Abstract Background Child marriage/cohabitation before 18 years of age disproportionately affects girls worldwide, but its impacts on mental health are poorly understood. Existing research is mostly cross-sectional, hence unable to estimate causal impacts or longer-term outcomes of child marriage. Methods We analysed longitudinal cohort data across Ethiopia, India, Peru, and Vietnam from Young Lives to investigate the relationship between child marriage/cohabitation and life satisfaction and emotional symptoms. We used linear regression, difference-in-differences estimation (DiD), and propensity score matching (PSM) to examine short and longer-term impacts from age 19 to 29. Findings Across countries 5% (Peru) to 20% (India) of girls were child brides. Child marriage/cohabitation predicted lower life satisfaction – pooled estimates at age 19 (-0.25 [95%CI=0.40,-0.10]), across 19-29 (-0.22 [95%CI=-0.32,-0.13]), and heterogeneity estimates suggest consistently negative impacts across countries. However, child brides have lower life satisfaction at age 8 even before marriage occurs, likely due to pre-existing disadvantages such as poverty that increase child marriage likelihood. DiD and PSM analyses confirm that most of the differences are due to pre-existing vulnerability and there is a small additional impact of child marriage on worse life satisfaction at age 19 (pooled matched estimate -0.09 [95%CI=-0.19, 0.00]). No differences in emotional symptoms were observed, nor any differences by age of marriage within the child-married sample. Interpretation Child brides have lower life satisfaction from childhood through to early adulthood, which is mostly explained by prior disadvantages and risk factors, with a small additional impact of child marriage itself. Funding Wellcome Trust

AIMS:The relationship between retirement and mental health remains unclear, with mixed evidence likely driven by methodological challenges and heterogeneity across population subgroups. This study explores the relationship between retirement, time since retirement and mental health, focusing on differences between those living alone and cohabiting. METHODS:We used data from 10,698 participants (48,815 observations) in the Survey of Health, Ageing and Retirement in Europe, waves 1-8, spanning 20 countries and 16 years. Participants were included if they were employed at baseline and retired during follow-up. We applied a triangulated approach using (1) multilevel linear spline models to examine trajectories and (2) fixed-effects instrumental variable analyses (IV) using statutory retirement age as an instrument to establish causal effects. The outcome was depressive symptoms measured using the EURO-D scale (higher scores indicate more depressive symptoms). RESULTS:Multilevel spline models showed minimal change in depressive symptoms before retirement. At retirement, a small decline in EURO-D scores was indicated (-0.07 points per year [95% CI: -0.13 to -0.0003]), followed by an increase starting two years post-retirement (0.09 per year, 95% CI: 0.02 to 0.16). IV analyses showed that retirement was associated with fewer depressive symptoms (-0.26, 95% CI: -0.45 to -0.07). Individuals living alone reported higher depressive symptoms, but cohabitation status did not moderate the relationship between retirement and mental health. CONCLUSIONS:Retirement is associated with a short-term reduction in depressive symptoms, but the effect diminishes over time. While individuals living alone consistently report higher depressive symptoms, cohabitation status does not moderate the retirement-mental health relationship.

Amid worsening mental health of adolescents, the proliferation of digital technologies over the last two decades has attracted particular attention as one potential contributing factor. However, there is a widely cited lack of causal evidence and most prior studies rely on correlational designs vulnerable to reverse causation, unmeasured confounding, and measurement error, while being limited in geographic scope. We estimate the effects of screen time and social media use on adolescent wellbeing using data from 615,133 fifteen-year-olds across 54 countries, applying instrumental variable methods that exploit cross-national and temporal variation in digital environments during the rapid technological diffusion of the mid-2010s. We use year-specific country-level Information and Communication Technology (ICT) usage index and social media penetration rate as instruments generating exogenous variation in adolescents' digital engagement. Instrumental Variables analyses indicate that higher screen time and more social media use caused lower wellbeing in the mid 2010s. The findings were robust to assumption testing and robustness checks. This study contributes multinational causally informed evidence to an empirically contested but policy-relevant debate on the impacts of digital technology on adolescent wellbeing.

