Psychotropic medication use during pregnancy is a challenging issue.

Several Mental Elf blogs have covered this topic already. For example, Joanne Wallace blogged about a large cohort study that found that antipsychotic medication use was not associated with an increased risk of major congenital malformation. More recently, Flo Martin blogged about the findings from an umbrella review that revealed the dearth of high-quality evidence in this field. There are two things worth highlighting from these blogs. First, as Martin states in her blog, the evidence base for this topic relies almost exclusively on the findings from observational studies, because pregnant women are almost always excluded from randomised controlled trials. Second, as Wallace states in her blog: “For each individual women the decision to continue or discontinue psychotropic treatment encompasses a range of factors and for some this could be the hardest decision of their lives.”

To support expectant mothers in assessing the risk-benefit balance, we need to know the potential risks and benefits of antipsychotic medication use during pregnancy. Using the National Health Information Database of South Korea, Kang et al. (2025) have conducted an impressive array of analyses to progress our understanding of this important clinical question.

Methods

The National Health Information Database in South Korea contains information from the single provider of mandatory health insurance for the entire national population. The study identified women who delivered live births at least two years after the first diagnosis of schizophrenia and were younger than 50 years of age (n = 3,026).

To control for potential confounders, particularly the severity of schizophrenia, the self-controlled case series method was used. In this simple yet elegant method, each individual acts as their own control. In this study, the incidence rate ratio (IRR) was calculated by comparing the rate of admission for psychosis six months postpartum with the rate during the period between two years before delivery and one year before delivery (the reference period).

The women were categorised into three groups:

• Non-users: those who did not use antipsychotics in the period from one year before delivery to 39 weeks before delivery (i.e. abstained from antipsychotics before becoming pregnant),
• Discontinuers: those who used antipsychotics in the period from one year to 39 weeks before delivery, but discontinued before delivery, or,
• Continuers: those who used antipsychotics in the period from one year to 39 weeks before delivery and continued taking their medication before delivery.

The authors then calculated the relative risk ratios (RRRs) for the IRRs for each group with the discounters as the reference group.

Results

Of 3,026 women with schizophrenia, most were either non-users (43.1%) or discontinuers (41.6%). Only 15.3% of women continued antipsychotic medication during pregnancy.

Overall, the IRR of admission for psychosis in the six-month postpartum period was 2.35 (95% confidence interval [CI] 1.99 to 2.78) compared to the reference period, meaning there was a significantly higher risk of admission postpartum across the whole sample. The risk was highest immediately after delivery (one to ten days after delivery, with IRR = 5.44), and it decreased over time until reaching a rate similar to the reference period at one to two years after delivery.

In terms of different medication categories, the incident rates during the reference period were highest among the continuers (144.7 per 1,000 person-years) compared to the discontinuers (118.3 per 1,000 person-years) and the non-users (29.9 per 1,000 person-years). However, the incident rates increased significantly in the six-month postpartum period for the non-users (128.5 per 1,000 person-years) and the discontinuers (277.9 per 1,000 person-years), but not for the continuers (191.3 per 1,000 person-years). The IRR of relapse was thus the highest for the non-user group (4.18, 95% CI 2.85 to 6.12), followed by the discontinuer group (IRR 2.34, 95% CI 1.87 to 2.91). The IRR was not significant for the continuer group (IRR 1.31, 95% 0.89 to 1.92). In other words, the risk of relapse was not significantly different for the continuer group either before or after delivery. Using the continuer group as the reference group, the IRR was significantly higher for the non-user group (RRR = 1.79, 95% CI 1.15 to 2.78) and significantly lower for the continuer group (RRR = 0.56, 95% CI 0.36 to 0.87).

The authors conducted seven subgroup analyses stratified by; (i) the age at delivery (younger than 34 or 34 and older), (ii) insurance premiums, (iii) mode of delivery (vaginal or Caesarean section), (iv) number of prenatal care visits (fewer than 13 or 13 and more), (v) diagnosis of schizoaffective disorder, (vi) comorbid depressive disorders and, (vii) comorbid mood disorders. Further, the study also conducted six sensitivity analyses, which are a method of testing how changes in assumptions or inputs affect the results of a statistical model. Here the tests were; (i) excluding admissions with antidepressant use, (ii) the reference period set from two to three years before delivery, (iii) excluding women admitted for psychosis within one year before delivery, (iv) restricting the analysis to women who used antipsychotic medication within the 13 weeks before delivery, (v) changing the length of the grace period for discontinuation to 14 or 60 days rather than 30 days, and (vi) excluding women who were admitted for more than seven days for a live birth delivery.

These subgroup and sensitivity analyses largely maintained the general pattern of the risk of relapse being higher for the non-user group and lower for the continuer group compared to the discontinuer group – although not all the sub-analyses demonstrated clear statistical distinctions as the primary analyses.

Finally, the authors also examined the timing of antipsychotic discontinuation over different timeframes (one year to 39 weeks before delivery, 39 to 26 weeks, 26 to 13 weeks, and 13 weeks to date of delivery). They found that the risk of relapse did not differ by the timing of antipsychotic discontinuation.

Conclusions

The authors concluded:

In women with schizophrenia, antipsychotic continuation during pregnancy was associated with a reduced risk of postpartum relapse.

Strengths and limitations

As mentioned at the beginning of this blog, the evidence base for pregnant women is built on the findings from observational studies. In the current study, the authors used several statistical methods to address the potential biases and limitations. First, the study uses the nationwide database that captures almost everyone with schizophrenia who had live births in South Korea. Second, they utilised the self-controlled case series method to control for the severity of schizophrenia among women in the dataset. Third, the authors conducted multiple subgroup and sensitivity analyses to adjust for those with comorbid bipolar disorder and depressive disorder, as well as for the use of other psychotropic medications, including antidepressants and mood stabilisers.

Despite these strengths, there are several limitations worth noting. As the study was conducted in South Korea with presumably predominantly South Korean women, the generalisability of the findings to our practice in Australia (or any other non-South Korean country) may be limited. Particularly, we wondered how much impact either comorbid substance use disorder or psychotogenic substance use would have on the decision-making process among women in South Korea compared to Australia. Moreover, as the authors acknowledge, the study was not able to examine specific types of antipsychotic medication.

While it may not be realistic to explore every unique antipsychotic type, we wondered if there may be some difference between oral and depot formulations, for example. Related to this, as with most routinely collected health data, it is important to acknowledge that medication prescription does not always equal medication consumption. Finally, the outcome examined (i.e. hospital admission for psychosis) may not be fully reflective of the benefits and risks associated with the exposure. For instance, there might have been many women whose psychotic symptoms deteriorated during the study period, but the deterioration did not lead to hospital admission for various reasons.

Implications for practice

Pregnancy can be a confusing time with multiple decisions thrust upon you with an ever-looming deadline. Some decisions can be paralysing, while other decisions can be life-changing. When as trainees, we had more than a few health professionals explicitly telling us that pregnant women are different; they are protected from mental illness by the aura of pending motherhood. Some even implicitly advised us to stop loading pregnant women with unnecessary pills. We now know that this is not true, and if anything, pregnancy is a vulnerable time for women with schizophrenia (Lefebvre et al, 2022). That said, from a clinician’s point of view, it is true that there is something different about pregnant women. Many of them are highly motivated by the impending motherhood to be the best parents that they can be. Often, this means they give up lots of things – cigarettes, alcohol and other drugs, as well as unhelpful relationships. Sometimes, the list also includes psychotropic medications.

There is often an almost knee-jerk reaction for many practitioners to advise cessation of psychotropic medications at pregnancy confirmation, with potentially significant adverse impacts on pregnant women’s mental health. It is difficult to make clinical decisions because all the existing evidence is, and will always be, based on someone else’s pregnancy and baby. You never know how your pregnancy will impact your baby. Unlike observational cohorts, you only have one baby in your study. At times, all we can do is respect the decision, monitor for as long and as closely as possible, and hope for the best for the mother and the baby. Sometimes we get through the pregnancy without a hitch. Other times, we need to make hard decisions. Wherever possible, shared decision making and close liaison with obstetric and midwifery colleagues are key. Ideally, the decisions are made with the mother, but sometimes they are made against her wishes.

Wherever possible, shared decision making and close liaison with obstetric and midwifery colleagues are key.

Pregnancy is a time in which consideration must be given to not only the pregnant woman sitting in front of you but also to her unborn baby. A prudent practitioner will also consider the postnatal period and breastfeeding considerations. In clinical practice, you tend to remember the ones that went wrong and forget about the ones that went well.

