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.

In this study, we have compared 229 Wechsler Adults Intelligence Scale – Fourth Edition (WAIS-IV) cognitive profiles of different severity adults with autism spectrum disorder to verify the impact of several variables including sex, age, level of education and autism severity level in an Italian sample. Moreover, we wanted to find out the optimal cut points for the major intelligence quotients in order to discriminate autism severity levels.

Participants were recruited from two National Health System Center in two different Italian regions and were assessed with gold-standard instruments as a part of their clinical evaluation. According to DSM-5, cognitive domains were also measured with multi-componential tests. We used the Italian adaptation of WAIS-IV. We checked our hypotheses using linear regression models and receiver operating characteristics (ROC) curves.

Our results showed that age and level of education have a strong impact on Verbal Comprehension (VCI) and Working Memory Indexes (WMI). Gender differences are relevant when considering the VCI and Processing Speed index (PSI) in which women obtained the best performance. These differences are still relevant when considering cut points of ROC because 69 resulted to be the optimal cut point for women, 65 for men.

Few conclusions can be assumed only examining Full Scale Intelligence Quotient (FSIQ) scores as it includes many different information about broader cognitive abilities. Looking deeper at main indexes and their subtests findings are consistent with previous research on the disorder (moderate correlations of FSIQ, Perceptual Reasoning index, WMI and PSI with the participants’ age), while other results are unforeseen (no effect of sex found on FSIQ score) or novel (significant effect of education on VCI and WMI). Using an algorithm predicting optimal cut point for discriminating through autism severity levels can help clinicians to better label and quantify the required help a person may need, a test cannot replace diagnostic and clinical evaluation by experienced clinicians.

Lithium has long been believed to reduce the risk of suicide and suicidal behaviour in people with mood disorders. Previous meta-analyses appeared to support this belief, but excluded relevant data due to the difficulty of conducting meta-analysis of rare events. The current study is an updated systematic review and meta-analysis that includes all eligible data, and evaluates suicide, non-fatal suicidal behaviour (including suicidal ideation) and suicide attempts.

We searched PubMed, PsycINFO and Embase and some trial registers. We included all randomised trials comparing lithium and placebo or treatment as usual in mood disorders published after 2000, to ensure suicide was reliably reported. Trial quality was assessed using the Cochrane Risk of Bias tool. Pooled data were analysed using Fisher's Exact test. In addition, meta-analysis was conducted using various methods, prioritizing the Exact method. All trials were included in the analysis of suicide initially, regardless of whether they reported on suicide or not. We conducted a sensitivity analysis with trials that specifically reported on suicides and one that included trials published before 2000. Pre-specified subgroup analyses were performed involving suicide prevention trials, trials excluding people already taking lithium, trials involving people with bipolar disorder exclusively and those involving people with mixed affective diagnoses. Non-fatal suicidal behaviour and suicide attempts were analysed using the same methods, but only trials that reported these outcomes were included. PROSPERO registration: CRD42021265809.

Twelve eligible studies involving 2578 participants were included. The pooled suicide rate was 0.2% for people randomised to lithium and 0.4% with placebo or treatment as usual, which was not a statistically significant difference; odds ratio (OR) = 0.41 (95% confidence interval 0.03–2.49), p = 0.45. Meta-analysis using the Exact method produced an OR of 0.42 (95% confidence interval 0.01–4.5). The result was not substantially different when restricted to 11 trials that explicitly reported suicides and remained statistically non-significant when including 15 trials published before 2000 (mostly in the 1970s). There were no significant differences in any subgroup analysis. There was no difference in rates of all non-fatal suicidal behaviour in seven trials that reported this outcome, or in five trials that reported suicide attempts specifically. Meta-analyses using other methods also revealed no statistically significant differences.

Evidence from randomised trials is inconclusive and does not support the idea that lithium prevents suicide or suicidal behaviour.

To assess the association of sleep factors (sleep duration, trouble sleeping, sleep disorder) and combined sleep behaviours with the risk of clinically relevant depression (CRD).