Background: Systematic differences exist in Special Educational Needs and Disability (SEND) provision for Social, Emotional and Mental Health (SEMH) needs - the formalised pathway for mental health support in schools - and mental health-related hospital contacts. However, equity in coordination between these school and hospital systems remains poorly understood. Examining mental health-related pathways between these systems may identify opportunities for early intervention and equitable access. Aims: Developed in partnership with peer researchers and community stakeholders, we examined whether there are systematic differences based on gender and racial-ethnic group in cross-system pathways, between SEND-for-SEMH and mental health-related hospital contacts among school-aged children in England. Methods: Population-level analysis of linked school and hospital administrative data for 1.7m children aged 5-16 years attending state schools in England (2005-2018). We examined system recording patterns, contact intensity and risk ratios for the order of SEND-for-SEMH and mental health-related hospital contacts first and subsequently. Results: Substantial variation in experiences was found across gender, racial-ethnic groups, and at the intersection. Hospital-only identification was higher among girls, with nearly all girls significantly less likely to receive school SEND-for-SEMH first or following mental health-related hospital contact compared to White British boys. Among girls with mental health-related hospital contacts who were never recorded with SEND-for-SEMH, half (49.8%) had a mental health-related in-patient admission. All pupils with Asian, Black African, White Other, Mixed Other and Other unspecified racial-ethnic backgrounds were significantly less likely to be recorded with SEND-for-SEMH following hospital contacts. Girls with White and Mixed race/ethnicity backgrounds were significantly more likely to have hospital contacts first and following SEND-for-SEMH. Conclusions: Findings reveal systematic coordination failures and intersectional discrimination in mental health pathways. Statutory integrated care pathways and mandatory equity frameworks are essential to address extensive unmet need and ensure equitable access to mental health support.

Abstract Background Various explanations have been proposed for increasing trends in diagnosed depression in the UK, including increases in the proportion of the population that experience symptoms, changes in the threshold for seeking treatment and changes in clinical recognition or coding practices. Identifying trends over time for the relationship between the experiences of psychological distress and receiving a diagnosis can help explain wider trends in the incidence of clinical depression, such as whether the threshold for seeking treatment and receiving a diagnosis of depression has changed. Aims This study aims to examine trends in the incidence of diagnosed depression, and relationships between psychological distress and recent depression diagnosis among UK adults between 2011 and 2022. We also assess whether the difference in psychological distress between adults with and without a recent depression diagnosis has changed over time and examine these relationships across subgroups (sex, ethnicity, age, cohort, education and financial stress). Methods Data were from 66,360 adults (341,764 observations) aged 16 or older from the UK Household Longitudinal Study (UKHLS) across nine fieldwork periods spanning 2011-2022. Psychological distress was reported with the GHQ-12 used as a continuous variable and as a binary variable indicating caseness. Recent depression diagnoses were self-reported. Analyses we run for the overall population and stratified by different sociodemographic characteristics. Results Incidence of diagnosed depression has not increased over time in the overall sample, but there was a notable increase in some sub-groups, most clearly seen for women aged 16 to 24. There has been a clear increase in the number of cases of psychological distress, but who have not received a recent diagnosis of depression. The level of psychological distress experienced by adults recently diagnosed with depression has slightly increased over time, whilst the difference in psychological distress experienced by adults with and without a recent depression diagnosis remained stable. Subgroup analyses show differences in the distress experienced by those with and without a recent diagnosis based on sex, age, cohort, ethnicity, education and financial situation: temporal trends were mostly similar across groups. Conclusions Stable trends in (a) the distress experienced by adults recently diagnosed with depression, and (b) the difference in psychological distress experienced by adults with a recent depression diagnosis compared to adults without suggests little support for the hypothesis that depression is being diagnosed at lower levels of psychological distress. Instead, our findings suggest there may be a growing population who are not receiving clinical support for high levels of distress.