When discussing the risk-benefit balance of antipsychotic medication with pregnant women, we wonder about the availability bias that impacts our decision and the hindsight bias that influences our perception. To investigate the risks and benefits of medication use during pregnancy, routinely collected clinical data, such as the ones examined in the current study, are critical in improving our clinical practice. Some would argue that it is our ethical obligation to examine such data scientifically as doing so would result in a greater understanding and improved outcomes for mothers and their offsprings (Grzeskowiak et al. 2013). In making sense of the findings derived from such data, however, we need to be mindful of potential limitations when interpreting them.

As outlined in the limitations section above, the available data is limited to what has been collected. This means we may lose some nuances associated with many aspects of the study and relevance to the mother in front of you (e.g. study population may not capture the full spectrum of women with schizophrenia you see in your clinic, the medication exposure may not be fully reflective of how often and how much women take antipsychotic medications in real life, and the admission for psychosis may be an outcome that you want to avoid, rather than an outcome of interest).

Nevertheless, the findings from the current study give us one more piece of the puzzle to help us judge the balance. Antipsychotic medications do seem to help reduce the relapse of schizophrenia in pregnant women. The implications of a relapse of psychosis in a pregnant woman cannot be understated, with risks for poor obstetric outcomes as well the risk of harm to self and from others. Should the relapse continue in the postpartum, this can have significant impacts on the mother-baby relationship as well. It is important to remember that a well mother gives her the greatest chance to be the mother she hopes to be. While acknowledging that there is a bigger picture and we definitely need more research to put together a complete picture, here’s another piece that may be helpful in the conversation.

Statement of interests

Shuichi is on the editorial board of the British Journal of Psychiatry, where the primary paper was published. He was not involved in reviewing or editing the paper.

 

Links

Primary paper

Kang K, Yang J, Yun B et al (2025) Antipsychotic Continuation during Pregnancy and Risk of Postpartum Relapse in Women with Schizophrenia: Nationwide Register-Based Study. The British Journal of Psychiatry, 1 – 8.

https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/antipsychotic-continuation-during-pregnancy-and-risk-of-postpartum-relapse-in-women-with-schizophrenia-nationwide-registerbased-study/14FBE96D35D76307454A33AAD6F1CBF2

Other references

Grzeskowiak L, Gilbert A, Morrison J. (2013) Methodological challenges in using routinely collected health data to investigate long-term effects of medication use during pregnancy. Therapeutic Advances in Drug Safety, 4(1), 27 – 37.
https://journals.sagepub.com/doi/10.1177/2042098612470389

Lefebvre A, Pouchon A, Bioulac S, et al (2022) Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations. Expert Opinion on Pharmacotherapy, 23(11), 1337–1350. https://www.tandfonline.com/doi/full/10.1080/14656566.2022.2102421

Martin F. Psychotropic medication during pregnancy: new umbrella review finds no convincing evidence of adverse health outcomes for the baby, The Mental Elf, 18 Nov 2024.

Psychotropic medication during pregnancy: new umbrella review finds no convincing evidence of adverse health outcomes for the baby

Wallace J. Psychotropic medication in pregnancy: new evidence may help achieve a safe balance, The Mental Elf, 17 May 2016.

Psychotropic medication in pregnancy: new evidence may help achieve a safe balance

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In one of my first sessions as a therapist, a 60-year-old outpatient with body dysmorphic disorder and chronic depression said to me: “This psychotherapy is the last chance that I’ve got.”

Her desperation was devastating, and her words placed an immense weight on me. How could I possibly respond to that? Initially, my approach was to lean on established therapeutic methods—but as our sessions progressed, I began to realise that the bond we were building was just as crucial, if not more so, in helping her.

“One of the most important things we can do is create a bond with a suicidal person,” emphasized Prof. Ute Lewitzka, a German psychiatrist, on World Suicide Prevention Day 2024. While it may seem obvious that the therapeutic alliance is important to help people at risk of suicide, this topic remains understudied in research. What do therapists and suicidal patients really think about their working alliance? Is it as simple as “Be nice to patients and they will get better?” Prof. Konrad Michel (2023), author of The Suicidal Person, offers straightforward guidance: “There is a name for it. It is called good clinical practice. It is about listening to our patients and developing a working alliance toward a shared goal.”

To recap, a therapeutic alliance is understood as a collaboration on shared goals, tasks, and emotional bond, as defined in Bordin’s pantheoretical model (1979). This process variable has been shown to be one of the most significant factors in psychotherapy outcomes, as demonstrated by a meta-analysis (Wampold & Flückinger, 2023). However, recent reviews on the therapeutic alliance in suicidality by Dunster-Page et al. (2017) and Huggett et al. (2022) reveal that findings are scarce and heterogeneous. While the Importance of the Therapeutic Alliance in psychotherapy for self-harm was discussed in another Mental Elf Blog, this new study by Huggett and colleagues (2024) is the first large, qualitative study to include perspectives from both patients and therapists, filling an important research gap.

Methods

The authors systematically searched for qualitative studies and conducted a meta-ethnography to compare, contrast, and synthesize relevant findings (Huggett et al., 2024). The study was pre-registered on PROSPERO (CRD42021268273). The literature search covered articles available from the inception of the databases—MEDLINE, PsycINFO, Web of Science, Embase, and CINAHL—through April 2024. Following the Critical Appraisal Skills Programme (CASP; 2018) checklist for systematic reviews, the authors included peer-reviewed qualitative studies focused on “client and/or therapist perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences.” The quality of eligible studies was ensured by an adaption of CASP for qualitative evidence synthesis (Long, French, & Brooks, 2020). Data extraction and synthesis were performed according to a revised approach to the seven phases of meta-ethnography by Noblit and Hare (1988).

Results

After screening 3,654 titles, 37 out of 82 papers were evaluated as eligible and included in the systematic review and synthesis. The studies were conducted worldwide, primarily in Europe (n = 21). Overall, 22 articles reported only the therapists’ perspective, 11 articles reported only the client’s perspective, and four articles included both perspectives. The conducted data analysis strategies were Thematic Analysis, Interpretative Phenomenological Analysis, and Grounded Theory.

The translation and synthesis of the studies revealed two main themes: “Working on the Edge” and “Being Ready, Willing, and Able to Build an Alliance in the Context of Suicidal Experiences,” each with two subthemes, which will be summarised as follows:

Working on the edge

The first main theme, “Working on the Edge,” refers to a quote by a therapist who used the metaphor of standing on a cliff edge to describe the therapeutic alliance with suicidal patients, emphasising the “high-risk, life-or-death nature” of the collaboration (see Huggett et al., 2024; Therapist: Fogarty, Houghton, Galavan, & O’Súilleabháin, 2021, p. 12). This theme comprises two subthemes. Some of the key points are:

Sense of responsibility and control over a client’s life, e.g.

• Internal tension between the client’s free will and the therapist’s responsibility
• A sense of purpose and ‘heroism’ vs. lack of control in this “life-death situation”

Balancing empathy for ‘suicide wish’ and holding hope, e.g.

• Inner conflict to navigate the tension between empathising with the client’s suicidal feelings and fostering a shared sense of hope
• Importance of showing understanding for ambivalence of wish to live and wish to die

Being ready, willing, and able to build an alliance in the context of suicidal experiences

The second main theme had two subthemes of ‘human connection’ and ‘reciprocal trust’ to describe the quality of the therapeutic relationship. Key points included:

Human connection, e.g.

• Strong, emotionally invested connection with suicidal clients
• Therapists’ self-disclosure accompanied by feelings of vulnerability

Reciprocal trust, e.g.

• Trust needs time to be built up on both sides
• Negative previous experiences with reactions to suicidality need to be addressed

To synthesise the results, the dynamic of the client-therapist relationship was conceptualised within a complex model, which can be accessed here and in the paper by Huggett and colleagues (2024; p.8). This model provides an overview of the processes underlying relationship building, ranging from suicide-specific micro-processes to systemic macro-processes that influence the therapeutic alliance.

A key finding is that validating the emotional pain of the client—rather than solely focusing on their resources—is a crucial driving factor in establishing and maintaining the alliance.

Conclusions

This is a very insightful and thought-provoking article that is the first one to synthesise the qualitative literature on the dynamics between therapists and patients at risk of suicide. The authors concluded:

Therapeutic alliance in the context of suicidal experiences is unique, fluid, potentially lifesaving, and influenced by multiple inter-connected internal and external processes and systems.

Huggett’s model (2024) not only enhances our understanding of the therapeutic alliance but also serves as a valuable tool for clinicians in tailoring their approach to better support clients at risk of suicide.

Strengths and limitations

The study’s strengths and limitations, as informed by the CASP criteria for synthesising qualitative evidence (Long, French, & Brooks, 2020) are discussed below:

a. Are the results of the study valid?

