BJPsych Bulletin最新文献

Aims and method: This study sought to obtain the views of doctors associated with the Royal College of Psychiatrists on the use of outcome measures in mental health services. An online survey was developed by the College's working group on outcome measures and widely disseminated to psychiatrists through College channels.

Results: In total, 339 completed responses were received. Respondents were mostly consultant psychiatrists; based in England; and working in the National Health Service with working-age adults. Almost half said they used outcome measures routinely, with almost half finding outcome measures clinically useful. Lack of time and inadequate information technology systems were identified as the top barriers to using outcome measures.

Clinical implications: Based on our results, psychiatrists are generally keen to use outcome measures, but are often prevented from doing so effectively by pressures on services and lack of appropriate support. The Royal College of Psychiatrists and other relevant organisations could enhance the use of outcome measures in mental health services through improved guidance, providing additional resources and integration of measures into electronic patient records.

Aims and method: This study aimed to develop and evaluate a predictive model using electronic health record (EHR) data from a large south London mental health service, in order to identify patients 3 months following first referral who are at risk of subsequent high-intensity service use over the subsequent 12 months. Early identification of such patients may support proactive and personalised care planning, reducing the need for high-cost episodes of care. Predictive models were developed using information from 18 869 patients newly referred between 2007 and 2011. High-intensity use was defined as the top 10% of estimated mental healthcare expenditure. The model was developed using demographic, clinical and service use variables, and was validated on data from the periods 2012-2017 and 2018-2023.

Results: A logistic regression model achieved an area under the receiver operating characteristic (AUROC) of 0.79 in development (sensitivity 0.82, specificity 0.54), with robust performance in validation sets (AUROC 0.81, 0.83, respectively). Key predictors included first 3 months service use, schizophrenia or eating disorder diagnoses and living alone. Natural language processing-derived features did not improve performance.

Clinical implications: Routine EHR data performed well in predicting the risk of high-cost care, potentially enabling targeted interventions and more efficient resource allocation.

Debate about borderline personality disorder (BPD) has intensified, with some proposing its absorption into complex post-traumatic stress disorder and others questioning whether the diagnosis is harmful. These debates often obscure the central issue of construct validity. This paper evaluates whether BPD constitutes a coherent clinical entity. Drawing on Robins and Guze's classic diagnostic validators - symptom specificity, heritability, course of illness, biological markers and treatment response - the evidence demonstrates that BPD is a robustly validated psychiatric disorder that should be retained in future classification systems. Concerns about stigma and dimensional models are considered but do not undermine its empirical grounding.

Aims and method: Serendipity has driven many of psychiatry's most important treatments, yet contemporary systems may undermine clinicians' ability to notice and develop unexpected therapeutic effects. This selective narrative review synthesises landmark discovery stories, conceptual accounts of serendipity and contemporary case examples to clarify how chance observations become robust advances.

Results: Across historical and modern examples, serendipitous discoveries consistently reflected the interaction of unexpected events with prepared observers working in supportive institutional and research systems. We identify current barriers created by standardised care, funding and trial structures, and professional fragmentation, and outline a multi-level framework for cultivating serendipity through phenomenological training, technology-enabled detection of anomalous responses, flexible funding and innovative designs such as adaptive platform and rapid-fail proof-of-concept trials.

Clinical implications: Deliberately creating pathways that move rare, surprising responses from bedside observation to formal evaluation could accelerate more precise, personalised treatments while preserving rigor in psychiatric care.

Psychiatry risks losing its conceptual boundaries as the scope of its concern expands to include all forms of human unhappiness. This editorial argues that the discipline must distinguish clearly between illness and adversity, recognising that not all suffering is pathological. Drawing on historical and contemporary debates - from Jaspers' foundational dualism to Engel's biopsychosocial model, and from diagnostic inflation to the medicalisation of social distress - the paper contends that integration without limits leads to dissolution. Psychiatry's legitimacy depends not on the eradication of unhappiness but on the understanding of illness and the protection of those whose suffering has crossed the threshold of disease.

Summary Despite co-produced guidelines and actions recommended by statutory bodies, there has been a persistent lack of progress in improving the quality of healthcare for those with eating disorders in the UK. Drawing on multiple evidence sources, including lived experience, the author analyses reasons for this. The concept of an 'ignorance culture' is theorised as a key barrier, defined as cultural practices that uphold systemic failures by ignoring concerns that harm clinicians, patients, caregivers and wider society. A shift towards a 'responsibility culture' is proposed, with recommendations aimed at creating greater accountability, shared learning, transparency and reflexivity. Prioritising cultural change is central to improving the quality of care for everyone affected by eating disorders.

The diagnosis and treatment of personality disorder are both highly contentious subjects. It is argued in this article that we have misunderstood personality pathology as yet another form of mental illness that should require treatment for its alleviation or removal. But it is not a typical mental illness; personality is a stable persistent component of the self and needs a different treatment approach based on adaptation.

Aims and method: This study investigated the prevalence of advance directives among patients receiving community care within the East London NHS Foundation Trust (ELFT), and to identify factors associated with their clinical application.We analysed data from electronic health records of 4807 patients (aged 18-75 years), managed under the Care Programme Approach (CPA) in ELFT during 2021-2022. Demographic, clinical, service-level and patient-reported measures were analysed (binomial logistic regression).

Results: A total of 31.2% of patients on the CPA had an advance directive. Black ethnicity, treatment in the forensic service or Newham, Luton and Bedfordshire localities, housing in socio-therapeutic facilities, diagnosis of personality disorder, ten or more previous admissions and engagement with DIALOG+ were positively associated with having an advance directive. DIALOG+ is the first approach that has been specifically developed to make routine patient-clinician meetings therapeutically effective. It is based on quality of life research, utilising the DIALOG scale (a patient-reported outcome measure), concepts of patient-centred communication, IT developments and components of solution-focused therapy, and is supported by an app.

Clinical implications: This study highlights a complex interplay of cultural, social and systemic factors that influence advance care plan status. Structured communication, stronger therapeutic relationships and staff facilitation are likely to encourage advance care planning.

The '27 Club' myth masks a public health problem: systems that amplify musicians' psychological vulnerability. This multiple-case study uses reflexive thematic analysis of Janis Joplin, Kurt Cobain and Amy Winehouse, triangulating biographies, archives and documentaries. Across cases we identify a vulnerability triad - emotional dysregulation, chronic distress and substance-mediated coping - and show how 'tortured genius' narratives, industry pressures and fragmented care normalise risk. Cohort evidence indicates musicians face 1.7-3 times excess mortality for decades post-fame, especially solo artists and trauma survivors. We propose integrated risk assessments in contracts, mobile dual-diagnosis support and narrative interventions.

High-functioning depression (HFD) describes individuals experiencing persistent depressive symptoms, such as low mood and emotional exhaustion, while maintaining outward success. Owing to preserved functionality, the underlying distress is often unnoticed, misattributed or suppressed. HFD challenges existing psychiatric frameworks, delays diagnosis and increases the risk of progression to major depressive disorder and suicidality. Current screening tools may lack sensitivity, and stigma can lead to disengagement from therapy. Expanded diagnostic awareness, improved clinician training and culturally attuned care are essential for recognising and validating internal suffering in this overlooked population.