A total of 17 859 participants (8806 males and 9053 females) aged 20–79 years from the National Health and Nutrition Examination Survey (NHANES) 2007–2014 waves were included. Sleep duration, trouble sleeping and sleep disorder were asked in the home by trained interviewers using the Computer-Assisted Personal Interviewing (CAPI) system. The combined sleep behaviours were referred to as ‘sleep patterns (healthy, intermediate and poor)’, with a ‘healthy sleep pattern’ defined as sleeping 7–9 h per night with no self-reported trouble sleeping or sleep disorders. And intermediate and poor sleep patterns indicated 1 and 2–3 sleep problems, respectively. Weighted logistic regression was performed to evaluate the association of sleep factors and sleep patterns with the risk of depressive symptoms.

The total prevalence of CRD was 9.5% among the 17 859 participants analysed, with females having almost twice as frequency than males. Compared to normal sleep duration (7–9 h), both short and long sleep duration were linked with a higher risk of CRD (short sleep: OR: 1.66, 95% CI: 1.39–1.98; long sleep: OR: 2.75, 95% CI: 1.93–3.92). The self-reported sleep complaints, whether trouble sleeping or sleep disorder, were significantly related with CRD (trouble sleeping: OR: 3.04, 95% CI: 2.59–3.56; sleep disorder: OR: 1.83, 95% CI: 1.44–2.34). Furthermore, the correlations appeared to be higher for individuals with poor sleep pattern (OR: 5.98, 95% CI: 4.91–7.29).

In this national representative survey, it was shown that there was a dose-response relationship between sleep patterns and CRD.

Despite reports of an elevated risk of breast cancer associated with antipsychotic use in women, existing evidence remains inconclusive. We aimed to examine existing observational data in the literature and determine this hypothesised association.

We searched Embase, PubMed and Web of Science™ databases on 27 January 2022 for articles reporting relevant cohort or case-control studies published since inception, supplemented with hand searches of the reference lists of the included articles. Quality of studies was assessed using the Newcastle-Ottawa Scale. We generated the pooled odds ratio (OR) and pooled hazard ratio (HR) using a random-effects model to quantify the association. This study was registered with PROSPERO (CRD42022307913).

Nine observational studies, including five cohort and four case-control studies, were eventually included for review (N = 2 031 380) and seven for meta-analysis (N = 1 557 013). All included studies were rated as high-quality (seven to nine stars). Six studies reported a significant association of antipsychotic use with breast cancer, and a stronger association was reported when a greater extent of antipsychotic use, e.g. longer duration, was operationalised as the exposure. Pooled estimates of HRs extracted from cohort studies and ORs from case-control studies were 1.39 [95% confidence interval (CI) 1.11–1.73] and 1.37 (95% CI 0.90–2.09), suggesting a moderate association of antipsychotic use with breast cancer.

Antipsychotic use is moderately associated with breast cancer, possibly mediated by prolactin-elevating properties of certain medications. This risk should be weighed against the potential treatment effects for a balanced prescription decision.

There has been increasing evidence of hormonal changes during reproductive events that lead to mood changes. However, studies on the severity of psychological problems according to the menopausal stage are limited. Thus, this study aimed to investigate the association between menopausal stages, depression and suicidality.

A total of 45 177 women who underwent regular health check-ups between 2015 and 2018 at Kangbuk Samsung Hospital were included. Participants were stratified into four groups (pre-menopause, early transition, late transition and post-menopause) based on the Stages of Reproductive Aging Workshop Criteria. The Center for Epidemiological Studies-Depression scale (CESD) was used to evaluate depressive symptoms, and the degree of depressive symptoms was classified as moderate (CESD score 16–24) or severe (CESD score ⩾ 25). To measure suicide risk, we administered questionnaires related to suicidal ideation.

Overall, the prevalence of CESD scores of 16–24 and ⩾ 25 was 7.6 and 2.8%, respectively. Menopausal stages were positively associated with depressive symptoms in a dose-dependent manner. Multivariable-adjusted prevalence ratios (PRs, 95% confidence intervals) for CESD scores of 16–24 comparing the stages of the early menopausal transition (MT), late MT and post-menopause to pre-menopause was 1.28 (1.16–1.42), 1.21 (1.05–1.38) and 1.58 (1.36–1.84), respectively. The multivariable-adjusted PRs for CESD scores ⩾ 25 comparing the stages of the early MT, late MT and post-menopause to pre-menopause were 1.31 (1.11–1.55), 1.39 (1.12–1.72), 1.86 (1.47–2.37), respectively. In addition, the multivariable-adjusted PRs for suicidal ideation comparing the early MT, late MT and post-menopause stages to the pre-menopause stage were 1.24 (1.12–1.38), 1.07 (0.93–1.24) and 1.46 (1.25–1.70) (p for trend <0.001), respectively.