The review addresses a focused research question using an appropriate range of sources. While the data quality was rated as good to excellent, challenges in the revision process and limitations were openly described. There has been an ongoing discussion about the value of qualitative methods in suicidology (e.g., White, 2016; Kabir, Wayland & Maple, 2023) and whether they offer scientific rigour beyond “hypothesis generation” (Joiner, 2011, p. 471). However, qualitative methods can contribute valuable insights into lived experiences and underlying processes.

b. What are the results?

Huggett and colleagues aimed to develop a qualitative, conceptual model of the therapeutic alliance in psychotherapy with suicidal patients, incorporating both therapist and client perspectives. The findings offer detailed insights into therapist-patient dynamics but remain limited by their qualitative nature.

c. Will the results help locally?

In clinical practice, the results may be transferred to the local population with careful consideration. A strength of the review is the international scope of the collected studies. Despite the detailed description of the dynamics between therapist and patient, these findings cannot be generalised due to their qualitative nature and the lack of demographic data in the studies. Instead, they provide an outlook for further research that needs to investigate these proposed topics in more detail.

Implications for practice

Forming a therapeutic alliance with suicidal clients is essential for suicide prevention and could be enhanced through targeted training for therapists in “suicide-specific alliance techniques”, in addition to the joint development of safety plans (Nuij et al., 2021). Moreover, the risk of therapist burnout should be kept in mind, especially for those primarily working with suicidal individuals. Effective communication and thoughtful language are crucial in assessing suicide risk, as they help maintain trust and prevent rigidity that could jeopardise the therapeutic relationship.

The authors concluded: “Clinical implications emphasise the need to improve training, supervision, and support for therapists to equip them with the additional skills required in navigating the intricacies of the therapeutic alliance with clients who have suicidal experiences.” Huggett and her co-authors (2024) further highlighted that “the nuances of the therapeutic alliance with suicidal clients are currently absent from guidelines.” They therefore advocate for the inclusion of both client and therapist perspectives in clinical guidelines, as well as a “multi-disciplinary team approach to suicide prevention.”

Future research should explore how these processes can be further operationalised in therapeutic settings to improve outcomes for clients facing suicidal thoughts and behaviours. For instance, micro-processes such as active listening and empathetic responses, alongside macro-processes like social support systems, play critical roles in fostering a strong therapeutic alliance. Additionally, it is important to report both sex and ethnicity, as their omission in previous studies has been criticised by the authors.

Looking back at the experience with my patient, I recognise both identified themes in working with her. I have learnt that it is important to be transparent and empathetic with a suicidal patient. To let them take responsibility for their own lives, but to do the best I can to offer support and create a bond. Also to reflect on the process with an advisor and prioritise self-care. Similar to the first author’s insights, I believe that many mental health professionals will find aspects of their own experiences reflected in this article.

Statement of interests

Laura knows one of the authors (CH). She has written an article on the therapeutic alliance and suicidal ideation.

Links

Primary paper

Huggett, C., Peters, S., Gooding, P., Berry, N., & Pratt, D. (2024). A systematic review and meta-ethnography of client and therapist perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences. Clinical Psychology Review, 102469. https://doi.org/10.1016/j.cpr.2024.102469

Other references

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research & practice, 16(3), 252. https://psycnet.apa.org/doi/10.1037/h0085885

Critical Appraisal Skills Programme. (2018). CASP Cohort Study Checklist. Retrieved by the authors on March 29, 2023, from https://casp-uk.net/casp-tools- checklists/.

Dunster-Page, C., Haddock, G., Wainwright, L., & Berry, K. (2017). The relationship between therapeutic alliance and patient’s suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review. Journal of Affective Disorders, 223, 165–174. https://doi.org/10.1016/j.jad.2017.07.040

Fogarty, B., Houghton, S., Galavan, E., & O’Súilleabh´ ain, P. S. (2021). Clinicians’  experience of collaboration in the treatment of suicidal clients within the collaborative assessment and Management of Suicidality Framework. Omega Journal of Death and Dying. https://doi.org/10.1177/00302228211020579, 302228211020579. Advance online publication.

Huggett, C., Gooding, P., Haddock, G., Quigley, J., & Pratt, D. (2022). The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clinical Psychology & Psychotherapy, 29(4), 1203–1235. https://doi.org/10.1002/cpp.2726

Joiner, T. (2011). Editorial: Scientific rigor as the guiding heuristic for SLTB’s editorial stance. Suicide and Life Threatening Behavior, 41(5), 471–473. https://doi.org/10.1111/j.1943-278X.2011.00056.x

Kabir, H., Wayland, S., & Maple, M. (2023). Qualitative research in suicidology: a systematic review of the literature of low-and middle-income countries. BMC Public Health, 23(1), 918. https://doi.org/10.1186/s12889-023-15767-9

Long, H. A., French, D. P., & Brooks, J. M. (2020). Optimising the value of the critical  appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence  synthesis. Research Methods in Medicine & Health Sciences, 1(1), 31–42. https://doi.org/10.1177/2632084320947559

Michel, K. (2023). The suicidal person: a new look at a human phenomenon. Columbia University Press.

Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Synthesizing qualitative studies. Sage Publications.

Nuij, C., van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A. & Riper, H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis. The British Journal of Psychiatry, 219(2), 419-426. https://doi.org/10.1192/bjp.2021.50

Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World psychiatry, 22(1), 25–41. https://doi.org/10.1002/wps.21035

White, J. (2016). Qualitative Evidence in Suicide Ideation, Attempts, and Suicide Prevention. In: Olson, K., Young, R., Schultz, I. (eds) Handbook of Qualitative Health Research for Evidence-Based Practice. Handbooks in Health, Work, and Disability, vol 4. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2920-7_20

Photo credits

Mental health professionals often work with people who have been traumatised in some way, either through being direct victims of abuse, violence, serious injury and threats of death, or by witnessing these events. Listening to patients sharing these stories can put the professional at risk of themselves experiencing what is known as ‘secondary traumatic stress’. Is this more likely to happen if the professional also has a history of trauma?

Terms used in this field can be confusing:

• Secondary traumatic stress is an acute reaction with symptoms rather like post-traumatic stress disorder (PTSD) and experienced when professionals get psychologically overwhelmed in their desire to support others (Orru et al, 2021)
• Vicarious trauma refers to the way our view of the world is altered when working with traumatised people over time. We struggle to continue to care, show empathy and understanding (Pearlman and Mac Ian, 1995)
• Compassion fatigue is a combination of secondary traumatic stress and burnout, leaving the professional mentally and physically exhausted (Figley, 1999)
• Burnout is the result of chronic stress in the workplace rather than working with traumatised patients (Edu-Valsania et al, 2022).

This review sets out both to identify the prevalence of a personal trauma history and secondary traumatic stress in mental health professionals and to examine whether there is an association between them.

Methods

The databases Medline, Embase, Web of Science and CINHAL were searched up to 17^th August 2023.

Inclusion Criteria:

• Articles that assessed personal trauma OR secondary trauma (which included secondary traumatic stress, vicarious trauma or compassion fatigue)

AND one or both of the following:

• The correlation between trauma history and secondary trauma (any of 3 as above).
• The prevalence of either personal trauma history and/or secondary trauma (any of 3 as above).

Plus

• The sample consisted of mental health professionals including those who had experienced their own trauma (and students on placement).
• Utilised valid measures to assess prevalence.

Studies reporting on burnout only were excluded. Data on the prevalence and association between personal trauma history and secondary trauma were extracted independently by two reviewers. Risk of Bias was assessed using an adapted version of the Newcastle-Ottawa Scale (Wells et al, 2013). Due to study heterogeneity a meta-analysis was not possible.

Results

Search results

Out of the 4,779 studies located in searches, 23 studies were finally included, all of which were cross-sectional, i.e. collecting data at one time point only.

Study quality

Overall, a majority of the studies were described as of ‘fair’ quality, with only 5/23 scoring more than 6 on the 8 point modified Newcastle-Ottawa Scale. The sample size was judged as satisfactory in only 4 studies.

Measuring personal trauma history

There was considerable variation in how the studies asked about life experience of trauma. Two extraordinarily only included a yes/no option. Some asked if the participant had ever had a diagnosis of PTSD, some used a simple rating of personal history of trauma (0-10 with ‘0’ for no trauma to ‘10’ for extreme personal trauma history). Others asked much more detailed questions or utilised tools that authors had either developed themselves or adapted from others.

Measuring secondary trauma

The term ‘secondary traumatic stress’ was used in 11 studies, ‘compassion fatigue’ in 5 and ‘vicarious trauma’ in 3 studies. One used PTSD and 2 separated secondary traumatic stress and vicarious trauma. A variety of different measures were used, but different versions or subscales of the Professional-Quality of Life Scale (Pro-QOL) (original: Linley and Joseph, 2007) were typically employed.

