of the Midlands, the largest NHS England region (population: approximately 11 million), using the Step Together toolkit

Post training, each ICS undertook its benchmarking with the toolkit and submitted their scores to Epilepsy Action, a national UK epilepsy charity, who oversaw the process. The outcomes were analysed descriptively to provide results, individual and cumulative, at care domain and system levels.

The toolkit was completed fully by nine of the 11 ICSs. Across all eight domains, overall score was 44.2% (mean 44.2%, median 43.3%, range 52.4%, interquartile range 23.8–76.2%). The domains of local planning (mean 31.1%, median 27.5%) and care planning (mean 31.4%, median 35.4%) scored the lowest, and sharing information scored the highest (mean 55.2%, median 62.5%). There was significant variability across each domain between the nine ICS. The user/carer participation domain had the widest variation across ICSs (0–100%).

The results demonstrate a significant variance in service provision for PwID and epilepsy across the nine ICSs. The toolkit identifies specific areas for improvement within each ICS and region.

Exposure to second-generation antipsychotics (SGAs) carries a risk of type 2 diabetes, but questions remain about the diabetogenic effects of SGAs.

To assess the diabetes risk associated with two frequently used SGAs.

This was a retrospective cohort study of adults with schizophrenia, bipolar I disorder or severe major depressive disorder (MDD) exposed during 2008–2013 to continuous monotherapy with aripiprazole or olanzapine for up to 24 months, with no pre-period exposure to other antipsychotics. Newly diagnosed type 2 diabetes was quantified with targeted minimum loss-based estimation; risk was summarised as the restricted mean survival time (RMST), the average number of diabetes-free months. Sensitivity analyses were used to evaluate potential confounding by indication.

Aripiprazole-treated patients had fewer diabetes-free months compared with olanzapine-treated patients. RMSTs were longer in olanzapine-treated patients, by 0.25 months [95% CI: 0.14, 0.36], 0.16 months [0.02, 0.31] and 0.22 months [0.01, 0.44] among patients with schizophrenia, bipolar I disorder and severe MDD, respectively. Although some sensitivity analyses suggest a risk of unobserved confounding, E-values indicate that this risk is not severe.

Using robust methods and accounting for exposure duration effects, we found a slightly higher risk of type 2 diabetes associated with aripiprazole compared with olanzapine monotherapy regardless of diagnosis. If this result was subject to unmeasured selection despite our methods, it would suggest clinician success in identifying olanzapine candidates with low diabetes risk. Confirmatory research is needed, but this insight suggests a potentially larger role for olanzapine in the treatment of well-selected patients, particularly for those with schizophrenia, given the drug's effectiveness advantage among them.