The duration of undiagnosed or untreated bipolar disorder (DUBD) has become a focus of research interest. However, its relationship with clinical characteristics and outcomes remains poorly understood.

The objective of this systematic review and meta-analysis was to examine DUBD and explore its relationships with clinical characteristics and outcomes in bipolar disorder.

We conducted a systematic search of the literature to identify studies reporting on DUBD and its relationships with clinical characteristics and outcomes including frequency of relapse into mood episodes, severity and persistence of mood symptoms, functional and cognitive measures, suicidality, hospital admission rate, and comorbidities such as substance use disorders.

Thirty articles met inclusion criteria for the systematic review, and 23 studies were included in the three different sets of meta-analyses. The pooled mean DUBD across all studies was 9.10 years. Early onset, depression as the polarity of the first mood episode, lifetime suicide attempts, comorbid anxiety and alcohol use disorders, and family history of bipolar disorder were associated with significantly longer DUBD, whereas diagnosis of bipolar I disorder and lifetime psychotic symptoms were associated with shorter DUBD. Studies that investigated outcomes subsequent to the diagnosis of bipolar disorder yielded conflicting results.

DUBD may be associated with certain adverse outcomes. This association indicates the importance of adopting a more comprehensive approach to assessing mood disorders, with an emphasis on prioritising early screening for bipolar disorder. The significant heterogeneity among included studies suggests a need for improved methodological rigour in future research.

Cognitive–behavioural therapy (CBT) is a first-line treatment for depressive disorders, but research on its neurobiological mechanisms is limited. Given the heterogeneity in CBT response, investigating the neurobiological effects of CBT may improve response prediction and outcomes.

To examine brain functional changes during negative emotion processing following naturalistic CBT.

In this case-control study, 59 patients with depressive disorders were investigated before and after 20 CBT sessions using a negative-emotion-processing paradigm during functional magnetic resonance imaging, clinical interviews and depressive symptom questionnaires. Healthy controls (n = 60) were also assessed twice within an equivalent time interval. Patients were classified into subgroups based on changes in diagnosis according to DSM-IV criteria (n = 40 responders, n = 19 non-responders). Brain activity changes were examined using group × time analysis of variance for limbic areas, and at the whole-brain level.

Analyses yielded a significant group × time interaction in the hippocampus (P family-wise error [PFWE] = 0.022, ηP2 = 0.101), and a significant main effect of time in the dorsal anterior cingulate cortex (PFWE = 0.043, ηP² = 0.098), resulting from activity decreases following CBT (PFWE ≤ 0.024, ηP² ≤ 0.233), with no changes in healthy controls. Hippocampal activity decreases were driven by responders (PFWE ≤ 0.020, ηP² ≤ 0.260) and correlated with symptom improvement (r = 0.293, P = 0.024). Responders exhibited higher pre-treatment hippocampal activity (PFWE = 0.017, ηP² = 0.189).

Following CBT, reduced activity in emotion-processing regions was observed in patients with depressive disorders, with hippocampal activity decreases linked to treatment response. This suggests successful CBT could correct biased emotion processing, potentially by altering activity in key areas of emotion processing.Hippocampal activity may function as a predictive marker of CBT response.

The identification of early warning signs is of great importance for identifying individuals at risk for mental disorders. Especially in the case of bipolar disorder, these research endeavours are imperative considering that the frequently delayed diagnoses and longer illness duration are associated with symptom exacerbation and lower recovery rates.

To multimodally investigate associations between hypomanic personality traits and altered social affect and social cognition to probe their role as early warning signs of bipolar disorder.

In a community sample (n = 140; 50.71% female), we investigated associations between hypomanic personality traits and both behavioural and neural activity measures of empathy and theory of mind (ToM) based on data from a functional magnetic resonance imaging paradigm.