Prevalence of personal trauma history

For the 19 studies that reported on personal trauma history, 13 used percentages to present their findings – ranging from 21.2% to 83.3%. So, between a fifth and over four-fifths of mental health professionals had experienced a history of personal trauma. The authors note this is significantly higher than the reported findings for the general population in the 3 main study locations (United States of America, Australia and United Kingdom).

Prevalence of secondary traumatic stress

17 studies reported significant levels of secondary traumatic stress. For the 6 that reported this in percentages, this ranged from 19-70%, between a fifth and over two thirds of mental health professionals reported experiencing secondary traumatic stress.

Association between secondary traumatic stress and trauma history

Fourteen of the studies found a positive association between secondary traumatic stress and a mental health professional’s experience of their own trauma history, 4 found no association and 5 did not report on this.

Conclusions

The authors concluded that:

both personal trauma history and secondary traumatic stress are common in mental health professionals,

and

personal trauma history is associated with post-traumatic stress.

They believe this finding is important for those involved in training, supervision and management of mental health professionals, as presence of a trauma history can put workers at higher risk of developing traumatic stress.

Strengths and limitations

There has been only one previous systematic review of this topic. Leung and colleagues (2022) used different inclusion criteria, (including burnout) and a very broad definition of ‘mental health professionals’ including volunteers and even non-clinical workers. A single reviewer carried out assessments of suitability for inclusion and there was no quality assessment of included studies.

The present authors have vastly improved on this by defining the terms to describe ‘post-traumatic stress’, excluding burnout, and including studies focussed on clinical mental health professionals. Instead of a single reviewer, two reviewers assessed studies independently and a third was involved when they were unable to reach an agreement. Study quality was also assessed.

However, the authors themselves comment they only included studies written in English, and participant ethnicity was not recorded in many of the studies, limiting the generalisability of the findings. Reported correlations were small and many studies were likely underpowered. Those experiencing a personal trauma history and/or secondary traumatic stress were perhaps more likely to participate in such research, and all of the papers were of cross-sectional design, meaning this would have excluded those who left the workplace after developing secondary traumatic stress.

Given the considerable variation between the studies included in terms of sample size, typology of professionals included, setting in which they worked, and measures employed for assessing trauma history and secondary traumatic stress (asking a yes/no question about having either of these experiences is really insufficient). The decision to publish as a narrative review is quite understandable. However, I do wonder if the authors might have considered, after their initial scoping review, to narrow their inclusion criteria further to include only higher quality studies? The wide variation in the reported percentages of personal trauma history (in those 13 papers that included percentages) also makes the reported comparison with national data highly unreliable.

Implications for practice

I agree with the authors that “there is a common acknowledgement in the workplace that those attracted to a career in this field of mental health are often those of some knowledge and experience of difficult life events.” This is true not only for me, but for many others I have known, yet it is rarely, if ever, acknowledged in our training. Quite the opposite, we have until recently been discouraged from and stigmatised for admitting we might need support or are actually seeking it.

As this review does demonstrate clearly through the breadth of its scope, the overall quality of research carried out in this area has been limited. We need prospective studies, not only to discern the strength of the association between personal trauma history and secondary traumatic stress, but also to explore when those with such a history are most at risk of developing it in their careers, and how to distinguish this from burnout, although this may co-exist. What makes us vulnerable and what can we do to prevent it? What part do gender and ethnicity play?

To be able to carry out such research requires much more widespread acknowledgement of the issue by those who train, supervise and manage mental health professionals. We need to teach about it and provide specialist supervision for those at risk of it. This is important for understanding not only how to retain our professional staff in mental health services, but improving the experience and outcomes of patients and service users. We continue to struggle in mental health services with not only unkind and unprofessional behaviour from mental health professionals, but sometimes frankly abusive actions. I can fully understand how service users and patients might believe that a focus on secondary traumatic stress experienced by professionals might be misplaced, when set against the potentially retraumatising impact of some mental health care (Hennessy et al, 2022), but a greater understanding could benefit not only professional wellbeing, but ultimately patients and service users too.

Statement of interests

I have no competing interests.

Links

Primary paper

Anita Henderson, Tom Jewell, Xia Huang, Alan Simpson. (2024) Personal trauma history and secondary traumatic stress in mental health professionals: A systematic review. (PDF) Journal of Psychiatric and Mental Health Nursing. 2024 Jun 30.

Other references

Edú-Valsania S, Laguía A, Moriano JA. (2022) Burnout: A review of theory and measurement. (PDF) International Journal of Environmental Research and Public Health. 2022 Feb 4;19(3):1780.

Figley, C. R. (1999) Compassion fatigue: Towards a new understanding of the costs of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, & educators (2nd ed., pp. 3–28). Lutherville, MD: Sidran Press.

Hennessy B, Hunter A, Grealish A. (2022) A qualitative synthesis of patients’ experiences of re‐traumatization in acute mental health inpatient settings. (PDF) Journal of Psychiatric and Mental Health Nursing. 2023 Jun;30(3):398-434.

Leung T, Schmidt F, Mushquash C. A personal history of trauma and experience of secondary traumatic stress, vicarious trauma, and burnout in mental health workers: A systematic literature review. [PubMed Abstract] Psychological trauma: theory, research, practice, and policy 2022 15, 213-221

Linley PA, Joseph S. (2007) Therapy work and therapists’ positive and negative well–being. Journal of Social and Clinical Psychology. 2007 Mar;26(3):385-403.

Orrù G, Marzetti F, Conversano C. et al (2021) Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak. International Journal of Environmental research and public health. (PDF) 2021 Jan18(1) 337

Pearlman LA, Mac Ian PS. (1995) Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. (PDF) Professional Psychology: Research and practice. 1995 Dec;26(6):558.

Wells G, Shea B, O’Connell S. et al (2013) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Cochrane. http://www.ohri.ca/programs/clinical_epidemiology/oxford.as

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The approval of the first hormonal contraceptive (HC) in 1960 was a historical turning point for women, offering unprecedented autonomy over reproductive choices and greater control over the trajectories of their lives. As such, access to contraception is now recognised as an international human right (World Health Organisation, 2014).

An estimated 40% of reproductive-aged women use hormonal contraceptive (HCs) (Kristensen, 2021), but discontinuation is common due to perceived psychological side effects (Martell, 2023). Despite this, epidemiological research assessing the link between HCs and mood changes or depression has yielded mixed results. Some studies report a protective influence of HCs on mood in specific populations, e.g., those with premenopausal dysphoric disorder (PMDD) (Robakis, 2019), while other studies have reported a negative association or null findings for HCs and depressive symptoms (Skovlund, 2016; Worly, 2018). These inconsistencies may be explained by between-study variation; more research is needed to understand this relationship, accounting for nuances regarding the influence of different exogenous hormone formulations and deliveries (e.g., long-acting versus oral methods), and in different populations.

This blog entry reviews findings from a recent Danish study (Larsen et al, 2024) which estimated the risk of depression in new users of three different doses of the levonorgestrel-releasing intrauterine system (LNG-IUS). This work is necessary not only to provide informed counselling to users but also to support equitable access to contraception by addressing barriers related to concern regarding side effects.

Methods

This was a prospective study using data from the Danish national health registry. The study sample included women residing in Denmark who:

• Were born in 1978 or later,
• Started using an LNG-IUS between the ages of 15 and 44, and
• Had no previous mental health disorder.

Incident depression was determined using diagnostic records or prescription of antidepressants within 12 months of LNG-IUS insertion. Risk of depression was calculated using Cox regression, adjusted for other known and measured confounders (i.e., age, education, family history of mental health disorder, postpartum IUS use and medical disorders for which a high-dose IUS is indicated).

Results

The analysis included 149,200 new users of the LNG-IUS; 14.8%, 32% and 53.3% of whom used a low, medium and high dose device, respectively. High-dose IUS users were more likely to be older, to have had children, and to have been diagnosed with a medical indication for an LNG-IUS (e.g., heavy menstrual bleeding, dysmenorrhoea, endometriosis or uterine fibroids).

The total number of depression cases, based on both diagnoses and antidepressant prescriptions, was 2,258. After 12 months, the percentage of low, medium and high dose LNG-IUS users with depression was 1.21%, 1.46%, and 1.84%, respectively.  This translates to 0.26% more of the medium dose group having depression compared to the low dose group, and 0.63% more in the high compared to low dose group; relatively modest differences in risk.

