Codes of ethics in medicine have an ancient tradition, extending back to the Oath of Hippocrates. Yet it was only in the early 1970s that the speciality of psychiatry developed a specific code to address the unique ethical dilemmas and complexities arising in psychiatric practice. As the 50th anniversary of the publication of psychiatry's first code of ethics approaches, it is timely to reflect on the progress, role, and impact of such codes.

Our aim is to provide a historically informed review of codes of ethics in psychiatry – their origins and evolution, the current picture, and the possibilities for future development.

We conducted a selective review of relevant literature (including all codes of ethics accessible on the websites of World Psychiatric Association members states), analysis of the form and content of codes and related documents in psychiatry, and interviews of psychiatrists who have played central roles in their evolution.

Of the 143 WPA member states, only 15 codes of ethics for psychiatrists were identified, and few of these were associated with professional disciplinary processes. We found that these codes are rarely revised and sometimes supplemented with other statements and guidelines.

While there are difficulties in measuring the direct effectiveness of codes of ethics on the practice of psychiatrists, we conclude that these codes help to (1) promote professional solidarity and autonomy, (2) enhance moral sensitivity, and (3) aid in psychiatric education and training.

Sexual minority men (SMM) experience higher suicidal ideation and suicide attempts than the general population. We examined the associations of adverse childhood experiences (ACES) and protective and compensatory childhood experiences (PACES) with suicidal ideation and suicide attempts in adulthood via thwarted belongingness and perceived burdensomeness among SMM.

Data are from the UNITE study, a national longitudinal cohort study of HIV-negative SMM from the 50 U.S. states and Puerto Rico. Between 2017 and 2019, participants (N = 6303) completed web-based assessments at baseline and 12-month follow-up. ACES and PACES occurring before the age of 18, and current symptoms of thwarted belongingness and perceived burdensomeness were assessed at baseline. Past-week suicidal ideation and past-year suicide attempt were assessed at follow-up.

424 (6.7%) participants reported past-week suicidal ideation and 123 (2.0%) reported a past-year suicide attempt. The results of our multivariate model suggest that each additional adverse childhood experience was prospectively associated with 14% higher odds of past-week suicidal ideation (AOR = 1.14, 95% CI 1.09–1.19) and 19% higher odds of past-year suicide attempt (AOR = 1.19, 95% CI 1.11–1.29). Each additional protective childhood experience was prospectively associated with 15% lower odds of past-week suicidal ideation (AOR = 0.85, 95% CI 0.81–0.90) and 11% lower odds of past-year suicide attempt (AOR = 0.89, 95% CI 0.82–0.98). Perceived burdensomeness partially mediated these prospective associations.

To reduce suicide, screening and treating perceived burdensomeness among SMM with high ACES may be warranted. PACES may decrease perceived burdensomeness and associated suicide risk.

A dominant feature of anxiety disorders is familial aggregation. However, the underlying mechanisms of between- and within-generational anxiety resemblance remain poorly understood. By disentangling the genetic v. environmental sources of familial resemblance in anxiety, we can help prevent within-family transmission of anxiety disorders. Therefore, data from both parents and twins are needed to obtain unbiased and detailed estimations of genetic and environmental sources of similarity between family members.

We examined data from 991 families with same-sex twins. Trait anxiety in twins was assessed via self-report and parent report, while parental trait anxiety was assessed via self-report. We established a nuclear twin family model and estimated genetic and environmental variances using two survey waves.

The results suggested that additive genetic (A), dominant genetic (D), and non-shared environmental (E) influences significantly contributed to trait anxiety, whereas familial environmental influences (F) and passive gene–environment correlations (rGE) did not. Sibling environmental influences (S) were only found in self-report data, and increased when genetic influences decreased from Wave 1 to Wave 2.

Our study highlights the important role of broad heritability in intrafamilial trait anxiety similarity. Parent–child resemblance occurred primarily due to shared genetic makeup rather than direct environmental transmission. Sibling-specific environments, as the only source of shared environments, need further investigation. These findings have both theoretical and practical significance for anxiety disorders. Future research can expand our understanding by examining the gene–environment interplay and sex differences.

Anticipatory pleasure deficits are closely correlated with negative symptoms in schizophrenia, and may be found in both clinical and subclinical populations along the psychosis continuum. Prospection, which is an important component of anticipatory pleasure, is impaired in individuals with social anhedonia (SocAnh). In this study, we examined the neural correlates of envisioning positive future events in individuals with SocAnh.

Forty-nine individuals with SocAnh and 33 matched controls were recruited to undergo functional MRI scanning, during which they were instructed to simulate positive or neutral future episodes according to cue words. Two stages of prospection were distinguished: construction and elaboration.

Reduced activation at the caudate and the precuneus when prospecting positive (v. neutral) future events was observed in individuals with SocAnh. Furthermore, compared with controls, increased functional connectivity between the caudate and the inferior occipital gyrus during positive (v. neutral) prospection was found in individuals with SocAnh. Both groups exhibited a similar pattern of brain activation for the construction v. elaboration contrast, regardless of the emotional context.