Although analyses revealed no significant associations between behavioural or neural correlates of empathy and hypomanic personality traits, these traits were significantly associated with elevated ToM-related neural activity in the anterior rostral medial prefrontal cortex and anterior cingulate cortex. These neural activation differences were not accompanied by differences in behavioural ToM performance, suggesting more intense recruitment of task-relevant brain regions but unaffected behavioural outcomes.

Our findings indicate hypomanic personality traits to be positively associated with ToM-related neural activity but not with behavioural ToM performance. Prospectively, our study contributes to driving towards a more comprehensive and potentially neurobiologically grounded phenotype of bipolar disorder risk that contributes to a more differential understanding of risk and resilience mechanisms.

Having a relapse of schizophrenia or recurrent psychosis is feared by patients, can cause social and personal disruption and has been suggested to cause long-term deterioration, possibly because of a toxic biological process.

To assess whether relapse affected the social and clinical outcomes of people enrolled in a 24-month randomised controlled trial of antipsychotic medication dose reduction versus maintenance treatment.

The trial involved participants with a diagnosis of schizophrenia or recurrent, non-affective psychosis. Relapse was defined as admission to hospital or significant deterioration (assessed by a blinded end-point committee). We analysed the relationship between relapse during the trial and social functioning, quality of life, symptom scores (Positive and Negative Syndrome Scale) and rates of being in employment, education or training at 24-month follow-up. We also analysed changes in these measures during the trial among those who relapsed and those who did not. Sensitivity analyses were conducted examining the effects of ‘severe’ relapse (i.e. admission to hospital).

During the course of the trial, 82 out of 253 participants relapsed. There was no evidence for a difference between those who relapsed and those who did not on changes in social functioning, quality of life, symptom scores or overall employment rates between baseline and 24-month follow-up. Those who relapsed showed no change in their social functioning or quality of life, and a slight improvement in symptoms compared to baseline. They were more likely than those who did not relapse to have had a change in their employment status (mostly moving out of employment, education or training), although numbers changing status were small. Sensitivity analyses showed the same results for those who experienced a ‘severe’ relapse.

Our data provide little evidence that relapse has a detrimental effect in the long term in people with schizophrenia and recurrent psychosis.

Young adults with a psychotic disorder often experience difficulties in social functioning. We developed a modular virtual reality treatment to improve social activities and participation by targeting common causes of social functioning difficulties in patients with a psychotic disorder (VR-SOAP). This paper details the development of this intervention, encompassing a piloting phase.

Using an iterative Scrum method with software engineers, clinicians, researchers, and individuals with lived experience of psychosis, we developed a treatment protocol along with a software prototype. Subsequently five patients with a psychotic disorder, aged 18–40, and three therapists, piloted VR-SOAP. Feasibility was assessed by means of interviews and session forms. Acceptability was evaluated along the seven domains of the Theoretical Framework of Acceptability (i.e. affective attitude, burden, ethicality, intervention coherence, opportunity costs, self-efficacy, and perceived effectiveness).

The final protocol consisted of the following modules and targets: 1. Motivation and Pleasure (negative symptoms); 2. Understanding Others (social cognition); 3. Safety and Trust (paranoid ideations and social anxiety); 4. Self-Image (self-esteem and self-stigma); 5. Communication (communication and interaction skills). Modules were piloted by the participating patients and therapists. The modules proved feasible and showed a high degree of acceptability on all seven domains of the acceptability framework.

The modular VR-SOAP treatment protocol and prototype was acceptable and feasible for therapists and patients. The primary recommendation for enhancement underscores the need for flexibility regarding the number of sessions and the content.

1. (1) Understanding the development and structure of a novel modular CBT treatment in VR.

2. (2) Learning to use specific VR modules to target negative symptoms, social cognition, paranoid ideations, social anxiety, self-esteem, and communication skills.

3. (3) Gaining insights into the feasibility and acceptability assessments of a novel modular CBT treatment in VR.

