BMJ mental health最新文献

Background: Undisturbed circadian rhythms of rest/activity are crucial to health and well-being. There is growing evidence to suggest that circadian rhythm disruptions are also associated with adverse mental health outcomes (and vice versa), but important questions about the relationship between circadian rhythms and mental health remain unanswered.

Objective: To determine future priorities for research in the area of mental health and circadian rhythms, a James Lind Alliance Priority Setting Partnership exercise in collaboration with a steering group comprising individuals with lived experience, carers and clinicians was undertaken.

Methods: An initial survey among UK residents provided a set of 964 questions supplied by 247 respondents (227 lived experience, 44 carers (including 40 carers with lived experience), 41 clinicians (including 37 clinicians with lived experience)). Responses were processed into 171 summary questions by the steering group. Reviews of published research and existing clinical guidelines reduced this to 63 unanswered summary questions. A ranking survey of these 63 questions asked respondents to select their 10 most important research questions, from which the most highly ranked would be taken to the final stage. This was completed by 222 respondents (200 lived experience, 33 carers (including 29 carers with lived experience), 38 clinicians (including 30 clinicians with lived experience)).

Findings: In a final face-to-face workshop, 19 individuals, including individuals with lived experience, carers and clinicians, discussed and ranked a list of questions to produce a ranking of the top 25 research questions/priorities, with a particular focus on the Top 10.

Discussion: The final research questions are presented to inform researchers and funding bodies when setting future research priorities across the fields of mental health and circadian rhythms.

Clinical implications: Addressing the priorities identified here should lead to greater understanding of the relationships between mental health and circadian rhythms and will have longer-term impacts on research, healthcare innovation and public health policy.

The National Institute for Health and Care Excellence (NICE) guideline for self-harm advises against the use of risk assessment tools to predict future occurrence of repeat self-harm or suicide in individuals who have self-harmed, or to inform decisions regarding their treatment and discharge. In this perspective article, we discuss shortcomings in the process of developing this guideline, including: (1) limitations in the NICE evidence review underpinning these recommendations, which resulted in very minimal evidence being included; (2) developing definitive recommendations and drawing strong conclusions regarding the limited predictive ability and potential harms of tools, which were almost entirely based on the committee's expertise and experience and (3) not acknowledging the uncertainty and gaps in the evidence base, particularly around model impact, acceptability and feasibility. We highlight new evidence since this 2022 guideline, including examples of international work assessing model implementation and cost-effectiveness. We propose that there is an urgent need for more rigorous primary research assessing model impact, feasibility and acceptability, as well as empirical work addressing concerns about potential harms and misuse of tools, notably the denial of care. While prediction models should not be prematurely implemented in clinical practice without adequate validation and impact assessment, well-developed and validated tools in this area have the potential to improve clinical care for individuals who self-harm. Future updates to the guideline should be informed by emerging higher quality evidence in the field.

Background: Clozapine is highly effective for treatment-resistant schizophrenia but has been associated with an increased risk of agranulocytosis. As a result, until 2025, the Food and Drug Administration required patients receiving clozapine to undergo regular blood testing to monitor for neutropenia as part of a Risk Evaluation and Mitigation Strategy (REMS) programme.

Objective: This study sought to compare the risk of neutropenia-related hospitalisations between clozapine and olanzapine initiators.

Methods: The study cohort was nested in claims data from Medicaid and two commercial health insurance databases and consisted of adults initiating clozapine or olanzapine who had a recorded diagnosis of schizophrenia or schizoaffective disorder and ≥1 dispensing of a different antipsychotic in the 6 months before initiation. Propensity score matching (1:1) was used to mitigate confounding. The primary outcome was hospitalisation with a neutropenia diagnosis in the primary position. Both as-treated and intention-to-treat analyses were implemented.

Findings: After propensity score matching, there were 16 873 initiators in each group. At 6 months postinitiation, there were 12 neutropenia-related hospitalisations among the clozapine cohort (incidence rate: 2.21 per 1000 person-years; 95% CI 1.25 to 3.89) and <11 among the olanzapine cohort (0.18; 95% CI 0.03 to 1.29), corresponding to an incidence rate ratio (IRR) of 12.18 (95% CI 1.58 to 93.71). The IRRs were 5.77 (95% CI 1.29 to 25.76) at 1 year, 5.50 (95% CI 1.23 to 24.55) at 2 years and 5.40 (95% CI 1.21 to 24.13) at 3 years postinitiation. Associations remained but were attenuated in intention-to-treat analyses.

Conclusions: Clozapine initiators had an elevated risk of neutropenia-related hospitalisation, especially during the first 6 months of treatment, although the absolute risk was low.