Objective: To examine whether schools respond equitably to indicators of mental health need - absences and exclusions - across racial-ethnic group and gender, by examining rates, timing and pathways between these indicators and school Special Educational Needs and Disability (SEND) provision for Social, Emotional and Mental Health (SEMH) needs or mental health-related hospital contacts. Design: Population-level longitudinal analysis of linked administrative school and hospital records, developed in partnership with peer researchers with lived experience and community stakeholders. Setting: State-maintained schools in England, 2005-2018. Participants: 1,696,198 children aged 5-16 years born 2000-2002. Main outcome measures: Rates and timing of severe absences and exclusions. Risk ratios for pathways between indicators of need and SEND-for-SEMH and mental health-related hospital contacts. Results: School responses to the same indicators of need differed systematically based on racial-ethnic group and gender, with simultaneous over-punishment and under-recognition. Over-punishment manifested in boys from Mixed White-Black, Mixed Other, Black, Pakistani, Bangladeshi, Romani, Irish Traveller and Other racial-ethnic groups, and girls from Mixed White-Black Caribbean, Black Caribbean, and Romani backgrounds, being significantly more likely to be excluded before SEND-for-SEMH compared to White British boys. Boys from Mixed White-Black, Mixed Other, Black Caribbean, Black Other, Romani and Irish Traveller backgrounds were significantly more likely to be excluded after SEND-for-SEMH. Black Caribbean, Irish Traveller, Mixed White-Black Caribbean, and Romani pupils experienced exclusions younger. Under-recognition manifested in most girls and pupils from Asian, Black African, White Other and Other racial-ethnic groups being significantly less likely to receive SEND-for-SEMH following severe absences or exclusions. Among girls with indicators who accessed hospital services, three quarters had high-need contacts, predominantly inpatient admissions. Conclusions: Differential school responses to indicators of need based on gender and racial-ethnic group constitute intersectional discrimination, breaching the Public Sector Equality Duty. Mandatory equity-oriented frameworks, formal concern pathways and accountability mechanisms are urgently needed.

ABSTRACT Background Young people who are Not in Education, Employment, or Training (NEET) represent a major public health and societal challenge. Existing evidence has linked adolescent mental health problems and health risk behaviours to NEET but has largely treated NEET as a static, rather than longitudinal outcome and overlooked the combined effects of multiple health conditions. Methods Using data from 5,262 participants born between 1993 and 2000 in the UK Household Longitudinal Study, this study examined the independent and combined associations of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity) and health risk behaviours (regular smoking, drug use, alcohol use, and high social media use) with ever-NEET status, NEET chronicity, and NEET trajectories from ages 16 to 24, using modified Poisson, proportional odds, and multilevel logistic regression models, respectively. Findings All mental health problems were associated with ever-NEET status (RRs 1.24-1.27) and NEET chronicity (ORs 1.41-1.98); emotional symptoms showed a widening disadvantage with age, while the disadvantages associated with conduct problems and hyperactivity remained stable. Among health risk behaviours, regular smoking showed the strongest and most persistent relationships with NEET (ever-NEET RR 1.54; chronicity OR 1.64); drug use was related to ever-NEET status (RR 1.37) and an increasing disadvantage after age 21-22, while alcohol use and social media use showed limited associations. NEET risk generally increased with the number of co-occurring conditions, but for recurrent NEET (three or more occasions), risk was only elevated at three or more co-occurring conditions. Interpretation Adolescent health exposures were associated with NEET risk during ages 16-24, but the strength and pattern varied by exposure and outcome, offering potential insights into the timing and emphasis of any interventions.