Unhealthy lifestyle behaviors are prevalent among people with mental illness (MI), affecting their physical and mental health. Most research has focused on the isolated effects of lifestyle behaviors, leaving the interconnectedness between these behaviors and health outcomes unexplored. This study aimed to examine these relationships and identify the most strongly connected lifestyle behavior or health outcome within a network.

We conducted a cross-sectional study with 423 inpatients with MI, receiving care as usual. Lifestyle behaviors, physical and mental health outcomes were assessed through questionnaires and routine data. A Gaussian Graphical Model was estimated, and strength centrality was calculated to identify the most influential nodes.

Mean age was 55.5 years, 42% were female, and 41% were diagnosed with schizophrenia. Psychological and physical quality of life (QoL), nighttime sleep problems, and overall sleep quality were the most strongly connected nodes. Sleep was strongly associated with physical QoL. Furthermore, there were negative associations between healthy food intake and cholesterol ratio, and positive associations between daily doses of antipsychotics and length of hospital stay. Node strength was stable (CS(cor = 0.7) = 0.75). No clear pattern emerged among other lifestyle behaviors and health outcomes.

This study offers insights into the interrelatedness of lifestyle behaviors and health outcomes. Addressing sleep problems could enhance QoL and potentially influence other health outcomes. Psychological and physical QoL were also strongly associated, emphasizing the importance of perceived well-being in health outcomes. Future research could explore causal pathways to identify treatment targets to improve care.

Exposure and response prevention (ERP) is the first-line psychological treatment for obsessive compulsive disorder (OCD). Recent research shows that the Bergen 4-day Treatment (B4DT), which is a concentrated ERP program, can be very effective. However, this intensive format has not been widely implemented, and it is unclear whether positive outcomes are unique to B4DT, or whether a similar intensive ERP program (not based on B4DT) is equally effective. We examined short- and long-term outcomes of the Melbourne Intensive Treatment-OCD (MIT-O) program, an out-patient intensive ERP program for OCD involving an intensive phase of four full-day sessions conducted over two weeks, and a supportive 21-day phase involving self-directed tasks and twice-a-week check-in calls with the therapy team. Participants were 21 individuals with OCD. The severity of OCD, depression, anxiety, stress, obsessive beliefs, and emotion regulation difficulties were assessed at four time points (pre-treatment, post-treatment, 6-month, and 12-month follow-up). Results showed a large and significant decrease in OCD and obsessive beliefs at post-treatment. These improvements were maintained at 12-month follow-up. Using international consensus criteria for treatment response, almost all participants (90.5%) showed at least partial treatment response and one-third were in remission at the final assessment. These results showed that the MIT-O program was effective, but post-treatment and 12-month remission rates were somewhat less favourable than previously published results from the B4DT program. Nevertheless, the MIT-O post-treatment outcomes were comparable to other CBT programs for OCD and should be considered when other longer term treatment formats such as in-patient treatments are not feasible.

1. (1) To evaluate the effectiveness of an intensive exposure and response prevention program in reducing obsessive compulsive disorder (OCD) symptoms.

2. (2) To examine the long-term maintenance of treatment gains at 6-month and 12-month follow-up assessments.

3. (3) To report the treatment response rate and remission outcomes achieved through the intensive format.

4. (4) To consider the broader implementation of intensive exposure and response prevention programs as an alternative format for OCD treatment.

There are 117.3 million people forcibly displaced because of war, conflict and natural disasters: 40% are children. With growing numbers, many high-income countries have adopted or are considering increasingly restrictive policies of immigration detention. Research on the impact of detention on mental health has focused on adults, although recent studies report on children.

To synthesise data on the impact of immigration detention on children’s mental health.

Systematic searches were conducted in PsycINFO, MEDLINE and Embase databases and grey literature and studies assessed using PRISMA guidelines (PROSPERO registration CRD42023369680). Included studies were quantitative, assessed children younger than 18 years who had been in immigration detention and reported mental health symptoms or diagnoses. Methodological quality was assessed using the Appraisal Tool for Cross-Sectional Studies. Meta-analyses estimated prevalence for major depression and post-traumatic stress disorder (PTSD).

