The effectiveness of Early Intervention in Psychosis (EIP) services for individuals with a first episode of psychosis (FEP) could be thwarted by high rates of early disengagement.

To investigate which factors predict disengagement with EIP services.

Using data from a naturalistic cohort of 786 EIP clients in East Anglia (UK), we investigated the association between sociodemographic and clinical predictors and disengagement using univariable and multivariable Cox proportional hazards models.

Over half (54.3%) of our sample were discharged before receiving 3 years of EIP care, with 92 (11.7%) participants discharged due to disengagement. Milder negative symptoms, more severe hallucinations, not receiving an FEP diagnosis, polysubstance use and being employed were associated with greater disengagement.

Our findings highlight heterogeneous reasons for disengagement with EIP services. For some patients, early disengagement may hinder efforts to sustain positive long-term EIP outcomes. Efforts to identify true FEP cases and target patients with substance use problems and more severe positive symptoms may increase engagement.

None.

Pregnancy and childbirth are a period of high risk for women with bipolar disorder and involve difficult decisions particularly about continuing or stopping medications.

To explore what clinical predictors may help to individualise the risk of perinatal recurrence in women with bipolar disorder.

Information was gathered retrospectively by semi-structured interview, questionnaires and case-note review from 887 women with bipolar disorder who have had children. Clinical predictors were selected using backwards stepwise logistic regression, conditional permutation random forests and reinforcement learning trees.

Previous perinatal history of affective psychosis or depression was the most significant predictor of a perinatal recurrence (odds ratio (OR) = 8.5, 95% CI 5.04–14.82 and OR = 3.6, 95% CI 2.55–5.07 respectively) but even parous women with bipolar disorder without a previous perinatal mood episode were at risk following a subsequent pregnancy, with 7% developing postpartum psychosis.

Previous perinatal history of affective psychosis or depression is the most important predictor of perinatal recurrence in women with bipolar disorder and can be used to individualise risk assessments.

None.

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Personality disorder is a severe health issue. However, the epidemiology of personality disorders is insufficiently described and surveys report very heterogeneous rates.

We aimed to conduct a meta-analysis on the prevalence of personality disorders in adult populations and examine potential moderators that affect heterogeneity.

We searched PsycINFO, PSYNDEX and Medline for studies that used standardised diagnostics (DSM-IV/-5, ICD-10) to report prevalence rates of personality disorders in community populations in Western countries. Prevalence rates were extracted and aggregated by random-effects models. Meta-regression and sensitivity analyses were performed and publication bias was assessed.

The final sample comprised ten studies, with a total of 113 998 individuals. Prevalence rates were fairly high for any personality disorder (12.16%; 95% CI, 8.01–17.02%) and similarly high for DSM Clusters A, B and C, between 5.53 (95% CI, 3.20–8.43%) and 7.23% (95% CI, 2.37–14.42%). Prevalence was highest for obsessive–compulsive personality disorder (4.32%; 95% CI, 2.16–7.16%) and lowest for dependent personality disorder (0.78%; 95% CI, 0.37–1.32%). A low prevalence was significantly associated with expert-rated assessment (versus self-rated) and reporting of descriptive statistics for antisocial personality disorder.

Epidemiological studies on personality disorders in community samples are rare, whereas prevalence rates are fairly high and vary substantially depending on samples and methods. Future studies investigating the epidemiology of personality disorders based on the DSM-5 and ICD-11 and models of personality functioning and traits are needed, and efficient treatment should be a priority for healthcare systems to reduce disease burden.

None.

Former child soldiers are at high risk of developing mental disorders such as post-traumatic stress disorder (PTSD); however, their comprehensive mental health has yet to be examined.

This study looks at the prevalence of PTSD, depression and associated risk factors such as disturbed self-esteem among former child soldiers of the so-called ‘Islamic State’.

The psychological effect of traumatic events was assessed in 81 Yazidi children who had been child soldiers for the Islamic State in northern Iraq between 2014 and 2017 for at least 6 months. The children were between 8 and 14 years of age. Thirty-two Yazidi boys and 31 Muslim boys who were not child soldiers in Iraq served as control groups. A structured psychological interview and established psychometric questionnaires were used to assess traumatisation and mental disorders.

The child soldiers showed a significantly higher prevalence of PTSD (48.3%), depressive disorders (45.6%), anxiety disorders (45.8%) and somatic disturbances (50.6%) than the boys who had not been child soldiers. Developmentally crucial self-esteem was significantly reduced in former child soldiers. No significant differences between the two control groups could be found.

PTSD and other mental disorders are highly present among former child soldiers in northern Iraq. The study highlights the huge and as yet unmet need for psychological services among former child soldiers.