Our results provide further evidence on the neural mechanism of anticipatory pleasure deficits in subclinical individuals with SocAnh and suggest that altered cortico-striatal circuit may play a role in anticipatory pleasure deficits in these individuals.

Risk of suicide-related behaviors is elevated among military personnel transitioning to civilian life. An earlier report showed that high-risk U.S. Army soldiers could be identified shortly before this transition with a machine learning model that included predictors from administrative systems, self-report surveys, and geospatial data. Based on this result, a Veterans Affairs and Army initiative was launched to evaluate a suicide-prevention intervention for high-risk transitioning soldiers. To make targeting practical, though, a streamlined model and risk calculator were needed that used only a short series of self-report survey questions.

We revised the original model in a sample of n = 8335 observations from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in one of three Army STARRS 2011–2014 baseline surveys while in service and in one or more subsequent panel surveys (LS1: 2016–2018, LS2: 2018–2019) after leaving service. We trained ensemble machine learning models with constrained numbers of item-level survey predictors in a 70% training sample. The outcome was self-reported post-transition suicide attempts (SA). The models were validated in the 30% test sample.

Twelve-month post-transition SA prevalence was 1.0% (s.e. = 0.1). The best constrained model, with only 17 predictors, had a test sample ROC-AUC of 0.85 (s.e. = 0.03). The 10–30% of respondents with the highest predicted risk included 44.9–92.5% of 12-month SAs.

An accurate SA risk calculator based on a short self-report survey can target transitioning soldiers shortly before leaving service for intervention to prevent post-transition SA.

Evidence on sex-specific incidence and comorbidity risk factors of suicide among patients with bipolar disorder is scarce. This study investigated the sex-specific risk profiles for suicide among the bipolar disorder population in terms of incidence, healthcare utilization and comorbidity.

Using data from the Taiwan National Health Insurance Research Database between 1 January 2000 and 31 December 2016, this nationwide cohort study included patients with bipolar disorder (N = 46 490) and individuals representative of the general population (N = 185 960) matched by age and sex at a 1:4 ratio. Mortality rate ratios (MRRs) of suicide were calculated between suicide rates of bipolar disorder cohort and general population. In addition, a nested case–control study (1428 cases died by suicide and 5710 living controls) was conducted in the bipolar disorder cohort to examine the sex-specific risk of healthcare utilization and comorbidities.

Suicide risk was considerably higher in the cohort (MRR = 21.9) than in the general population, especially among women (MRR = 35.6). Sex-stratified analyses revealed distinct healthcare utilization patterns and physical comorbidity risk profiles between the sexes. Although female patients who died by suicide had higher risks of nonhypertensive cardiovascular disease, pneumonia, chronic kidney disease, peptic ulcer, irritable bowel syndrome, and sepsis compared to their living counterparts, male patients who died by suicide had higher risks of chronic kidney disease and sepsis compared to the living controls.

Patients with bipolar disorder who died by suicide had sex-specific risk profiles in incidence and physical comorbidities. Identifying these modifiable risk factors may guide interventions for suicide risk reduction.

Moral injury exposure (MIE) and distress (MID) may indirectly affect the relationship between trauma exposure and alterations in autonomic regulation [assessed via high-frequency heart rate variability (hfHRV)] in civilians, but this has not been tested in prior research. We conducted two exploratory studies to examine trauma types' associations with MIE and MID among civilian medical patients (Study 1) and explore how these facets may indirectly affect the relationship between trauma type and hfHRV among civilians seeking mental health services (Study 2).

Participants recruited from a public hospital and/or community advertisements (Study 1, n = 72, 87.5% Black, 83.3% women; Study 2, n = 46, 71.7% Black, 97.8% women) completed measures assessing trauma type, MIE, and MID. In Study 1, trauma types that emerged as significant correlates of MIE and MID were entered into separate linear regression analyses. Trauma types identified were included as predictors in indirect effects models with MIE or MID as the mediator and resting hfHRV (assayed via electrocardiography) as the outcome.

Childhood sexual abuse emerged as the only significant predictor of MIE, b = 0.38, p < 0.001; childhood sexual abuse, b = 0.26, p < 0.05, and adulthood sexual assault, b = 0.23, p < 0.05 were significant predictors of MID. Participants with greater MIE and MID demonstrated lower hfHRV. Adulthood sexual assault showed an indirect effect on hfHRV through MID, B = −0.10, s.e. = 0.06, 95%CI (−0.232 to −0.005).

Moral injury was uniquely associated with sexual violence and lower hfHRV in civilians. Data highlight moral injury as a pathway through which autonomic dysregulation may emerge and its salience for trauma treatment selection.

Certain personality traits predispose to criminal behavior (CB). We further clarify this relationship in a Swedish national sample.

Psychological strength (PS) was assessed on a nine-point scale at personal interview in 1 653 721 Swedish men aged 18–20 years. We examined the association between PS and total, violent and recurrent CB over the lifetime (logistic regression), prospectively (Cox regression) and by bivariate Cholesky decomposition in 2507 monozygotic and 2244 dizygotic twin pairs (OpenMx).