BACKGROUND:Mental health problems in adolescents are increasing. Universal school-based interventions may play an important preventative role. AIMS:The aim of the Approaches for Well-being and Mental Health Literacy: Research in Education (AWARE) trial was to evaluate two universal, school-based interventions that previously yielded evidence of impact in other countries: Youth Aware of Mental Health (YAM) and The Mental Health and High School Curriculum Guide (The Guide). METHOD:AWARE was a multi-school, parallel group, cluster randomised controlled trial in English secondary schools. Schools were allocated on a 1:1:1 ratio to one of two interventions or a usual practice control group, balanced on current levels of mental health provision within schools, school location, deprivation and urbanicity. Eligible participants were pupils in schools across England in Year 9 (aged 13-14 years) at baseline. The statistician, quantitative data analyst and economist were masked. Primary outcomes were depressive symptoms measured with the Short Mood and Feelings Questionnaire for YAM and intended help-seeking, measured with the General Help Seeking Questionnaire for The Guide (both at 3-6 months). RESULTS:153 schools were randomised, including 12 166 pupils (NYAM = 4028 pupils, Nguide = 3997 pupils, Ncontrol = 4141 pupils). We found that for YAM vs control (N = 5516) there was no improvement in depressive symptoms s.m.d. = 0.02; 95% CI -0.05 to 0.10), and for The Guide vs control (N = 5409) we found increased intended help-seeking compared with the control group (s.m.d. = 0.10; 95% CI 0.02 to 0.19). A notable minority of schools were unable to deliver YAM because of challenges in implementing it. Increased depressive symptoms scores were observed in both intervention conditions, compared with control at the longer-term follow-up. CONCLUSIONS:The findings indicate that participating in The Guide is effective at improving intended help-seeking. However, due to the increases in depressive symptoms associated with each intervention at the long-term follow-up, further investigation of the potential negative impacts of these programmes is advised before further rollout in English schools.Trial registration number: ISRCTN17631228.

Abstract Background High rates of young people who are not in education, employment or training (NEET) are a major societal concern in the UK. Whilst other studies have highlighted that adolescent health can predict NEET status in young adulthood, robust and recent longitudinal evidence remains limited. Methods This study used data from the Millennium Cohort Study, a longitudinal study of people born in the UK in the early 2000s, to estimate the extent to which mental health conditions, physical health conditions and health behaviours during adolescence predict NEET status in early adulthood (median age: 23). Co-occurrence of exposures was also considered and population attributable fractions were calculated to account for differences in exposure prevalence. Results Among 8,374 young people, 12.5% were NEET at age 23; approximately two thirds were seeking work and one third were economically inactive. Estimates adjusted for demographic factors indicated that multiple health exposures increased risk of being NEET at age 23, with mental health conditions predicting greater risk than physical health conditions and health behaviours. For instance, a longstanding mental health condition more than doubled the risk of being NEET (adjusted relative risk [aRR] = 2.39, 95% CIs = 1.85, 3.09), while autism (aRR = 3.60, 95% CIs = 2.69, 4.83) and ADHD (aRR = 3.25, 95% CIs = 2.38, 4.44) more than tripled the risk. A greater number of reported adolescent mental health conditions was associated with greater risk of being NEET in young adulthood. Obesity predicted being NEET at age 23 (aRR = 1.54, 95% CIs = 1.18, 2.01) and obesity accompanied by a mental health condition further increased risk (aRR = 2.01, 95% CIs = 1.38, 2.93). Follow-up analyses indicated that associations between adolescent mental health and young adult NEET status were more pronounced for females than males and for the economically inactive than those seeking work. Conclusions Findings indicate that adolescent health, especially mental health, strongly predicts being NEET in early adulthood. Early, integrated health and education interventions may help reduce later educational and labour market disengagement.