These findings indicate that the prevalence of depressive symptoms and suicidal ideation increases with advancing menopausal stage, even pre-menopause.

Health services research (HSR) is affected by a widespread problem related to service terminology including non-commensurability (using different units of analysis for comparisons) and terminological unclarity due to ambiguity and vagueness of terms. The aim of this study was to identify the magnitude of the terminological bias in health and social services research and health economics by applying an international classification system.

This study, that was part of the PECUNIA project, followed an ontoterminology approach (disambiguation of technical and scientific terms using a taxonomy and a glossary of terms). A listing of 56 types of health and social services relevant for mental health was compiled from a systematic review of the literature and feedback provided by 29 experts in six European countries. The disambiguation of terms was performed using an ontology-based classification of services (Description and Evaluation of Services and DirectoriEs – DESDE), and its glossary of terms. The analysis focused on the commensurability and the clarity of definitions according to the reference classification system. Interrater reliability was analysed using κ.

The disambiguation revealed that only 13 terms (23%) of the 56 services selected were accurate. Six terms (11%) were confusing as they did not correspond to services as defined in the reference classification system (non-commensurability bias), 27 (48%) did not include a clear definition of the target population for which the service was intended, and the definition of types of services was unclear in 59% of the terms: 15 were ambiguous and 11 vague. The κ analyses were significant for agreements in unit of analysis and assignment of DESDE codes and very high in definition of target population.

Service terminology is a source of systematic bias in health service research, and certainly in mental healthcare. The magnitude of the problem is substantial. This finding has major implications for the international comparability of resource use in health economics, quality and equality research. The approach presented in this paper contributes to minimise differentiation between services by taking into account key features such as target population, care setting, main activities and type and number of professionals among others. This approach also contributes to support financial incentives for effective health promotion and disease prevention. A detailed analysis of services in terms of cost measurement for economic evaluations reveals the necessity and usefulness of defining services using a coding system and taxonomical criteria rather than by ‘text-based descriptions’.

We investigate the prevalence and risk factor profiles of Intermittent Explosive Disorder (IED) and comparison between two diagnostic measures for IED in a large population-based study of three ethnic groups of refugees (Chin, Kachin and Rohingya) from Myanmar resettled in Malaysia.

Trained field personnel interviewed in total 2058 refugees, applying a clustered, probabilistic, proportional-to-size sampling framework and using the DSM-IV and DSM-5 criteria to diagnose IED. We used descriptive and bivariate analyses to explore associations of IED (using DSM IV or DMS 5) with ethnic group membership, sociodemographic characteristics and exposure to premigration traumatic events (TEs) and postmigration living difficulties (PMLDs). We also examined associations of IED with other common mental disorders (CMDs) (depression, anxiety and posttraumatic stress disorder) and with domains of functional impairment. Finally, we compared whether IED measured using DSM IV or DSM 5 generated the same or different prevalence.

For the whole sample (n = 2058), the 12-month prevalence of DSM-IV IED was 5.9% (n = 122) and for DSM-5, 3.4% (n = 71). Across the three ethnic groups, 12-month DSM-5 IED prevalence was 2.1% (Chin), 2.9% (Rohingya) and 8.0% (Kachin), whereas DSM-IV defined IED prevalence was 3.2% (Chin), 7% (Rohingya) and 9.2% (Kachin). Being single, and exposure to greater premigration TEs and PMLDs were each associated with IED. Over 80% of persons with IED recorded one or more comorbid CMDs. Persons with IED also showed greater levels of functional impairment compared with those without IED.

The pooled IED prevalence was higher than global norms but there was substantial variation in prevalence across the three study groups.

