Background A substantial subset of patients with major depressive disorder (MDD) experience treatment-resistant depression (TRD), typically defined as failure to respond to at least two sequential antidepressant trials at adequate dose and length. Aims To examine clinical and service-level associations of TRD, and the experiences of people with TRD and clinicians involved in their care within a large, diverse National Health Service trust in the UK. Method This mixed-methods study integrated quantitative analysis of electronic health records with thematic analysis of semi-structured interviews. Chi-squared tests and one-way analysis of variance were used to assess associations between lines of antidepressant treatments and sociodemographic and clinical variables, and binary logistic regression was used to identify associations of TRD status. Results Nearly half (48%) of MDD patients met TRD criteria, with 36.9% having trialled ≥4 antidepressant treatments. People with TRD had higher rates of recurrent depression (odds ratio = 1.24, 95% CI: 1.05–1.45, P = 0.008), comorbid anxiety disorders (odds ratio = 1.21, 95% CI: 1.03–1.41, P = 0.019), personality disorders (odds ratio=1.35, 95% CI: 1.10–1.65, P = 0.003), self-harm (odds ratio = 1.76, 95% CI: 1.06–2.93, P = 0.029) and cardiovascular diseases (odds ratio = 1.46, 95% CI: 1.02–2.07, P = 0.0374). Greater treatment resistance was linked to increased economic inactivity and functional loss. Qualitative findings revealed severe emotional distress and frustration with existing treatments, as well as organisational and illness-related barriers to effective care. Conclusions TRD is characterised by increasing mental and physical morbidity and functional decline, with individuals experiencing barriers to effective care. Improved pathways, service structures and more effective biological and psychological interventions are needed.

This chapter outlines some of the most widely used clinician-rated (e.g., HAM-D, MADRS, YMRS) and self-rated (e.g., BDI, PHQ-9, QIDS, ISS, ASRM) tools for depression and bipolar disorder and summarises the evidence to date on their psychometric properties and practicality for use in research and clinical practice. The chapter also discusses the emerging research surrounding affective instability (AI), a core trait-like feature known to underpin the development and emergence of mood disorder symptoms and describes how digital technologies can aid in the monitoring of both mood and AI. A novel mood-monitoring methodology, called experience sampling method, is introduced and its benefits over traditional approaches are discussed. The chapter concludes with a summary of the current and upcoming mood rating tools, as well as their future role and potential applications in clinical practice.

Background Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II. Methods We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the ‘early course’ of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach. Results From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course. Conclusions and recommendations While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.

Background Evidence regarding the rate of relapse in people with bipolar disorder (BD), particularly from the UK, is lacking. This study aimed to evaluate the rate and associations of clinician-defined relapse over 5 years in a large sample of BD patients receiving routine care from a UK mental health service. Method We utilised de-identified electronic health records to sample people with BD at baseline. Relapse was defined as either hospitalisation, or a referral to acute mental health crisis services, between June 2014 and June 2019. We calculated the 5-year rate of relapse and examined the sociodemographic and clinical factors that were independently associated with relapse status and the number of relapses, over the 5-year period. Results Of 2649 patients diagnosed with BD and receiving care from secondary mental health services, 25.5% (n = 676) experienced at least one relapse over 5 years. Of the 676 people who relapsed, 60.9% experienced one relapse, with the remainder experiencing multiple relapses. 7.2% of the baseline sample had died during the 5-year follow-up. Significant factors associated with experiencing any relapse, after adjustment for relevant covariates, were history of self-harm/suicidality (OR 2.17, CI 1.15–4.10, p = 0.02), comorbidity (OR 2.59, CI 1.35–4.97, p = 0.004) and psychotic symptoms (OR 3.66, CI 1.89–7.08, p < 0.001). Factors associated with the number of relapses over 5 years, after adjustment for covariates, were self-harm/suicidality ( β = 0.69, CI 0.21–1.17, p = 0.005), history of trauma ( β = 0.51, CI = 0.07–0.95, p = 0.03), psychotic symptoms ( β = 1.05, CI 0.55–1.56, p < 0.001), comorbidity ( β = 0.52, CI 0.07–1.03, p = 0.047) and ethnicity ( β = − 0.44, CI − 0.87 to − 0.003, p = 0.048). Conclusions Around 1 in 4 people with BD in a large sample of people with BD receiving secondary mental health services in the UK relapsed over a 5-year period. Interventions targeting the impacts of trauma, suicidality, presence of psychotic symptoms and comorbidity could help to prevent relapse in people with BD and should be considered in relapse prevention plans.