In a purely meritocratic society educational outcomes would reflect ability, and only ability. Vocabulary size is a common measure of cognitive ability that predicts educational outcomes but is confounded with socioeconomic circumstances (SEC). Methods. In preregistered analyses of the nationally representative UK Millennium Cohort Study data (N=15,576), we used a series of multiple linear and logistic regression analyses to investigate the predictive value of age-5 vocabulary for age-16 educational outcomes and assess whether socioeconomic circumstance moderated this relation. Results. We show that age-5 vocabulary strongly predicted age-16 educational attainment, even after adjusting for both SEC and caregiver vocabulary (OR = 1.62, 95% CIs = [1.52;1.72]; ( = .22, 95% CIs = [.19;.24]). However, the weight of evidence for the effect was lower than that for the effect of SEC (i.e., SEC was found to have better predictive value. Further, a larger vocabulary was most advantageous for those in middle SEC groups (interaction term OR 1.09 [1.03; 1.15). Conclusions. This demonstrates that even children who enter school with relatively strong language skills are not that likely to gain gateway qualifications if they experience socio-economic disadvantage. Early language interventions may help children to access education but cannot by themselves be expected to counteract the effect of social inequality on life chances.

Background: Exposure to complex trauma may influence how children develop their social relationships and increase risk for social thinning: an impoverishment in objective and subjective aspects of their social functioning and environment (here termed “social architecture”). Methods: In this prospective observational study using data from the Millennium Cohort Study of 7058 children born in the United Kingdom, we used mixed-effects models to test whether complex trauma exposure measured at ages 5 and 7 (trauma N = 2024; control N = 5034) was associated with (a) impoverishment in social architecture (six preregistered outcomes) and (b) poor mental health (two preregistered outcomes) across ages 11, 14 and 17. Results: Averaging over available time-points, the trauma-exposed group reported less positive feelings about friends (COR: 0.75), lower perceived social support (COR: 0.75), lower participation in social activities (b = -0.47) and higher emotional (b = 0.34) and conduct (b = 0.44) symptoms compared with the control group. Contrary to our hypothesis, adolescents with complex trauma exposure had a greater increase in spending time with friends between ages 11-17 than the control group, yet reported reduced positive feelings about friends and social support. Conclusions: Adolescents with experience of complex trauma in childhood show a pattern of social thinning and poorer mental health. While this group of young people spent increasing time with friends, they subjectively felt more disconnected from them, highlighting the importance of capturing mechanisms underlying relationship quality to better understand the long-term impact of early interpersonal adversity on social functioning and mental health.

Background: Racial-ethnic and gender inequalities exist in England’s Special Educational Needs and Disability (SEND) system, with identification of Social, Emotional and Mental Health (SEMH) needs particularly vulnerable to bias. Systematic differences in mental health-related referrals, hospital admissions and treatment experiences also indicate potential bias in identifying need and response. Objective: Developed in partnership with peer researchers and community stakeholders, we examined intersectional differences based on racial-ethnic group and gender in school and hospital system responses to mental health needs identifying opportunities for equitable provision and access. Design: Population-level analysis of linked school and hospital administrative data for 1.7m children aged 5-16 years attending state schools in England (2005-2018). We examined rates, age distributions and timing (Kaplan-Meier Curves) of SEND-for-SEMH and mental health-related hospital contacts, including in-patient and out-patient contacts. Results: Findings confirm higher rates of SEND-for-SEMH Black Caribbean, Mixed White-Black Caribbean and Irish Traveller pupils, with schools faster to record boys from these groups, and lower rates among Asian and White Other pupils (from 16 per 1,000 Indian girls to 240 per 1,000 Black Caribbean boys). Boys access mental health-related hospital-based services earlier and more steadily across school years, primarily through out-patient appointments. Girls are consistently older when first recorded with SEND-for-SEMH, simultaneously experiencing increases in mental health-related hospital contacts, with higher rates of in-patient admissions. Conclusions: Findings indicate systematic differences in mental health-related SEND and hospital contacts emphasising the need for standardised mental health guidance and equity-oriented frameworks to address persistent simultaneous over-pathologisation and under-recognition of mental health needs.