Adolescent suicide is a severe public health problem in low- and middle-income countries (LMICs), and adolescents who are victims of bullying have a higher risk of suicidal behaviours. However, detailed global data concerning the association between bullying victimisation and suicide are lacking; thus, further multicontinental studies exploring the association of bullying victimisation at different frequencies and types with suicidal behaviours are urgent.

The data were extracted from the Global School-based Student Health Survey (GSHS) (2010–2017) conducted in 40 LMICs (n = 151 184, mean age: 14.77 years, s.d.: 1.59, 54.2% females). Data concerning past-30-day bullying victimisation, past 12-month suicidal behaviours (suicidal ideation, suicidal plans and suicidal attempts) and other adverse health behaviours or outcomes were collected. Chi-square tests were used to explore the correlations among the main variables. A multivariable logistic regression and stratified logistic regressions were conducted to assess the associations.

The overall prevalence of bullying victimisation, suicidal ideation, suicidal plans and suicidal attempts were 28.72, 12.64, 11.84 and 10.79%, respectively. The results showed a positive association of different frequencies and types of bullying victimisation with suicidal behaviours: suicidal ideation (odds ratio (OR) = 2.43, 2.06–2.87), suicidal plans (OR = 2.69, 2.28–3.17) and suicidal attempts (OR = 3.23, 2.73–3.82). Adolescents also reported the effects of being made fun of because of their religion: suicidal ideation (OR = 1.63, 1.41–1.88), suicidal plans (OR = 1.44, 1.24–1.66) and suicidal attempts (OR = 1.73, 1.50–1.98). Moreover, these associations varied among teenagers of different gender and body mass indexes (BMIs) and were stronger among males and adolescents who were underweight, overweight or obese.

Different types of bullying victimisation were positively related to suicidal behaviours; these associations varied among adolescents by gender and BMI. This study offers a theoretical basis for the identification of adolescents at a high risk of suicide and is beneficial for informing effective psychological interventions for constructing sound school environments, improving adolescents’ mental health and reducing the risk of suicide to promote health in LMICs and globally.

The aim of this study was to determine possible differences in psychiatric care contact and the type of contact in the year prior to suicide by migrant status and region of origin compared to Swedish persons.

A population-based open cohort design, using linked national registers, to study all individuals aged 20–64 years who died by suicide between 1 January 2006 and 31 December 2016 in Sweden (N = 12 474). The primary exposure was migrant status compared to the Swedish majority population in the following categories: non-refugee migrants, refugee migrants and children of migrants. The secondary exposure was region of origin in seven regions: Sweden, other Nordic countries, Europe, Sub-Saharan Africa, the Middle East and North Africa, Asia, the Americas and Oceania. The four outcomes were psychiatric in- and outpatient care, prescribed and purchased psychotropic medication and a variable composing the other variables, all measured the year before death. Logistic regression models adjusted for age, sex, income and marital status estimated the likelihood of psychiatric care utilisation by type of care within the year prior to death by migrant status and region of origin (individually and combined).

Out of all who had died by suicide, 81% had had psychiatric care of any type in the year before death by suicide. Among refugees the prevalence of psychiatric care before death by suicide was 88%. Compared with the Swedish reference group, non-refugees and persons from Asia and Sub-Saharan Africa had a lower likelihood of utilising psychiatric care prior to suicide driven by a lower use of prescribed psychotropic medication. Persons from the Middle East and North Africa had a higher likelihood, driven by higher use of psychiatric outpatient care and prescribed psychotropic medication. Non-refugees' likelihood of utilising care before death by suicide was lower within the first 5 years of living in Sweden.

A large share of those who die by suicide use psychiatric care the year before they die. Non-refugee migrants and persons from Asia and Sub-Saharan Africa have a lower likelihood of utilising psychiatric care prior to suicide compared to Swedish, whereas persons from the Middle East and North Africa have a higher likelihood. Health care and policy makers should consider both migrant status, region of origin and time in the new country for further suicide prevention efforts.

The utility of quality of life (QoL) as an outcome measure in youth-specific primary mental health care settings has yet to be determined. We aimed to determine: (i) whether heterogeneity on individual items of a QoL measure could be used to identify distinct groups of help-seeking young people; and (ii) the validity of these groups based on having clinically meaningful differences in demographic and clinical characteristics.