Cases of depression were predominantly identified through antidepressant prescriptions (n=2,110), whereas 366 women had received a formal diagnosis. To overcome potential bias from including women who received antidepressants for conditions other than depression (e.g., anxiety disorders, chronic pain conditions, premenstrual dysphoric disorder [PMDD]), the analysis was rerun with those for which depression was specified as the indication (n=1,198). In this case, the absolute risks were 0.59% (low dose), 0.70% (medium dose), and 1.02% (high dose).

The risk differences between low–medium and low–high doses were small; however, a dose–response pattern (i.e., increasingly higher risk with a higher levonorgestrel dose) was evident regardless of the method used to identify depression cases.

The elevated risk of depression in the high- compared to the low-dose LNG-IUS group persisted following a series of robustness checks. For example, the authors conducted separate analyses with the following parameters: nulliparous women (i.e., with no birth history); women under the age of 30; and those who initiated an LNG-IUS after 2017 (to overcome bias from variable prescription patterns over time). Using propensity score weighting, an analysis technique that aims to mimic randomisation of baseline characteristics within the study sample, the authors again found a dose–response relationship between levonorgestrel dose and depression risk.

Another analysis using only those with a prior mental health disorder diagnosis (48,937 women) reported risks for low, medium and high dose LNG-IUS to be 4.80%, 5.22% and 5.91%, respectively. In this analysis, the difference in the proportion of high compared to low dose LNG-IUS users who developed depression (1.11%) is larger than in the group with no prior mental health diagnosis, suggesting that this group may be slightly more sensitive to the increased LNG dose.

Conclusions

The authors concluded that their study:

provides evidence of a dose-dependent association between LNG exposure and risk of subsequent depression across three dosages, which was consistent after considering potential confounders, such as menstrual bleeding indications for high-dose LNG-IUS use.

A range of additional robustness checks were conducted to overcome sources of bias, and this dose-dependent relationship persisted regardless of the analysis parameters. However, it must be acknowledged that the risk differences (0.27 to 0.66%) were modest between low and medium to high LNG doses, respectively, and that this small increased risk of depression must be considered alongside other potential beneficial effects. Clinicians should be mindful that higher LNG-IUS doses may marginally increase the risk of depression, but the choice of LNG dose should ultimately be holistically informed, accounting for comorbid conditions and patient preferences.

Strengths and limitations

Nordic countries are renowned for their excellent contributions to epidemiological research due to their population-based registries that provide routinely collected, virtually complete prospective data (Laugesen et al. 2021). This Danish study is an example of such, benefitting from a large sample size spanning the extent of the national population, and consequently, has a high level of statistical power leading to precise estimates and a vastly reduced chance of selection bias. Furthermore, such registries have a high positive predictive value for depression (individuals flagged as having depression are more likely to be accurately identified—there are fewer “false positives”).

The study also did well to address confounding by gynaecological conditions that are often treated with high-dose LNG-IUS, postpartum initiation, and history of mental health disorders. Potential sources of bias were addressed through conducting a series of sensitivity analyses, each of which maintained a dose-dependent pattern for depression risk by increasing levonorgestrel dose.

However, some limitations must be noted. As suggested by Soares (2024) in an editorial response, the exclusion of non-LNG-IUS users means that the absolute risks of depression are not given in context of the general population. The annual incidence rate of depression in Danish women is approximately 1.3% (Musliner et al. 2019); therefore, low to medium dose LNG-IUS users may not incur a meaningfully higher risk than would be expected in general. This is an important consideration when interpreting results.

It is possible that this study underestimated the true risk of incident depression, as depression diagnoses were taken from the Psychiatric Central Register but were unavailable for primary care. There may be a subset of patients with milder depressive symptoms who may have received counselling focused on lifestyle changes rather than medical intervention. Furthermore, mild unfavourable reactions to previous hormonal contraceptives were unknown; it is possible that women were switched to LNG-IUS who have an existing sensitivity to exogenous hormones.

Lastly, while differences between the three dosing groups were adjusted for in analyses, there remains a chance that other unknown or unmeasured factors may have influenced results.

Implications for practice

Contraceptive counselling is not always straightforward. Medical professionals must weigh up the risks and benefits of a range of hormonal or non-hormonal options, all while considering the unique needs of each individual in terms of their medical history, lifestyle, previous contraceptive experiences, and their personal preferences. The complex relationship between hormonal contraceptives and mental health is not well understood, with mixed findings for protective effects, increased risks or null findings for different contraceptives and depression.

Larsen et al. (2024) provide novel evidence for an increasing risk of incident depression as the dose of LNG-IUS increases. Considering the dose–response pattern and the complementary preclinical evidence for the effects of levonorgestrel on relevant mechanistic pathways in the central and peripheral nervous systems, it is plausible that levonorgestrel does modestly increase depression risk. However, given the observational nature of this study, causal relationships cannot be established.

It is also noteworthy that the absolute depression risk was only marginally higher than that expected in the general population. For high-dose LNG-IUS, approximately one in every 152 women may develop clinical depression within 12 months following initiation, compared to low dose or the general population. This could be considered a small risk overall.

At the same time, it is important for healthcare providers to be aware of this small risk. It has been thought that the LNG-IUS acts only within the intrauterine environment and that it has little influence on widespread physiological processes, for example, within the central nervous system. The dose–dependent pattern identified in this research suggests that exogenous hormones from the LNG-IUS may indeed influence depression risk, perhaps explained by influence of neuroendocrine pathways, such as potentiation of hypothalamic-pituitary-adrenal (HPA) axis reactivity (Aleknaviciute et al. 2017). Healthcare providers should validate patient’s concerns regarding anticipated effects of the LNG-IUS on mental health outcomes and consider monitoring for symptoms, especially in those with a psychiatric history or prior sensitivity to other hormonal contraceptives.

Furthermore, this study captured depression diagnoses or antidepressant prescriptions, which likely represents women with more severe depressive symptoms; yet it is possible that women may experience milder symptoms that still have an impact on their quality of life. Therefore, the relatively small risk of depression estimated by this study should not be used to dismiss patients’ concerns. Future research is warranted to explore LNG-IUS influences on a wider range of mental health symptoms and at different severities.

Statement of interests

I currently supervise a DPhil student who is studying the influence of postpartum LNG-IUS on breastfeeding rates.

Links

Primary paper

Larsen SV, Mikkelsen AP, Ozenne B, et al. Association Between Intrauterine System Hormone Dosage and Depression Risk. American Journal of Psychiatry 2024; 181(9) 834–841. https://psychiatryonline.org/doi/full/10.1176/appi.ajp.20230909.

Other references

World Health Organisation (WHO). Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations. 2014. Geneva Switzerland Department of Reproductive Health and Research.
https://iris.who.int/bitstream/handle/10665/102539/9789241506748_eng.pdf;sequence=1

Kristensen SI, Lidegaard Ø. Hormonal contraceptive use in Denmark 2010-2019. Dan Med J. 2021; 68(6).
https://content.ugeskriftet.dk/sites/default/files/scientific_article_files/2021-05/a08200599_web.pdf

Martell S, Marini C, Kondas CA et al. Psychological side effects of hormonal contraception: a disconnect between patients and providers. Contracept Reprod Med. 2023; 8(9). https://doi.org/10.1186/s40834-022-00204-w

Robakis T, Williams KE, Nutkiewicz L. et al. Hormonal Contraceptives and Mood: Review of the Literature and Implications for Future Research. Curr Psychiatry Rep 2019;21(57). https://doi.org/10.1007/s11920-019-1034-z

Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception with Depression. JAMA Psychiatry. 2016;73(11):1154–1162. doi:10.1001/jamapsychiatry.2016.2387

Worly BL, Gur TL, Schaffir J.  The relationship between progestin hormonal contraception and depression: a systematic review. Contraception. 2018;97(6):478–489.
https://www.sciencedirect.com/science/article/pii/S0010782418300325?casa_token=wS982ncxPCUAAAAA:y-UQcrwyQHRkj81OYeLNcHr-B8581rp58G5XERqbb1kWrxwB9_1_MorHaUAxt0As_N7kO4byprA#ab0005

Laugesen K, Ludvigsson JF, Schmidt M, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021;13:533–554. https://pmc.ncbi.nlm.nih.gov/articles/PMC8302231/#:~:text=The%20Nordic%20registries%20provide%20population,up%20and%20exact%20censoring%20information.

Soares CN. Contraception, Intrauterine Systems, and Depression: Can We Spot the Real Perpetrator? Am J of Psych. 2024; 181(9):789–92. https://psychiatryonline.org/doi/full/10.1176/appi.ajp.20240647.