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Consent to research with decision-making capacity for research (DMC-R) is normally a requirement for study participation. Although the symptoms of schizophrenia and related psychoses are known to affect decision-making capacity for treatment (DMC-T), we know little about their effect on DMC-R.

We aimed to determine if DMC-R differs from DMC-T in proportion and associated symptoms in an in-patient sample of people with schizophrenia and related psychoses.

Cross-sectional study of psychiatric in-patients admitted for assessment and/or treatment of schizophrenia and related psychoses. We measured DMC-R and DMC-T using ‘expert judgement’ clinical assessment guided by the MacArthur Competence Assessment Tool for Clinical Research, the MacArthur Competence Assessment Tool for Treatment and the legal framework of the Mental Capacity Act (2005), in addition to symptoms of psychosis.

There were 84 participants in the study. Half the participants had DMC-R (51%, 95% CI 40–62%) and a third had DMC-T (31%, 95% CI 21–43%) and this difference was statistically significant (P < 0.01). Thought disorder was most associated with lacking DMC-R (odds ratio 5.72, 95% CI 2.01–16.31, P = 0.001), whereas lack of insight was most associated with lacking DMC-T (odds ratio 26.34, 95% CI 3.60–192.66, P = 0.001). With the exception of improved education status and better DMC-R, there was no effect of sociodemographic variables on either DMC-R or DMC-T.

We have shown that even when severely unwell, people with schizophrenia and related psychoses in in-patient settings commonly retain DMC-R despite lacking DMC-T. Furthermore, different symptoms have different effects on decision-making abilities for different decisions. We should not view in-patient psychiatric settings as a research ‘no-go area’ and, where appropriate, should recruit in these settings.

None.

Interpersonal violence is a leading cause of morbidity and mortality. The strength and population effect of modifiable risk factors for interpersonal violence, and the quality of the research evidence is not known.

We aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence, and the quality and reproducibility of the research evidence.

We conducted an umbrella review of systematic reviews and meta-analyses of risk factors for interpersonal violence. A systematic search was conducted to identify systematic reviews and meta-analyses in general population samples. Effect sizes were extracted, converted into odds ratios and synthesised, and population attributable risk fractions (PAF) were calculated. Quality analyses were performed, including of small study effects, adjustment for confounders and heterogeneity. Secondary analyses for aggression, intimate partner violence and homicide were conducted, and systematic reviews (without meta-analyses) were summarised.

We identified 22 meta-analyses reporting on risk factors for interpersonal violence. Neuropsychiatric disorders were among the strongest in relative and absolute terms. The neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders, with a PAF of 14.8% (95% CI 9.0–21.6%), and the most important historical factor was witnessing or being a victim of violence in childhood (PAF = 12.2%, 95% CI 6.5–17.4%). There was evidence of small study effects and large heterogeneity.

National strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors.

J.R.G. is an NIHR Senior Investigator. The views expressed within this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Fractional anisotropy in the uncinate fasciculus and the cingulum may be biomarkers for bipolar disorder and may even be distinctly affected in different subtypes of bipolar disorder, an area in need of further research.

This study aims to establish if fractional anisotropy in the uncinate fasciculus and cingulum shows differences between healthy controls, patients with bipolar disorder type I (BD-I) and type II (BD-II), and their unaffected siblings.

Fractional anisotropy measures from the uncinate fasciculus, cingulum body and parahippocampal cingulum were compared with tractography methods in 40 healthy controls, 32 patients with BD-I, 34 patients with BD-II, 17 siblings of patients with BD-I and 14 siblings of patients with BD-II.

The main effects were found in both the right and left uncinate fasciculus, with patients with BD-I showing significantly lower fractional anisotropy than both patients with BD-II and healthy controls. Participants with BD-II did not differ from healthy controls. Siblings showed similar effects in the left uncinate fasciculus. In a subsequent complementary analysis, we investigated the association between fractional anisotropy in the uncinate fasciculus and polygenic risk for bipolar disorder and psychosis in a large cohort (n = 570) of healthy participants. However, we found no significant association.

Fractional anisotropy in the uncinate fasciculus differs significantly between patients with BD-I and patients with BD-II and healthy controls. This supports the hypothesis of differences in the physiological sub-tract between bipolar disorder subtypes. Similar results were found in unaffected siblings, suggesting the potential for this biomarker to represent an endophenotype for BD-I. However, fractional anisotropy in the uncinate fasciculus seems unrelated to polygenic risk for bipolar disorder or psychosis.

None.

M.J.T. reports personal fees from Sunovion, Otsuka, Lundbeck, outside the submitted work.

Many studies have identified changes in the brain associated with obsessive–compulsive disorder (OCD), but few have examined the relationship between genetic determinants of OCD and brain variation.