Young people, at their first presentation to one of five primary mental health services, completed a range of questionnaires, including the Assessment of Quality of Life–6 dimensions adolescent version (AQoL-6D). Latent class analysis (LCA) and multivariate multinomial logistic regression were used to define classes based on AQoL-6D and determine demographic and clinical characteristics associated with class membership.

1107 young people (12–25 years) participated. Four groups were identified: (i) no-to-mild impairment in QoL; (ii) moderate impairment across dimensions but especially mental health and coping; (iii) moderate impairment across dimensions but especially on the pain dimension; and (iv) poor QoL across all dimensions along with a greater likelihood of complex and severe clinical presentations. Differences between groups were observed with respect to demographic and clinical features.

Adding multi-attribute utility instruments such as the AQoL-6D to routine data collection in mental health services might generate insights into the care needs of young people beyond reducing psychological distress and promoting symptom recovery. In young people with impairments across all QoL dimensions, the need for a holistic and personalised approach to treatment and recovery is heightened.

Research shows persistent ethnic inequities in mental health experiences and outcomes, with a higher incidence of illnesses among minoritised ethnic groups. People with psychosis have an increased risk of multiple long-term conditions (MLTC; multimorbidity). However, there is limited research regarding ethnic inequities in multimorbidity in people with psychosis. This study investigates ethnic inequities in physical health multimorbidity in a cohort of people with psychosis.

In this retrospective cohort study, using the Clinical Records Interactive Search (CRIS) system, we identified service-users of the South London and Maudsley NHS Trust with a schizophrenia spectrum disorder, and then additional diagnoses of diabetes, hypertension, low blood pressure, overweight or obesity and rheumatoid arthritis. Logistic and multinomial logistic regressions were used to investigate ethnic inequities in odds of multimorbidity (psychosis plus one physical health condition), and multimorbidity severity (having one or two physical health conditions, or three or more conditions), compared with no additional health conditions (no multimorbidity), respectively. The regression models adjusted for age and duration of care and investigated the influence of gender and area-level deprivation.

On a sample of 20 800 service-users with psychosis, aged 13–65, ethnic differences were observed in the odds for multimorbidity. Controlling for sociodemographic factors and duration of care, compared to White British people, higher odds of multimorbidity were found for people of Black African [adjusted Odds Ratio = 1.41, 95% Confidence Intervals (1.23–1.56)], Black Caribbean [aOR = 1.79, 95% CI (1.58–2.03)] and Black British [aOR = 1.64, 95% CI (1.49–1.81)] ethnicity. Reduced odds were observed among people of Chinese [aOR = 0.61, 95% CI (0.43–0.88)] and Other ethnic [aOR = 0.67, 95% CI (0.59–0.76)] backgrounds. Increased odds of severe multimorbidity (three or more physical health conditions) were also observed for people of any Black background.

Ethnic inequities are observed for multimorbidity among people with psychosis. Further research is needed to understand the aetiology and impact of these inequities. These findings support the provision of integrated health care interventions and public health preventive policies and actions.

Refugees typically spend years in a state of protracted displacement prior to permanent resettlement. Little is known about how various prior displacement contexts influence long-term mental health in resettled refugees. In this study, we aimed to determine whether having lived in refugee camps v. community settings prior to resettlement impacted the course of refugees' psychological distress over the 4 years following arrival in Australia.

Participants were 1887 refugees who had taken part in the Building a New Life in Australia study, which comprised of five annual face-to-face or telephone surveys from the year of first arrival in Australia.

Latent growth curve modelling revealed that refugees who had lived in camps showed greater initial psychological distress (as indexed by the K6) and faster decreases in psychological distress in the 4 years after resettling in Australia, compared to those who had lived in community settings. Investigation of refugee camp characteristics revealed that poorer access to services in camps was associated with greater initial distress after resettlement, and greater ability to meet one's basic needs in camps was associated with faster decreases in psychological distress over time.

These findings highlight the importance of the displacement context in influencing the course of post-resettlement mental health. Increasing available services and meeting basic needs in the displacement environment may promote better mental health outcomes in resettled refugees.

Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics.

We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history.

IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries.

IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon.

In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely.

CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F(1, 22) = 6.49, p < 0.018) and on the GroupACT (Mann–Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours.

This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.