Background:The impact of emotion regulation (ER) interventions on mental health and wellbeing has been extensively documented in the literature, although only recently have digital technologies been incorporated in intervention design. The aim of this review is to explore available published literature relating to the efficacy, barriers and facilitators of digital technologies in enhancing emotion/mood regulation skills.Methods:A review of the literature was performed to explore the effectiveness of digital technology in enhancing ER skills. MEDLINE, CINAHL, PsycINFO and Web of Science databases were searched from inception to 31st August 2020. In addition, the first 10 pages of Google Scholar were examined for relevant articles. The following MeSH term and key words were used to identify relevant articles: "emotion regulation OR mood regulation" AND "intervention OR treatment OR program$ OR therap$" AND "digital technologies OR web-based OR mobile application OR App." Reference lists of retrieved papers were hand searched to identify additional publications. Findings were summarized narratively.Results:Titles and abstracts were reviewed by one reviewer in two phases, and confirmed by a second reviewer; discrepancies were resolved through discussion. First, the retrieved titles and abstracts were reviewed to identify relevant studies. Full texts of retrieved studies were then read to determine eligibility. The search resulted in 209 studies of which 191 citations were identified as potentially meeting the inclusion criteria. After reviewing the title and abstract of the 191 papers, 33 studies were identified as potentially meeting the inclusion criteria. Following full-text review, 10 studies met the inclusion criteria. Findings indicated the potential effectiveness of online, text-messaging, and smartphone interventions for enhancing ER skills.Conclusion:There is encouraging evidence that digital technologies may be beneficial for enhancing ER skills and providing personalized care remotely. Digital technologies, particularly the use of smartphones, were instrumental in facilitating assessments and delivering online self-help interventions such as cognitive behavioral therapy. Continued research is required to rigorously evaluate the effectiveness of digital technologies in ER skills and carefully consider risks/benefits while determining how emerging technologies might support the scale-up of ER skills and mental health treatment.

Abstract Background Patterns of development and underlying factors explaining anxiety disorders in children and adolescents are under‐researched, despite their high prevalence, impact and associations with other mental disorders. We aimed to a] understand the pattern and persistence of specific anxiety disorders; b] examine differing trajectories of symptoms of specific anxiety disorders and; c] examine socio‐demographic and health‐related predictors of persistent anxiety disorder‐specific symptoms, across middle childhood to early adolescence. Methods The current study used data from 8122 participants in the Avon Longitudinal Study of Parents and Children birth cohort. The Development and Wellbeing Assessment questionnaire was administered to parents to capture child and adolescent anxiety total scores and DAWBA‐derived diagnoses. Separation anxiety, specific phobia, social anxiety, acute stress reaction, and generalized anxiety at 8, 10 and 13 years were selected. Further, we included the following socio‐demographic and health‐related predictors: sex, birth weight, sleep difficulties at 3.5 years, ethnicity, family adversity, maternal age at birth, maternal postnatal anxiety, maternal postnatal depression, maternal bonding, maternal socio‐economic status and maternal education. Results Different anxiety disorders presented different prevalence and patterns of development over time. Further, latent class growth analyses yielded a trajectory characterized by individuals with persistent high levels of anxiety across childhood and adolescence; for specific phobia (high = 5.8%; moderate = 20.5%; low = 73.6%), social anxiety (high = 3.4%; moderate = 12.1%; low = 84.5%), acute stress reaction (high = 1.9%; low = 98.1%) and generalized anxiety (high = 5.4%; moderate = 21.7%; low = 72.9%). Finally, the risk factors associated with each of the persistent high levels of anxiety disorders were child sleeping difficulties and postnatal maternal depression and anxiety. Conclusions Our findings show that a small group of children and young adolescents continue to suffer from frequent and severe anxiety. When considering treatment strategies for anxiety disorders in this group, children's sleep difficulties and postnatal maternal depression and anxiety need to be assessed as these may predict a more prolonged and severe course of illness.