OBJECTIVE:Adolescents' social relationships might partly explain the increased risk of mental health problems in adolescents living in poorer economic circumstances. There are few studies in low- and middle-income countries, where most of the world's adolescents live. This study investigated whether adolescents' relationships with their parents and peers mediated the association between their economic circumstances and emotional symptoms in Ethiopia, India, Peru, and Vietnam. METHOD:Longitudinal data of 3,529 adolescents from the Young Lives study (1,741 female [49.3%]) were analyzed. Household consumption expenditure and adolescents' subjective assessment of household wealth were measured at age 15. The mediators-adolescents' positive relationships with their parents and peers-were measured at age 19. The outcome-emotional symptoms, characterized by low mood and anxiety-was measured at age 22. Mediation was assessed through counterfactual g-computation formula, adjusting for baseline and intermediate confounders. RESULTS:No evidence was found that adolescents' positive relationships with their parents or peers mediated the association between economic circumstances and emotional symptoms in any country. Living in poorer economic circumstances was typically associated with more severe emotional symptoms. CONCLUSION:Adolescents' parent and peer relationships might not mediate the effects of poorer economic circumstances on emotional symptoms in these countries, contrasting with previous studies that highlight an important role of relationships in high-income countries. Further research is needed that addresses limitations of this study and to explore other potential mechanisms, including different aspects of social relationships, that might influence mental health outcomes for adolescents living in poverty across different settings. PLAIN LANGUAGE SUMMARY:Poverty can lead to worse mental health. This study explored whether this is because poverty affects adolescents' relationships with their parents and peers. Researchers analyzed longitudinal data from the Young Lives study of 3,529 adolescents from Ethiopia, India, Peru, and Vietnam from ages 15 to 22. Study measures included objective economic circumstance, subjective economic assessment, parental and peer relationships, and emotional symptoms. Results showed that better economic circumstances were associated with fewer emotional symptoms in Ethiopia, Peru, and Vietnam, but positive relationships with parents or peers did not mediate this relationship. These findings differ from studies in high-income countries, primarily from North America, which suggest that the ways poverty affects adolescents' emotional symptoms might vary across countries. STUDY REGISTRATION INFORMATION:Socio-Economic Inequality in Adolescent Mental Health: Mediating Roles of Adolescents' Relationships With Their Peers and Parents Across Four Countries; https://osf.io/sb67c/overview.

This study examines how different forms of social isolation, such as living alone, lack of community engagement, and unemployment, are associated with mental health in mid-life (ages 42–46), a life stage often overlooked when examining the impacts of social isolation. Using longitudinal data (1999–2016) from two British birth cohort studies: 1970 British Cohort Study N = 16,585 and the 1958 National Child Development Study N = 15,806, this study investigated whether different forms of isolation have independent effects, contribute to cumulative risk, or interact additively or multiplicatively. Effects varied by isolation type and mental health outcomes. Being out of employment was linked to higher psychological distress and lower life satisfaction and self-rated health, while living alone was only associated with lower life satisfaction. Limited contact with friends and relatives and a lack of community engagement were associated with lower life satisfaction and self-rated health. Greater social isolation corresponded to increased psychological distress, lower life satisfaction, and poorer self-rated health, demonstrating cumulative risk. Effects appeared additive rather than multiplicative. No consistent sex or cohort differences were observed. The study underscores the need to examine both separate and combined effects of social isolation across the complete mental health state. Isolation in its various forms was detrimental for mental health in mid-life and was most consistently linked to lower life satisfaction. Efforts to reduce isolation and its negative mental health impacts must recognise the complexity of these experiences.