Twenty-one studies reported data on 9620 children. Most studies were cross-sectional, had small sample sizes and used convenience sampling. A profoundly detrimental impact on children’s mental health across a variety of countries and detention settings was demonstrated. Meta-analysis found pooled prevalence of 42.2% for depression [95% CI 22.9, 64.3] and 32.0% for PTSD [95% CI 19.4, 48.0]. Severity of mental health impact increased with exposure to indefinite or protracted held detention.

Immigration detention harms children. No period of detention can be deemed safe, as all immigration detention is associated with adverse impacts on mental health. Our review highlights the urgency of alternative immigration policies that end the practice of detaining children and families.

Vaping is increasing in popularity. Vape products are offered in a wide variety and promise to reduce harms associated with cigarette smoking, among other claims. The motivations for vaping in patients with substance use disorder are largely unknown.

To describe perceptions and motivations regarding vaping among patients with opioid use disorder (OUD) who vape.

A convergent mixed-methods study design was used, and individual, semi-structured interviews were conducted with 41 individuals with OUD who were receiving medication for OUD and also vaped. An inductive data-driven approach was employed to characterise perspectives on vaping.

The mean ages at which participants had been introduced to vaping and initiated regular vaping were 33.95 years (s.d. 12.70) and 34.85 years (s.d. 12.38), respectively. Daily vaping (85%) of nicotine, flavoured nicotine or cannabis was common, with 27% reporting vaping both nicotine and cannabis. Qualitative analysis identified 14 themes describing motivations for vaping, including viewing vaping as a smoking cessation tool, convenience and popularity among youth.

Mixed-methods findings indicated that patients with OUD who vape perceived vaping to be healthier, cleaner and more convenient than cigarette and cannabis smoking, without appreciating the health risks. The perspectives reflected the importance of health education, guidelines and screening tools for vaping and could provide direction for healthcare providers and future vaping cessation programmes.

The study examines the behavioural and psychological symptoms (BPSs) associated with dementia and mild cognitive impairment (MCI), highlighting the prevalence and impact of these symptoms on individuals with varying levels of cognitive function, particularly in the context of the increasing incidence of dementia among the ageing population.

To explore the BPSs among out-patients with different cognitive statuses.

This cross-sectional study enrolled out-patients who attended the cognitive assessment out-patient clinic at our hospital between January 2018 and October 2022. The patients’ cognitive status was evaluated using the Neuropsychiatric Inventory (NPI), Activities of Daily Living and the Montreal Cognitive Assessment-Basic scales.

The study enrolled 3273 out-patients, including 688 (21%) with cognitively unimpairment, 1831 (56%) with MCI and 754 (23%) with dementia. The NPI score, the percentage of patients with BPSs and the number of BPSs increased with decreasing cognition level. Unordered logistic regression analysis showed that after adjustment of confounding variables, delusions, depression, euphoria and psychomotor alterations were independently associated with MCI. Delusions, agitation, euphoria, apathy, psychomotor alterations and sleep change were independently associated with dementia.

NPI scores, the percentage of patients with BPSs and the numbers of BPSs increased with declining cognitive function.

Adolescence marks a critical transition period, with significant mental health challenges including anxiety and depression symptoms that affect long-term happiness. There has been a lack of research exploring the factors mediating adolescent happiness.

To investigate the mediating effects of anxiety and depression on adolescent happiness, as well as the contributions of sociodemographic factors.

We recruited 392 adolescents. Anxiety symptoms, depression symptoms and happiness were assessed by the seven-item Generalized Anxiety Disorder scale, nine-item Patient Health Questionnaire and single-item happiness scale, respectively. Self-administered questionnaires were used to collect sociodemographic information.