Childhood trauma, particularly emotional abuse, is prevalent in bipolar disorder, and affective instability mechanistically explains the relationship between childhood trauma and poor bipolar disorder outcomes. Yet, trauma-focused interventions in bipolar disorder are lacking. This editorial calls for future early interventions to target the effects of childhood trauma and affective instability in this population.

Children are frequently witnesses of crime. In the witness literature and legal systems, children are often deemed to have unreliable memories. Yet, in the basic developmental literature, young children can monitor their memory. To address these contradictory conclusions, we reanalysed the confidence-accuracy relationship in basic and applied research. Confidence provided considerable information about memory accuracy, from at least age 8, but possibly younger. We also conducted an experiment where children in young(4–6 years), middle(7–9 years), and late(10–17 years) childhood (N=2,205) watched a person in a video, and then identified that person from a police lineup. Children provided a confidence rating (an explicit judgement), and used an interactive lineup—in which the lineup faces can be rotated—and we analyzed children’s viewing behavior (an implicit measure of metacognition). A strong confidence-accuracy relationship was observed from age 10, and an emerging relationship from age 7. A constant likelihood ratio signal-detection model can be used to understand these findings. Moreover, in all ages, interactive viewing behavior differed in children who made correct versus incorrect suspect identifications. Our research reconciles the apparent divide between applied and basic research findings and suggests that the fundamental architecture of metacognition that has previously been evidenced in basic list-learning paradigms also underlies performance on complex applied tasks. Contrary to what is believed by legal practitioners, but similar to what has been found in the basic literature, identifications made by children can be reliable when appropriate metacognitive measures are used to estimate accuracy.

Children are frequently witnesses of crime. In the witness literature and legal systems, children are often deemed to have unreliable memories. Yet, in the basic developmental literature, young children can monitor their memory. To address these contradictory conclusions, we reanalyzed the confidence-accuracy relationship in basic and applied research. Confidence provided considerable information about memory accuracy, from at least age 8, but possibly younger. We also conducted an experiment where children in young (4-6 years), middle (7-9 years), and late (10-17 years) childhood (N = 2,205) watched a person in a video and then identified that person from a police lineup. Children provided a confidence rating (an explicit judgment) and used an interactive lineup-in which the lineup faces can be rotated-and we analyzed children's viewing behavior (an implicit measure of metacognition). A strong confidence-accuracy relationship was observed from age 10 and an emerging relationship from age 7. A constant likelihood ratio signal-detection model can be used to understand these findings. Moreover, in all ages, interactive viewing behavior differed in children who made correct versus incorrect suspect identifications. Our research reconciles the apparent divide between applied and basic research findings and suggests that the fundamental architecture of metacognition that has previously been evidenced in basic list-learning paradigms also underlies performance on complex applied tasks. Contrary to what is believed by legal practitioners, but similar to what has been found in the basic literature, identifications made by children can be reliable when appropriate metacognitive measures are used to estimate accuracy.

Background: There is evidence that repetitive transcranial magnetic stimulation (rTMS) is effective for treating adult depression. However, it remains unclear whether rTMS is an effective treatment for adolescent depression. This systematic review examines the existing literature on the effectiveness and acceptability of rTMS in the treatment of adolescent depression. Methods: After protocol registration (PROSPERO), we searched PubMed, Embase, PsycINFO, WoS and CENTRAL databases and the grey literature. We included studies that used rTMS in adolescents aged 12-25 years old who had a clinical diagnosis of depression. Study quality was assessed using the Newcastle-Ottawa Scale. Results: Fourteen studies were identified, which included 8 open-trial studies (N = 142 participants) and six studies which performed further post-hoc/follow-up analyses on these open-trial datasets. All studies suffered from multiple biases but reported that rTMS treatment reduced depression scores in adolescents. A single study on theta burst stimulation also found a positive effect. No study to date includes a sham control. Reported side effects of rTMS included scalp pain, headache and dizziness. Limitations: Study methodologies precluded a meta-analysis. Conclusions: The current literature signals that rTMS could reduce adolescent depressive symptoms. However, sham controlled randomized trials are needed. These findings suggest that rTMS may be a promising treatment option for adolescents with depression.