Clinical implications: Despite removal of the REMS programme, it is important for prescribers to monitor patients for neutropenia after initiating clozapine.

Background: Loneliness is highly prevalent among Chinese older adults. Mindfulness-based interventions for older adults (MBOA) have demonstrated potential in alleviating loneliness. However, few studies have employed active controls with long-term follow-up.

Objective: This study aimed to assess the efficacy of MBOA in reducing loneliness compared with social contact control (SCC).

Methods: This parallel, randomised controlled trial (RCT) assigned community-dwelling lonely Chinese older adults (≥60 years) in Hong Kong to MBOA or SCC. Both interventions comprised 8 weekly 1.5-hour group-based face-to-face sessions. Assessments were conducted at baseline, postintervention and at 6-month and 12-month postrandomisation. The primary outcome was loneliness score at 12 months, analysed using analysis of covariance under the intention-to-treat approach. Secondary outcomes included depression, anxiety, health-related quality of life and healthcare utilisation. Changes in psychological measures were analysed using linear mixed models.

Findings: A total of 245 eligible participants were randomised to MBOA (n=123) or SCC (n=122). No significant between-group difference in primary outcome was found (mean difference=-0.14, p=0.52, effect size=-0.21), although both groups showed improvement in loneliness (within-group effect size: MBOA=-0.58, SCC=-0.31). MBOA participants reported reduced depressive symptoms and a decreasing trend in anxiety at 6 months compared with SCC.

Conclusion: This is the first RCT examining efficacy of MBOA in alleviating loneliness among Chinese older adults using an active control with long-term assessments. MBOA is not superior to SCC in reducing loneliness, although it may reduce psychological symptoms.

Clinical implication: Clinicians could consider prioritising mindfulness-based interventions for lonely older adults when depressive or anxiety symptoms are prominent.

Mental health clinical trials in the UK face significant recruitment barriers, with mental health studies comprising just 3.3% of approved interventional medicinal product trials. Challenges include the limited numbers of trials and clinician gatekeeping-where clinicians decide whether or not to inform patients about research opportunities, limiting patient awareness and recruitment. The 'Count Me In' (CMI) approach, an opt-out recruitment model launched in Oxford in 2021 and then in Liverpool City Region in 2024, aimed to address these issues by directly contacting patients to discuss research opportunities, empower them in the shared decision process and embed participation in research into real-world clinical care. In this paper, we discuss the need for advancing beyond the original CMI model, including the requirement for enhanced data capture, mechanism for patient outreach that prioritises inclusive practices for improving participation and ensuring diverse, representative trial populations.

Background: Epistemic trust describes the capacity to appropriately identify others as reliable and relevant sources of information, an ability closely linked to attachment and social learning. Epistemic disruption can manifest as heightened suspicion (mistrust) or excessive reliance (credulity) vis-à-vis others, affecting mentalizing abilities and increasing vulnerability to psychopathology and maladaptive traits. These interdependent and multidirectional dynamics are pivotal to therapeutic learning, and thus to therapeutic change.

Objective: This study examined associations between epistemic trust and disruption, markers of psychopathology, therapeutic relationship quality and treatment-seeking behaviour.

Method: A naturalistic sample of 912 participants, recruited via a mental health app, completed the Epistemic Trust, Mistrust and Credulity Questionnaire, along with self-reports capturing internalising symptoms, personality functioning, maladaptive traits and the perceived therapeutic relationship within the previous 6 months. Treatment-seeking behaviour and the number of sessions utilized in the past year were further explored-both in psychotherapeutic and psychiatric contexts.

Findings: Epistemic mistrust and credulity showed consistent relationships with markers of psychopathology. Higher epistemic (mis)trust correlated with more positive (negative) ratings of various aspects of the therapeutic relationship, including genuineness, realism, expectations, congruence and responsivity-over the past 6 months. Epistemic trust positively predicted the amount of psychotherapy sessions, while epistemic mistrust negatively predicted treatment-seeking, both controlled for personality dysfunction. Epistemic credulity predicted mental health app use-all assessed retrospectively (past year).

Conclusion: The results encourage further in-depth exploration of trust-related aspects of the therapeutic alliance and investigation of mechanisms of change in therapeutic processes that may facilitate the transition from mistrust and credulity to trust.

Clinical implications: Even though the magnitude and direction of effects remain to be clarified, patients with epistemic mistrust may enter a self-reinforcing cycle of reduced openness and ineffective mentalizing, potentially impacting therapeutic effectiveness. Interventions targeting epistemic disruption and impaired personality functioning seem to be crucial for improving therapeutic outcomes, including psychopharmacological treatment effectiveness.