Spearman correlation analysis showed significant negative correlations of happiness with anxiety (r = −0.37, P < 0.0001) and depression (r = −0.47, P < 0.0001). Positive predictors of happiness included quality of parents’ marriage (β = 0.12, P = 0.006), regular physical exercise (β = 0.13, P = 0.006) and regular diet (β = 0.10, P = 0.03). Mediation analysis indicated that depressive symptoms (estimate = 0.50, 95% CI: 0.25 to 0.80) and anxiety symptoms (estimate = 0.32, 95% CI: 0.12 to 0.57) partially mediated the relationship between regular exercise and happiness, whereas depressive symptoms completely mediated the relationship between anxiety symptoms and happiness (estimate = −0.14, 95% CI: −0.20 to −0.08).

The findings of this study highlight the intricate interplay of mental health issues, lifestyle factors and adolescent happiness and emphasise the need for comprehensive interventions focusing on enhancing physical activity and addressing psychological health to foster happiness among adolescents.

Mental health problems in adolescence are increasingly prevalent and have tremendous impacts on life-long health and mortality. Although household poverty is a known risk factor for adolescent mental health, evidence of the timing hypothesis is scarce. We aimed to examine the longitudinal associations of poverty across childhood with mental health in adolescence, focusing on the timing of exposure.

We used the data of 5,671 children from a Japanese population-based longitudinal cohort, which recruited the first graders (aged 6–7 years) and followed biannually until eighth grade (aged 13–14 years) in Adachi, Tokyo. Household poverty was defined as households having any of the following experiences: annual income less than Japanese yen 3 million, payment difficulties and material deprivations, measured in first, second, fourth, sixth and eighth grades. Adolescent mental health included parent-report internalizing and externalizing problems (the Strengths and Difficulties Questionnaire), self-report depression (the Patient Health Questionnaire-9) and self-esteem (the Japanese version Children’s Perceived Competence Scale) in eighth grade. We applied g-estimation of structural nested mean modelling to account for time-varying confounders.

If adolescents were exposed to household poverty at any grade across childhood, on average, they would report more severe depressive symptoms (ψ = 0.32 [95% CI 0.13; 0.51]) and lower self-esteem (ψ = −0.41 [−0.62; −0.21]) in eighth grade. There were also average associations of household poverty at any grade with more internalizing (ψ = 0.19 [0.10; 0.29]) and externalizing problems (ψ = 0.10 [0.002; 0.19]). Although the associations between household poverty and mental health were stronger in younger ages (e.g., poverty in the second grade → depression: ψ = 0.54 [−0.12; 1.19] vs. poverty in the eighth grade → depression: ψ = −0.01 [−0.66; 0.64]), overlapping 95% CIs indicated no statistically significantly different associations by the timing of exposure.

We found the average effect of exposure to household poverty at any grade on mental health outcomes in eighth grade, failing to support the timing hypothesis. The findings indicate that the effects of household poverty accumulate over time in childhood and impact adolescent mental health (cumulative hypothesis) rather than the effects differ by the timing of exposure. While cumulative effects suggest a persistent intervention in poor households across childhood, we highlight intervention at any timing in childhood may be effective in alleviating adolescent mental health problems.

Cognitive behavioural therapists and practitioners often feel uncertain about how to treat post-traumatic stress disorder (PTSD) following rape and sexual assault. There are many myths and rumours about what you should and should not do. All too frequently, this uncertainty results in therapists avoiding doing trauma-focused work with these clients. Whilst understandable, this means that the survivor continues to re-experience the rape as flashbacks and/or nightmares. This article outlines an evidence-based cognitive behavioural therapy (CBT) approach to treating PTSD following a rape in adulthood. It aims to be a practical, ‘how to’ guide for therapists, drawing on the authors’ decades of experience in this area. We have included film links to demonstrate how to undertake each step of the treatment pathway. Our aim is for CBT practitioners to feel more confident in delivering effective trauma-focused therapy to this client group. We consider how to assess and formulate PTSD following a rape in adulthood, then how to deliver cognitive therapy for PTSD (CT-PTSD; Ehlers and Clark, 2000). We will cover both client and therapist factors when working with memories of rape, as well as legal, social, cultural and interpersonal considerations.