Musliner KL, Liu X, Gasse C, et al. Incidence of medically treated depression in Denmark among individuals 15–44 years old: a comprehensive overview based on population registers. Acta Psychiatr Scand. 2019; 139:548–557. https://pubmed.ncbi.nlm.nih.gov/30908590/

Aleknaviciute J, Tulen JHM, De Rijke YB, et al; The levonorgestrel-releasing intrauterine device potentiates stress reactivity. Psychoneuroendocrinology 2017; 80:39–45.
https://europepmc.org/article/med/28315609

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Around 8-12% of the general population experiences multiple childhood adversities, including abuse or neglect, typically within the caregiving environment. These early-life traumas often lead to chronic, recurrent depressive episodes that ‘resist’ traditional treatments, deeply impacting one’s sense of safety and ability to form relationships (Rokita et al., 2018).

The empirical literature has been inconclusive about which therapeutic intervention works best for this clinical population, particularly regarding long-term treatments (e.g. Fonagy et al., 2015; Leuzinger et al., 2019). While some evidence suggests that patients with family-related trauma respond better to psychodynamic approaches compared to solution-focused therapy, more research is needed.

The large trial of long-term psychotherapies for chronic depression, known as the LAC Study (Krakau et al., 2024), investigated whether psychoanalytic therapy (PAT) might be more effective than cognitive-behavioural therapy (CBT) for chronic depression patients with a history of trauma. Each intervention focused on different elements; PAT aims to understand symptoms within disrupted developmental processes, addressing unconscious conflicts within the therapeutic relationship itself, while CBT targets cognitive dysfunctions and irrational beliefs resulting from past trauma, focusing on symptom management through specific skills and techniques. Both interventions aim to promote long-lasting changes to depressive symptoms in the ‘here and now’ that may stem from childhood adversities.

The authors of this study hypothesised that PAT’s specific treatment focus on addressing early disruptions through exploring life narratives and past experiences and its longer duration might be particularly beneficial for this group compared to CBT.

Methods

The Outcomes of Long-term Psychotherapies of Chronically Depressed Patients (LAC) study was a multicentre, controlled, single-blind 4-arm trial, with separate sections for randomised participants and those who were assigned according to preference of which psychotherapy modality they wished to receive. The study was conducted across 4 study centers in Germany (Frankfurt, Mainz, Berlin and Hamburg) and examined 252 participants aged 21-60 with chronic depression. Outcome measures included yearly assessments of depressive symptoms over five years using the Beck Depression Inventory-II and Quick Inventory of Depressive Symptomatology Clinician Rating for assessment. Childhood trauma was measured using the Childhood Trauma Questionnaire (CTQ).

Psychoanalytic Therapy (PAT)

PAT focused on addressing embodied memories and early trauma, working through unconscious conflicts within the therapeutic relationship. The approach recognises how childhood trauma affects safety and trust, using transference to facilitate healing.

Cognitive-Behavioural Therapy (CBT)

CBT followed an established protocol with five key modules, including behavioural activation, cognitive restructuring, and social skill training. The approach targeted threat-related processing and emotional reactivity in the context of trauma.

Participants could either choose their treatment or be randomised to either therapeutic modality, so this was not a standard randomised controlled trial, but rather a partially randomised patient preference trial. Treatment length varied significantly, with CBT comprising up to 80 sessions and PAT extending to 300 sessions under insurance coverage. Both treatments demonstrated strong adherence to their respective therapeutic approaches.

Results

From an initial cohort of 554 participants who underwent diagnostic interviews, 252 were included in the intention-to-treat sample and 210 participants were included in the final analysis with exclusions made due to missing data. Linear mixed-effects models were used to analyse the interaction between therapy type, childhood trauma, and time on depressive symptom changes. The analysis accounted for baseline depression severity and therapy dose.

The study revealed patterns in the types of early traumatic experiences among participants. Emotional neglect emerged as the most prevalent form of childhood trauma, affecting 53.6% of participants, followed by emotional abuse at 42.5%. Physical neglect was reported by 31.7%, while sexual abuse and physical abuse were experienced by 24.6% and 15.5% of participants, respectively.

Both CBT and PAT demonstrated significant reductions in depressive symptoms over time. The treatment length varied markedly between approaches, with median session numbers at 242 for PAT compared to CBT’s 59. The analysis revealed that while both treatments showed similar effectiveness for patients with lower trauma levels, PAT demonstrated superior outcomes for those with higher levels of childhood trauma, which was demonstrated by a significant three-way interaction between time, treatment type and CTQ (Childhood Trauma Questionnaire) levels on changes in depressive symptoms (p = 0.016).  Furthermore, within the PAT treatment group, participants with higher trauma levels showed more substantial improvement over time, suggesting that PAT’s approach may be especially beneficial for individuals whose depression is rooted in significant childhood adversity. Analysing the subscales of the CTQ separately, a significant interaction was found for the sexual abuse (p = 0.016) and family inconsistency (p = 0.019) subscales of the CTQ. A trend for the models testing physical abuse (p = 0.080) and physical neglect (p = 0.053) was observed, but neither reached significance.

These results suggest that PAT (psychoanalytic therapy) may be more helpful to patients who have experienced specific types of trauma in their childhoods.

The research faced substantial participant drop out over its five-year course, with missing data ranging from 26.58% in year one to 52.38% by year four. Sensitivity analyses largely confirmed the main findings, particularly regarding the overall trauma score. At the five-year mark, 17 PAT participants and one CBT participant were still receiving treatment, reflecting the longer-term nature of psychoanalytic therapy.

Conclusions

This study provides evidence that patients with higher levels of childhood trauma may benefit more from psychoanalytic therapy than cognitive-behavioural therapy over a five-year period. However, the confounding effect of treatment intensity and methodological limitations suggest these findings should be replicated in studies with more comparable treatment doses. Future research should focus on disentangling the effects of treatment modality from treatment intensity.

Strengths and limitations

This study stands out for its comprehensive comparison of two major therapeutic approaches within a single trial, using consistent measurement points and instruments. It is commendable to conduct such a far-reaching longitudinal study into treatment effects. The long-term follow-up period of five years provides valuable insights into treatment sustainability. The inclusion of both randomised and preference-based treatment allocation enhances ecological validity, reflecting real-world clinical practice, however, certain limitations also arise from this – to be discussed in the limitations section next.

Several limitations warrant careful interpretation of the results. The substantial difference in session numbers between PAT (242 sessions) and CBT (59 sessions) makes it difficult to determine whether outcomes are attributable to treatment modality or simply treatment intensity. While the study hypothesised that PAT’s focus on life narratives and past experiences would be more beneficial for trauma survivors, the significantly higher number of PAT sessions confounds this interpretation – improved outcomes could simply reflect more intensive treatment rather than the specific therapeutic approach.

The high attrition rate (52.38% by year 4) raises concerns about selection bias and the representativeness of the final sample. The missing data was accounted for with the missing at random assumption, which could be problematic as often data is not missing at random. This is increasingly likely given the complexity of the design, long duration of the study and the recruitment of a patient population that tends to be resistant to treatment, which could all be factors to missing data not occurring at random.

The trial was a single-blind trial where participants could indicate their preference of treatment group, which has implications for interpreting results. This resulted in the PAT preference group (N = 101) being larger than the CBT preference group (N = 63). Where participants did not indicate a preference, they were randomised into the groups so that the ‘randomised to intervention’ samples were of more equal size. The post-hoc nature of the trauma analysis suggests these findings weren’t part of the original study design. The trial was originally intended as a chronic depression study rather than a chronic depression related to childhood trauma study. While the baseline levels of childhood trauma were comparable between the groups, this was not stratified during the randomisation process.

Additionally, the reliance on self-reported childhood trauma, while pragmatic, may be subject to recall bias. Finally, the merging of randomised and preference-based treatment groups, though statistically justified, could mask important differences in patient characteristics and treatment engagement. Participants’ ability to choose their treatment allocation could impact their engagement levels, but also potentially their treatment expectations.

Implications for practice

This study offers important insights for personalising treatment approaches for chronic depression, particularly for individuals with childhood trauma histories. The findings suggest that psychoanalytic therapy may be beneficial for patients with significant childhood trauma, especially those reporting sexual abuse and family inconsistency experiences.

The results challenge the current “one-size-fits-all” approach to depression treatment. While both CBT and PAT showed effectiveness, the superior outcomes of PAT for trauma survivors suggest that trauma history should be considered in treatment planning. This could inform how we prioritise referrals and allocate limited psychotherapy resources.

The study raises important questions about healthcare coverage and session limits. The significant difference in session numbers between PAT (242) and CBT (59) highlights the need to consider longer-term therapeutic approaches when clinically indicated. The superior outcomes for trauma survivors in PAT suggest that limiting coverage to brief interventions may be counterproductive for this population.