Mental ill-health often emerges during adolescence, and the environments in which children grow up may shape this risk. Still, evidence is limited to single environmental exposures, urban samples, and short follow-ups. We investigated how built, social and chemical environments across childhood relate to common mental illness in adolescence, and whether associations differ by population density. Data were drawn from the Millennium Cohort Study, a nationally representative cohort born in 2000/2002 in the UK. High-resolution environmental data was linked to home addresses at birth and ages 3, 5, 7, 11, 14 and 17. Psychological distress (Kessler-6) and doctor diagnosed depression or serious anxiety were assessed at age 17. Confounder-adjusted and weighted generalized linear mixed models were fitted for single and domain-specific exposures. At age 17, ∼16% of participants had high psychological distress and ∼ 10.5% had been diagnosed with depression or anxiety (n = 7769-8374). Built and social environment from early childhood onwards (5 year: OR = 1.22 [95% CI: 1.07-1.39]; 7 year: OR = 1.16 [1.02, 1.33]; 11 year: OR = 1.15 [1.01-1.30]; 17 year: OR = 1.22 [1.05-1.39]; accumulation: OR = 1.21 [1.05-1.39])-especially lower greenness, greater distance to green space, more grey space, higher area deprivation and crime-were associated with high psychological distress, and, to a lesser extent, with diagnosis. Living close to the sea was associated with higher likelihood of common mental disorder, particular their diagnosis. Findings on air pollution were inconclusive. Associations with built and social environments were stronger in rural areas. Built and social environments in childhood and adolescence were significant correlates of adolescent common mental disorders. Future studies and interventions should consider urban/rural differences and timing of exposure.

Background: The two-child benefit cap, implemented in April 2017, restricted Universal Credit and Child Tax Credit to the first two children in households with three or more children. We evaluate the impact of the two-child benefit cap on parental mental, general, and financial health, as well as investigate how this may differ in particular sociodemographic and economic subgroups based on sex, ethnicity and income. Methods: Data was obtained from parents (youngest child aged 5 or under) in the UK Household Longitudinal Survey from 2009 to 2023. Outcomes included parental mental health (psychological distress and life satisfaction), general health (health-related quality of life (HRQoL), self-rated health and health satisfaction), and financial health (current financial situation and financial outlook). We used complementary policy evaluation methods with different strengths and assumptions to triangulate evidence and strengthen inference: interrupted time series (ITS), difference-in-differences (DiD) and controlled time series analysis (CITS). Subgroup analyses were stratified by sex, ethnicity, and income. Findings: Across methods, findings consistently indicate that the policy worsened life satisfaction, self-rated health, health satisfaction, and financial health for parents of 3+ children. Findings were less consistent across methods for psychological distress and HRQoL. For instance, for psychological distress ITS and CITS indicate adverse impacts of the policy; however, one DiD model did not support this conclusion due to greater average worsening in the control group between the pre- and post-periods. Subgroup analyses indicate greater mental health and general health impacts in lower income, male and ethnic minority parents; while financial health was negatively impacted in all subgroups examined. Conclusions: Using repeated cross-sectional panel data and triangulating across causal inference methods, we conclude that the two-child benefit cap in the UK had a measurable adverse impact on most health outcomes examined, with worse outcomes for male, lower income and ethnic minority parents. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement AP is on a PhD studentship funded by the Wellcome Trust (grant code 218497/Z/19/Z). The funders listed above had no role in the design or implementation of this study. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Data is available for download from UK Data Service following registration at the following link: https://datacatalogue.ukdataservice.ac.uk/studies/study/6614#details. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Background Religion is a central aspect of many people’s lives worldwide. While most research has concentrated on individual religiosity, less attention has been paid to the broader social and structural dimensions of religious affiliation, particularly how affiliation to minority religious groups influences mental health through experiences of discrimination, marginalisation, and unequal social, economic, and political position. Methods We conducted a systematic review across four databases from inception to December 2024 of quantitative studies on mental health outcomes among religious minorities and disparities between religious groups. Findings were synthesised narratively and with vote counting. We also mapped mechanisms linking religious minority status to mental health. Results 152 quantitative studies were included, mostly cross-sectional with small convenience samples. More than half of studies focused on one religious minority group in a country without comparison to other groups (57%), limiting our understanding of inequalities between groups. Where investigated, religious minority groups consistently demonstrated worse mental health outcomes compared to majority groups. Risk, protective, and contextual factors contributing to the mental health of religious minorities were also mapped from included studies and inform the development of a conceptual framework. Conclusions Our systematic review highlights the limited scope and quality of studies examining religious disparities in mental health. Building on the mechanisms mapped from the review, we propose a conceptual framework integrating existing evidence with broader literature to advance our understanding of religious affiliation as a social determinant of mental health.