We present the first genome-wide investigation of overlapping genetic risk for OCD and genetic influences on subcortical brain structures.

Using single nucleotide polymorphism effect concordance analysis, we measured genetic overlap between the first genome-wide association study (GWAS) of OCD (1465 participants with OCD, 5557 controls) and recent GWASs of eight subcortical brain volumes (13 171 participants).

We found evidence of significant positive concordance between OCD risk variants and variants associated with greater nucleus accumbens and putamen volumes. When conditioning OCD risk variants on brain volume, variants influencing putamen, amygdala and thalamus volumes were associated with risk for OCD.

These results are consistent with current OCD neurocircuitry models. Further evidence will clarify the relationship between putamen volume and OCD risk, and the roles of the detected variants in this disorder.

The authors have declared that no competing interests exist.

P.A.T. holds an honorary consultant contract with the Tees, Esk and Wear Valleys NHS Foundation Trust.

People with psychotic disorders account for most acute admissions to psychiatric wards. Psychological therapies are a treatment adjunct to standard medication and nursing care, but the evidence base for such therapies within in-patient settings is unclear.

To conduct a systematic scoping review of the current evidence base for psychological therapies for psychosis delivered within acute in-patient settings (PROSPERO: CRD42015025623).

All study designs, and therapy models, were eligible for inclusion in the review. We searched PubMed, PsycINFO, EThOS, ProQuest, conference abstracts and trial registries.

We found 65 studies that met criteria for inclusion in the review, 21 of which were randomised controlled trials (RCTs). The majority of studies evaluated cognitive–behavioural interventions. Quality was variable across all study types. The RCTs were mostly small (n<25 in the treatment arm), and many had methodological limitations including poorly described randomisation methods, inadequate allocation concealment and non-masked outcome assessments. We found studies used a wide range of different outcome measures, and relatively few studies reported affective symptoms or recovery-based outcomes. Many studies described adaptations to treatment delivery within in-patient settings, including increased frequency of sessions, briefer interventions and use of single-session formats.

Based on these findings, there is a clear need to improve methodological rigour within in-patient research. Interpretation of the current evidence base is challenging given the wide range of different therapies, outcome measures and models of delivery described in the literature.

None.

Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.

Our aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters.

This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics.

Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27–0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43–2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies.

Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.

None.

Attention-deficit hyperactivity disorder (ADHD) and anxiety disorders have been proposed as precursors of bipolar disorder, but their joint and relative roles in the development of bipolar disorder are unknown.

To test the prospective relationship of ADHD and anxiety with onset of bipolar disorder.

We examined the relationship between ADHD, anxiety disorders and bipolar disorder in a birth cohort of 2 409 236 individuals born in Denmark between 1955 and 1991. Individuals were followed from their sixteenth birthday or from January 1995 to their first clinical contact for bipolar disorder or until December 2012. We calculated incidence rates per 10 000 person-years and tested the effects of prior diagnoses on the risk of bipolar disorder in survival models.

Over 37 394 865 person-years follow-up, 9250 onsets of bipolar disorder occurred. The incidence rate of bipolar disorder was 2.17 (95% CI 2.12–2.19) in individuals with no prior diagnosis of ADHD or anxiety, 23.86 (95% CI 19.98–27.75) in individuals with a prior diagnosis of ADHD only, 26.05 (95% CI 24.47–27.62) in individuals with a prior diagnosis of anxiety only and 66.16 (95% CI 44.83–87.47) in those with prior diagnoses of both ADHD and anxiety. The combination of ADHD and anxiety increased the risk of bipolar disorder 30-fold (95% CI 21.66–41.40) compared with those with no prior ADHD or anxiety.

Early manifestations of both internalising and externalising psychopathology indicate liability to bipolar disorder. The combination of ADHD and anxiety is associated with a very high risk of bipolar disorder.

None.

Pathological worry is a hallmark feature of generalised anxiety disorder (GAD), associated with dysfunctional emotional processing. The ventromedial prefrontal cortex (vmPFC) is involved in the regulation of such processes, but the link between vmPFC emotional responses and pathological v. adaptive worry has not yet been examined.

To study the association between worry and vmPFC activity evoked by the processing of learned safety and threat signals.

In total, 27 unmedicated patients with GAD and 56 healthy controls (HC) underwent a differential fear conditioning paradigm during functional magnetic resonance imaging.

Compared to HC, the GAD group demonstrated reduced vmPFC activation to safety signals and no safety–threat processing differentiation. This response was positively correlated with worry severity in GAD, whereas the same variables showed a negative and weak correlation in HC.

Poor vmPFC safety–threat differentiation might characterise GAD, and its distinctive association with GAD worries suggests a neural-based qualitative difference between healthy and pathological worries.

None.