Examining linear effects by logistic regression, PS was robustly associated with lifetime risk of total CB (per point, odds ratio = 0.74) and even more strongly associated with risk for violent (0.69) and recurrent CB (0.52). Prospective predictions of these three forms of CB by PS were similar, with hazard ratios of 0.80, 0.73 and 0.54, respectively. Twin modeling demonstrated that, for all three CB types, the association with PS arose almost entirely from familial effects. Common shared environment accounted for 72, 56 and 43% of the phenotypic correlation between PS and, respectively, total, violent and recurrent CB. Parallel figures for common genetic effects were for 24, 37 and 54%, respectively.

PS is strongly related to risk for total CB, and even more strongly for violent and, especially, recurrent CB. This association is probably not causal but rather results from shared familial risk factors that make an impact both on PS and risk for CB. PS has a stronger overall correlation with more severe criminal outcomes and a higher proportion of that correlation results from common genetic factors.

Sedentary behaviour is potentially a modifiable risk factor for anxiety disorders, a major source of global disability that typically starts during adolescence. This is the first prospective study of associations between repeated, device-based measures of sedentary behaviour and anxiety symptoms in adolescents.

A UK cohort with 4257 adolescents aged 12 at baseline (56% female). Main exposures were sedentary behaviour and physical activity measured using accelerometers for 7-days at ages 12, 14, and 16. Primary outcome was anxiety symptom scores at age 18 from a Clinical Interview Schedule-Revised. We used adjusted negative binomial regression and iso-temporal substitution methods to analyse the data.

We found a positive association between sedentary behaviour at ages 12, 14, and 16, with anxiety symptoms at age 18, independent of total physical activity volume. Theoretically replacing an hour of daily sedentary behaviour for light activity at ages 12, 14, and 16, was associated with lower anxiety symptoms by age 18 by 15.9% (95% CI 8.7–22.4), 12.1% (95% CI 3.4–20.1), and 14.7% (95% CI 4–24.2), respectively. Whereas, theoretically replacing an hour of sedentary behaviour with moderate-to-vigorous physical activity was not associated with differences in anxiety symptoms. These results were robust to a series of sensitivity analyses.

Sedentary behaviour is a possible risk factor for increasing anxiety symptoms during adolescence, independent of total physical activity volume. Instead of focusing on moderate-to-vigorous activity, replacing daily sedentary behaviour with light activity during adolescence could be a more suitable method of reducing future anxiety symptoms.

Peer victimization predicts the development of mental health symptoms in the transition to adolescence, but it is unclear whether and how parents and school environments can buffer this link.

We analyzed two-year longitudinal data from the Adolescent Brain Cognitive Development (ABCD) study, involving a diverse sample of 11 844 children across the United States (average at baseline = 9.91 years; standard deviation = 0.63; range = 8.92–11.08; complete case sample = 8385). Longitudinal associations between peer victimization and two-year changes in mental health symptoms of major depression disorder (MDD), separation anxiety (SA), prodromal psychosis (PP), and attention-deficit/hyperactivity disorder (ADHD) were examined including a wide range of covariates. Mixed linear models were used to test for the moderating effects of parental warmth and prosocial school environment.

20% of children experienced peer victimization. Higher exposure to peer victimization was associated with increases in MDD, SA, and ADHD symptoms. Parental warmth was associated with decreases in MDD symptoms but did not robustly buffer the link between peer victimization and mental health symptoms. Prosocial school environment predicted decreases in PP symptoms and buffered the link between peer victimization and MDD symptoms but amplified the link between peer victimization and SA and ADHD symptoms.

Peer victimization is associated with increases in mental health symptoms during the transition to adolescence. Parental warmth and prosocial school environments might not be enough to counter the negative consequences of peer victimization on all mental health outcomes.

For decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses.

The current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined.

The prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably.

Order effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.

Military personnel deployed to combat and peacekeeping missions are exposed to high rates of traumatic events. Accumulating evidence suggests an important association between deployment and the development of other mental health symptoms beyond post-traumatic stress disorder.

This study examined the prevalence of agoraphobia, anxiety, depression, and hostility symptoms in a cohort of Dutch ISAF veterans (N = 978) from pre-deployment up to 10 years after homecoming. The interaction of potential moderating factors with the change in mental health symptoms relative to pre-deployment was investigated at each time point.

The probable prevalence of agoraphobia, anxiety, depression, and hostility symptoms significantly increased over time to respectively 6.5, 2.7, 3.5, and 6.2% at 10 years after deployment. Except for hostility symptoms, the probable prevalence at 10 years after deployment was the highest compared to all previous follow-up assessments. Importantly, less perceived social support after returning from deployment was found as a risk factor for all different mental health symptoms. Unit support was not associated with the development of mental health problems.

This study suggests a probable broad and long-term impact of deployment on the mental health of military service members. Due to the lack of a non-deployed control group, causal effects of deployment could not be demonstrated. Continued effort should nevertheless be made in the diagnosis and treatment of a wide range of mental health symptoms, even a decade after deployment. The findings also underscore the importance of social support after homecoming and its potential for the prevention of long-term mental health problems.