The extant literature is inconsistent over whether manic symptoms in first‐episode psychosis (FEP) impact on its development and trajectory. This study addressed the following: (1) Does Duration of Untreated Illness (DUI) and Duration of Untreated Psychosis (DUP) differ between FEP patients with and without manic symptoms? (2) Do manic symptoms in FEP have an impact on time to remission over 1 year?

BACKGROUND AND OBJECTIVES:Maladaptive metacognitive beliefs are associated with the development of post-traumatic stress disorder (PTSD) symptoms following trauma, however it remains unclear whether training people to adopt healthy metacognitive beliefs helps to protect against the development of PTSD symptoms. We developed and tested a new cognitive bias modification training protocol (CBMMetacog) that aimed to prevent analogue PTSD by training people to adopt healthy metacognitive beliefs prior to watching a distressing film. METHODS:Participants (N = 135) received CBMMetacog or a control CBM training and then watched a trauma film. We assessed participants' metacognitive appraisal style/beliefs, analogue PTSD symptoms, including intrusions and meta-awareness of their intrusions. RESULTS:CBMMetacog led participants to adopt healthier metacognitive beliefs relative to the control training. Importantly, CBMMetacog participants reported fewer film intrusions over a 7-day period compared to the control group. CBMMetacog did not increase participants' meta-awareness of their intrusions. LIMITATIONS:As this was the first study to manipulate metacognitive beliefs related to an analogue trauma via CBM, we chose to use a healthy participant sample. Therefore, further research is needed before these results can be generalised to clinical samples. CONCLUSIONS:Overall, these results suggest that training people to adopt healthy metacognitive beliefs, prior to trauma exposure, may help reduce vulnerability to PTSD.

Bipolar disorder (BD) is a debilitating mood disorder marked by manic, hypomanic and/or mixed or depressive episodes. It affects approximately 1–2% of the population and is linked to high rates of suicide, functional impairment and poorer quality of life. Presently, treatment options for BD are limited. There is a strong evidence base for pharmacological (e.g., lithium) and psychological (e.g., psychoeducation) treatments; however, both of these pose challenges for treatment outcomes (e.g., non-response, side-effects, limited access). Repetitive transcranial magnetic stimulation (rTMS), a non-invasive brain stimulation technique, is a recommended treatment for unipolar depression, but it is unclear whether rTMS is an effective, safe and well tolerated treatment in people with BD. This article reviews the extant literature on the use of rTMS to treat BD across different mood states. We found 34 studies in total ( N = 611 patients), with most assessing bipolar depression ( n = 26), versus bipolar mania ( n = 5), mixed state bipolar ( n = 2) or those not in a current affective episode ( n = 1). Across all studies, there appears to be a detectable signal of efficacy for rTMS treatment, as most studies report that rTMS treatment reduced bipolar symptoms. Importantly, within the randomised controlled trial (RCT) study designs, most reported that rTMS was not superior to sham in the treatment of bipolar depression. However, these RCTs are based on small samples ( NBD ⩽ 52). Reported side effects of rTMS in BD include headache, dizziness and sleep problems. Ten studies ( N = 14 patients) reported cases of affective switching; however, no clear pattern of potential risk factors for affective switching emerged. Future adequately powered, sham-controlled trials are needed to establish the ideal rTMS treatment parameters to help better determine the efficacy of rTMS for the treatment of BD.

Beliefs and thoughts about traumatic memory: Testing a metacognitive intervention to reduce post-traumatic stress symptoms

Military servicemen and women face a multitude of psychological stressors when deployed (e.g. witnessing the death or serious injury of military personnel or civilians). Previous research suggests that women are more vulnerable to developing PTSD compared to their male counterparts; however, little is known about the effects of combat trauma among military servicewomen. This is an important issue, given that women are now allowed to occupy front line roles. This article firstly highlights the lack of research surrounding the mental health of servicewomen exposed to combat trauma. Secondly, it discusses the need to develop more preventative interventions for PTSD which can aid psychological resilience prior to trauma exposure (e.g. primary prevention). Lastly, the article addresses the role of metacognition as a novel approach to the primary prevention of PTSD and explores ways in which this intervention could be delivered to military personnel.