INTRODUCTION:Psychological distress has been linked with cognitive impairment. However, whether the relationship is causal, reflects preclinical dementia neuropathology, or confounding by common causes remains unclear. METHODS:In five UK longitudinal studies, we examined associations of psychological distress with subsequent cognition using linear and mixed effects models, and dementia using logistic regression. We examined variation by age-at-assessment, severity, and distress persistence, combining study-specific estimates using two-stage individual participant data meta-analysis. RESULTS:Pooling across studies (N = 24,564), greater baseline psychological distress was associated with lower subsequent cognitive level (β = -0.03 [95% confidence interval [CI]: -0.06; -0.01]; I2 = 70%), and dementia (odd ratio [OR] = 1.1 [1.0; 1.2]; I2 = 0%), but not cognitive change. Associations were found for clinically significant, persistent and intermittent distress. Dementia was associated with distress assessed at ages 65-75, and 55-64, but not 45-54 years. DISCUSSION:Findings highlight the relevance of psychological distress in later cognitive outcomes, with potential future implications for dementia prevention and identifying high-risk groups.

BACKGROUND:Social health is increasingly recognised as an important factor influencing cognitive ageing and experiences of dementia. Yet definitions and measurements remain inconsistent, and evidence on how social health relates to cognitive outcomes remains limited. AIM AND METHODS:This narrative review presents the conceptual framework and synthesises the empirical findings from the Social Health and Reserve in the Dementia Patient Journey (SHARED) consortium, established to advance understanding of social health across the continuum from preclinical cognitive change to dementia, with a central aim to develop a comprehensive social health framework. SHARED combined conceptual framework development, global qualitative and quantitative studies, coordinated analyses across more than 40 cohorts (∼150,000 participants) and investigations of pathways underlying cognitive resilience. RESULTS:We refined the conceptualisation of social health by integrating individual capacities with features of the social environment. Qualitative interviews further identified novel and often unmeasured dimensions, informing refinement of the framework. Across multiple global cohorts, better social health was associated with higher cognitive performance, slower decline, and reduced risks of mild cognitive impairment and dementia, although associations varied across markers, domains, and contexts. Mechanistic analyses linked social health to markers of brain reserve, including total brain volume and white matter microstructure, and showed that depressive symptoms partially mediated social support-cognition associations. CONCLUSIONS:SHARED delivers a comprehensive, multidimensional framework for social health and provides strong multi-cohort evidence of its importance for cognitive ageing and dementia. Findings highlight the need for improved social health measurement and further work to disentangle its mechanisms and bidirectional links with cognitive ageing and dementia.

In a purely meritocratic society, educational outcomes would reflect ability and only ability. Vocabulary size is a common measure of cognitive ability that predicts educational outcomes but is confounded with socioeconomic circumstances (SEC). In preregistered analyses of the nationally representative UK Millennium Cohort Study data ( N  = 15,576), we used a series of multiple linear and logistic regression analyses to investigate the predictive value of age-5 vocabulary for age-16 educational outcomes and assess whether socioeconomic circumstance moderated this relation. We show that age-5 vocabulary strongly predicted age-16 educational attainment, even after adjusting for both SEC and caregiver vocabulary (OR = 1.62, 95% CIs = [1.52; 1.72]; β  = .22, 95% CIs = [0.19; 0.24]). SEC also predicts educational attainment (OR = 2.05, 95% CIs = [1.92; 2.19]), and modifies the association between vocabulary and educational attainment, whereby a larger vocabulary was most advantageous for those in middle SEC groups (interaction term OR = 1.09 [1.03; 1.15]). Early child vocabulary is a strong predictor of children's educational outcomes – even when controlling for proxy measures of the home environment and genetics. Nonetheless, children who enter school with strong vocabulary skills but disadvantaged socioeconomic circumstances still have only about a 50/50 chance of gaining gateway qualifications at age 16.