1. To understand the importance of providing effective, trauma-focused therapy for survivors of rape in adulthood who are experiencing symptoms of PTSD.

2. To be able to assess, formulate and treat PTSD following a rape in adulthood.

3. How to manage the dissociation common in this client group.

4. To be able to select and choose appropriate cognitive, behavioural and imagery techniques to help with feelings of shame, responsibility, anger, disgust, contamination and mistrust.

5. For therapists to learn how best to support their own ability to cope with working in a trauma-focused way with survivors of rape and sexual violence.

It is widely known that people with a severe and persistent mental illness (SPMI) are more at risk of poor physical health outcomes because of disparities in healthcare access and provision. Less is known about the quality of end-of-life (EoL) care in people with SPMI who have a life-limiting disease.

A comprehensive and systematic literature search in PubMed, Embase, Web of Science, Scopus, and CINAHL electronic databases (from inception to November 2023) was conducted, without language restriction, for reviews on EoL care and/or palliative sedation for people with SPMI and a life-limiting disease. A critical appraisal of the selected reviews was performed. Data were analyzed according to the four principles of biomedical ethics.

Ten reviews were included. These show that people with SPMI are at risk of suboptimal EoL care. Stigma among healthcare professionals, lack of integrated care policies, absence of advanced care planning, and insufficient expertise and training in palliative care of psychiatrists have been identified as key challenges to the provision of adequate EoL care for people with SPMI. No data were found about palliative sedation.

To optimize palliative and EoL care for SPMI patients with a life-limiting disease, a policy of coordinated and integrated mental and physical healthcare is needed. Moreover, education and training initiatives to reduce stigma and discrimination among all healthcare workers and to enhance palliative care skills in psychiatrists should be offered. Finally, more research is needed on EoL particularly on palliative sedation for people with SPMI and a life-limiting disease.

This study described the development and assessment of the psychometric properties of the Dissociation-Integration of Self-States Scale (D-ISS). This is a new scale to assess dissociation at the ‘between modes’ or self-state (personality) level. The D-ISS is rooted in cognitive behavioural theory and designed to measure between-mode dissociation (dissociation between self-states) in clinical practice and research.

Study 1: D-ISS scale items were generated and then answered by 344 young adults (16–25 years) who reported experiencing stressful times. An exploratory factor analysis (EFA) was conducted and the results were used to refine the scale to 25 items.

Study 2: The final 25-item D-ISS was completed by 383 adults (18–65 years) who reported experiencing mental health difficulties. A confirmatory factor analysis (CFA) was conducted using the second dataset. Internal consistency, test–retest reliability, convergent validity and divergent validity of the final D-ISS was assessed.

Study 1: The EFA showed a clear 5-factor solution, which was used to refine the D-ISS to a total of 25 items with five items in each factor.

Study 2: The 5-factor solution from Study 1 was confirmed as a good fit by the CFA using the data collected in Study 2. The D-ISS demonstrated good internal reliability and test–retest reliability. The D-ISS showed no correlations with divergent scales. For convergent validity, the D-ISS showed moderate correlations with the Dissociative Experiences Scale (DES-II).

The new D-ISS measure of between-mode dissociation is reliable and valid for the population represented by our sample. Further research into its use in clinical populations is required.

1. (1) To understand and be able to use a new measure of dissociation at the personality or self-states level.

2. (2) To understand the cognitive behavioural model of dissociation.

3. (3) To understand the theoretical underpinnings of the scale, in terms of the effects of childhood and adult adversity and other factors on psychological development.

4. (4) To consider the potential clinical and research applications of the scale.

5. (5) To appreciate the limitations of the research so far and the nature of future research required.