Indeed, in another paper I covered for the Mental Elf, the cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression was deemed low, while it was acknowledged that the current typical evaluation timeframes may be too short to capture the full benefits of psychoanalytic therapy. This study sheds light onto some of those benefits, and where the costs may be increasingly worthwhile. The evidence suggests that while PAT requires greater initial investment, its potential for reducing long-term healthcare utilisation and improving sustained outcomes for trauma survivors could make it the most valuable treatment option long-term.

This study validates the clinical intuition that some patients need more than symptom management – they need space to process and integrate their traumatic experiences within a secure therapeutic relationship. However, the significant time commitment and costs required for PAT do raise practical challenges in many healthcare settings as covered in my previous blog.

The findings suggest a need to balance evidence-based practice with personalized care. While CBT remains a valuable treatment option, the availability of longer-term psychoanalytic approaches should be preserved and supported by healthcare systems, particularly for patients with significant trauma histories. Further research addressing the study’s current limitations is needed to investigate how adequate blinding and matching the number of sessions in the therapy conditions impacts these results and their implications, so we can better understand what truly are driving symptom improvements in those with ‘treatment-resistant depression’ and a history of trauma.

Links

Primary paper

Krakau, L., Ernst, M., Hautzinger, M., Beutel, M. E., & Leuzinger-Bohleber, M. (2024). Childhood trauma and differential response to long-term psychoanalytic versus cognitive–behavioural therapy for chronic depression in adults. The British Journal of Psychiatry, 1-8.

Other references

Fonagy, P., Rost, F., Carlyle, J. A., McPherson, S., Thomas, R., Pasco Fearon, R. M., … & Taylor, D. (2015). Pragmatic randomized controlled trial of long‐term psychoanalytic psychotherapy for treatment‐resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry, 14(3), 312-321.

Koeser, L., Rost, F., Gabrio, A., Booker, T., Taylor, D., Fonagy, P., … & McCrone, P. (2023). Cost-effectiveness of long-term psychoanalytic psychotherapy for treatment-resistant depression: RCT evidence from the Tavistock Adult Depression Study (TADS). Journal of Affective Disorders, 335, 313-321.

Leuzinger-Bohleber, M., Hautzinger, M., Fiedler, G., Keller, W., Bahrke, U., Kallenbach, L., … & Beutel, M. (2019). Outcome of psychoanalytic and cognitive-behavioural long-term therapy with chronically depressed patients: a controlled trial with preferential and randomized allocation. The Canadian Journal of Psychiatry, 64(1), 47-58.

Rokita, K. I., Dauvermann, M. R., & Donohoe, G. (2018). Early life experiences and social cognition in major psychiatric disorders: A systematic review. European psychiatry, 53, 123-133.

My previous Mental Elf blog and the paper it covered: https://www.nationalelfservice.net/treatment/psychotherapy/long-term-psychoanalytic-psychotherapy-treatment-resistant-depression/

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Depression is a common condition that has a significant disease burden on those affected. While medication and psychotherapy are very effective for many patients, they do not work for everyone and can cause some undesirable side-effects, such as gastrointestinal symptoms (e.g., nausea), decreased sex drive or weight gain.

Non-invasive brain stimulation techniques, including transcranial direct current stimulation (tDCS), represent an alternative or add-on treatment option for depression that may have fewer side effects. Treatment with tDCS involves the application of a mild electrical current to the scalp to change how excitable certain parts of the brain are.

Meta-analyses – including two of my own (Mutz J. et al, 2018, 2019) – have generally found tDCS to be effective for treating depressive symptoms. While considered an experimental treatment in most countries, its use in clinical practice is more common in Brazil and parts of Europe. However, one barrier to more widespread use of tDCS is the need for patients to attend frequent visits to the clinic to receive treatment, usually five times per week for several weeks. Therefore, there is now considerable interest in exploring the potential for tDCS use at home.

Studies have demonstrated that home-based tDCS is feasible, however, none of the three previous randomised controlled trials (RCTs) found that tDCS was superior to sham treatment (Borrione L. et al, 2024; Kumpf U. et al, 2023; Oh J. et al, 2022). Two of these trials had a small sample size (less than 60 participants), all were limited to a treatment duration of six weeks and none were fully remote (i.e., all included in-person appointments).

In this new trial, Woodham and colleagues aimed to evaluate a 10-week tDCS treatment protocol in 174 patients and found promising results – spoiler: nearly half the patients in the active treatment group achieved remission, compared to just over 20% in the sham control group. However, as two of the largest tDCS trials conducted to date in clinical settings have yielded negative results (Loo C. et al, 2018; Burkhardt G. et al, 2023), one is left wondering: Is tDCS ready for widespread use?

Methods

The trial included 174 participants (69% women) randomly allocated to active tDCS or sham treatment. tDCS was completed by the participants in their home environment. A researcher was present via videoconferencing only for the initial session. The electrodes were placed over the left and right dorsolateral prefrontal cortex (i.e., on the forehead area), a brain region which is linked to neurophysiological differences observed in depression and is involved in regulating mood and cognitive functions. Sham stimulation involved a brief ramp-up and down to mimic the sensations of real treatment (e.g., tingling) so that the participants’ blinding would be maintained. This means gradually increasing the electrical current at the start of the session and then gradually decreasing it again.

Participants completed five 30-minute tDCS treatment sessions per week for the first three weeks and three sessions per week for the remaining seven weeks. Remote supervision was provided via videoconferencing to ensure appropriate device use. Two-thirds of patients were on stable antidepressant medication for at least six weeks prior to participation. Patients and researchers, including the outcome assessors, were blinded to treatment group (i.e., the trial design was double-blind).

Results

Patients in both the active tDCS and sham treatment groups experienced a decrease in depressive symptoms. However, reductions were greater in the active group, with statistically significant differences in the primary outcome, the Hamilton Depression Rating Scale (HDRS), at week 10 (95% confidence interval 0.51 to 4.01, p = 0.012). Differences between groups were also statistically significant at week four, but not at week seven. The reasons for the latter are unclear, but it is worth noting that the difference in symptoms assessed using the Montgomery-Åsberg Depression Rating Scale was also statistically significant at week seven.

Response rates, defined as a symptom decrease of at least 50%, were 58.3% in the active group and 37.8% in the sham group. Clinical remission rates, defined as a HDRS score of 7 or less, were 44.9% in the active group and 21.8% in the sham group. These effects were observed across both clinician-rated scales and a self-report scale. The trial was discontinued early based on the results of a pre-specified blinded interim analysis suggesting the treatment is efficacious.

tDCS treatment had a good safety profile. There was no overall difference in discontinuation rates between groups (14.9% and 13.7% in the active and sham groups, respectively). While transient side effects, such as skin redness, irritation and trouble concentrating, were more common in the active group, no serious adverse events were reported. Two participants in the active group experienced skin burns, which the authors speculate may be due to use of dried sponges. There was no evidence of differences in neuropsychological function, assessed using standardised tests, between the active and sham groups, suggesting that tDCS had neither beneficial nor adverse cognitive effects.

The authors also examined the effect of tDCS treatment on several other outcomes, such as anxiety and manic symptoms. One outcome that I found worth highlighting is quality of life. The authors observed no difference in overall quality of life between the active and sham groups. However, it is not obvious that a difference is to be expected after just 10 weeks of treatment. The measure of quality of life included items on five dimensions (mobility, self-care, usual activities, pain and discomfort), most of which reflect long-term, fairly stable factors. Moreover, the quality-of-life scores of the patients in this trial were high to start with, meaning there was limited room for improvement in these domains.

Challenges with blinding were notable: 77.6% of the participants in the active treatment group correctly guessed their treatment allocation, compared to 59.3% in the sham group. This could have influenced outcomes and may, in part, be due to visible side effects, such as skin redness, occurring more frequently in the active treatment group.

Conclusions

This RCT provides evidence supporting the feasibility and efficacy of fully remote home-based tDCS for treating depressive episodes of at least moderate severity. The treatment had a good safety profile, and no serious adverse events were reported.

The authors concluded that home-based tDCS offers a promising, non-invasive option that may serve as a first-line treatment for some patients (for example, those who do not prefer drug treatment), particularly given its portability and ease of administration. Identifying patient and/or treatment-related characteristics that predict a favourable treatment response in future research could further improve patient outcomes.

Strengths and limitations

The sample size of the trial was comparable to the largest tDCS trials completed to date in clinical settings. The use of both clinician-rated and patient-reported outcomes provides a good overview of treatment efficacy, and the 10-week duration distinguishes this trial from prior home-based tDCS trials, which were only up to six weeks long. The authors also report how many patients in their study received psychotherapy while participating in this trial (10.3% of the sample), which is an important variable rarely reported in brain stimulation trials.

Blinding challenges are a limitation in this study. The high rate of correct guesses in the active group (77.6%) compared to the sham group (59.3%) suggests that side effects, for example skin redness, may have influenced participant perceptions. The occurrence of electrical burns in two patients highlights the practical challenges in ensuring safe device use at home. This trial was remotely supervised and not full do-it-yourself tDCS. Interestingly, the sham response was about 10% lower in the present trial than in two previous home-based tDCS trials, likely because of it being fully remote and thus did not involve the experience of attending a clinical setting.

The sample’s relatively young (mean age ~37-38 years) and highly educated (1/4 of participants had a Masters or Doctoral degree) demographic could limit the generalisability of these findings to other populations. The sample composition likely reflects the trial’s recruitment strategy, which was done, in part, through the website of the device manufacturer. The moderate depression severity of the sample limits generalisability to more severe episodes of depression. The range of the HDRS is 0 to 52, and the sample average was 19.07 (SD = 2.73). Mild depression is usually defined by scores between 8 and 16, moderate depression by scores of 17 to 23 and severe depression by scores of at least 24. Patients with ‘treatment-resistant’ depression, according to the most common definition of at least two failed prior treatment attempts, were excluded from this trial.

Finally, it is worth keeping in mind that some investigators had financial ties to the device manufacturer and sponsor of the trial, Flow Neuroscience.

Implications for practice

tDCS is an alternative or add-on treatment option for patients with depression of at least moderate severity. A barrier to more widespread use of tDCS, and other non-invasive brain stimulation techniques, is the need to attend frequent visits to the clinic. tDCS delivered in the home setting, which resulted in higher response and remission rates than sham treatment in this trial, could increase accessibility to this treatment.

These positive results are encouraging but must be considered in the context of other tDCS trials. Two of the largest tDCS trials conducted in clinical settings yielded negative results (Loo et al., 2018; Burkhardt et al., 2023) and none of the previous home-based tDCS trials found the treatment to be superior to sham (Borrione L. et al, 2024; Kumpf U. et al, 2023; Oh J. et al, 2022).

The safety profile of home-based tDCS is good, with no serious adverse events reported. However, the occurrence of skin burns in two patients in the active treatment group highlights the need for careful safety monitoring and guidance. Policymakers should consider developing safety monitoring frameworks to support home-based tDCS treatment and to minimise risks.

Is home-based tDCS ready for widespread use? I am cautiously optimistic given that this trial supports treatment efficacy and suggests a good safety profile. No existing treatment option, whether drugs, psychotherapy or other brain stimulation technique, works in all patients. tDCS should thus be considered as an alternative or add-on treatment, depending on patient preference and clinician guidance, in those with depressive symptoms of at least moderate severity.

Future studies should focus on further improving patient outcomes by identifying predictors of response, and clarify which patients are most likely to respond to which type of treatment.

Statement of interests

I have previously co-authored publications with three of the authors of the current paper (Woodham, Young and Fu) but have not been involved in this trial.

Links

Primary paper

Woodham, R. D., Selvaraj, S., Lajmi, N., Hobday, H., Sheehan, G., Ghazi-Noori, A. R., … & Fu, C. H. (2024). Home-based transcranial direct current stimulation treatment for major depressive disorder: a fully remote phase 2 randomized sham-controlled trial. Nature Medicine, 31, 87-95. https://doi.org/10.1038/s41591-024-03305-y

Other references

Borrione, L., Cavendish, B. A., Aparicio, L. V., Luethi, M. S., Goerigk, S., Ramos, M. R., … & Brunoni, A. R. (2024). Home-use transcranial direct current stimulation for the treatment of a major depressive episode: a randomized clinical trial. JAMA Psychiatry, 81(4), 329-337. https://doi.org/10.1001/jamapsychiatry.2023.4948

Burkhardt, G., Kumpf, U., Crispin, A., Goerigk, S., Andre, E., Plewnia, C., … & Padberg, F. (2023). Transcranial direct current stimulation as an additional treatment to selective serotonin reuptake inhibitors in adults with major depressive disorder in Germany (DepressionDC): a triple-blind, randomised, sham-controlled, multicentre trial. The Lancet, 402(10401), 545-554. https://doi.org/10.1016/S0140-6736(23)00640-2

Kumpf, U., Palm, U., Eder, J., Ezim, H., Stadler, M., Burkhardt, G., … & Padberg, F. (2023). TDCS at home for depressive disorders: an updated systematic review and lessons learned from a prematurely terminated randomized controlled pilot study. European Archives of Psychiatry and Clinical Neuroscience, 273(7), 1403-1420. https://doi.org/10.1007/s00406-023-01620-y

Loo, C. K., Husain, M. M., McDonald, W. M., Aaronson, S., O’Reardon, J. P., Alonzo, A., … & Galvez, V. (2018). International randomized-controlled trial of transcranial direct current stimulation in depression. Brain stimulation, 11(1), 125-133. https://doi.org/10.1016/j.brs.2017.10.011

Mutz, J., Edgcumbe, D. R., Brunoni, A. R., & Fu, C. H. (2018). Efficacy and acceptability of non-invasive brain stimulation for the treatment of adult unipolar and bipolar depression: a systematic review and meta-analysis of randomised sham-controlled trials. Neuroscience & Biobehavioral Reviews, 92, 291-303. https://doi.org/10.1136/bmj.l1079

Mutz, J., Vipulananthan, V., Carter, B., Hurlemann, R., Fu, C. H., & Young, A. H. (2019). Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis. The BMJ, 364. https://doi.org/10.1016/j.neubiorev.2018.05.015

Oh, J., Jang, K. I., Jeon, S., & Chae, J. H. (2022). Effect of self-administered transcranial direct stimulation in patients with major depressive disorder: a randomized, single-blinded clinical trial. Clinical Psychopharmacology and Neuroscience, 20(1), 87-96. https://doi.org/10.9758/cpn.2022.20.1.87

Photo credits

Gambling is a pastime that nearly half of the UK population do, ranging from occasionally purchasing scratch cards to regularly betting on sports events. People tend to engage in certain types of gambling (e.g., daily scratch card purchases) more frequently than others (e.g., playing slot machines or blackjack at the casino weekly); however, for most individuals, these forms of betting are harmless and fun. Many can enjoy placing a bet, even if it results in financial loss. This does not mean they have a gambling disorder, just as someone who is occasionally tipsy or hungover after a celebration does not necessarily have an alcohol use disorder. However, between 0.4% and 2.8% of the UK population (Public Health England, 2019) may develop a significant gambling disorder, leading to serious problems with their health, finances, or other types of social problems.

The defining feature of a gambling disorder is its persistence, along with the widespread harms and risks associated with placing bets. Deceit—both towards others and oneself—is also a key characteristic of a gambling disorder. The urge to gamble is so intense that individuals will go to great lengths to place the next bet, often involving lying to conceal their whereabouts, activities, and finances. They underestimate losses and overestimate gains, often engaging in magical thinking: “My horse came second; next time, it will win’.

Gambling and suicide are closely linked, particularly among men (Livingstone & Rintoul, 2021). Problem gambling significantly increases the risk of suicidal thoughts, attempts, and fatalities, with problem gamblers being three to four times more likely to attempt suicide, (Karlsson & Håkansson, 2018) especially when their addiction results in financial distress, relationship breakdowns or co-occurring mental health conditions such as depression and anxiety. Financial difficulties often play a central role, as problem gamblers frequently find themselves facing overwhelming debts that lead to feelings of hopelessness.

Furthermore, mental health issues, including depression and anxiety, amplify the risk, as does the social isolation that many gamblers experience due to stigma or strained relationships. Research shows that among treatment-seeking patients with gambling disorder, a majority suffered from a concurrent psychiatric disorder, including depressive disorder, anxiety and co-morbid drug or alcohol addiction (Sanju & Gerada, 2011). Gamblers report higher rates of emotions such as guilt, shame, loss of self-esteem, loneliness, sleep problems and poor self-care.

Gambling disorder poses a public health issue. Tackling this matter necessitates early intervention and integrated treatment for addiction.

Despite the harms caused by gambling, only one in five individuals seek help, the remainder suffering in silence (Bijker et al., 2022). Recommended treatments include cognitive behavioural therapy, self-help strategies, participation in support groups, and addressing co-occurring issues such as housing, financial difficulties, health concerns, and practical solutions such as gambling blocking apps on mobile phones. However, unlike other areas of mental health, there is a lack of robust evidence to ascertain the most effective treatment options, particularly research conducted in the UK.

Methods

A recent paper (Seel et al., 2024) undertook a systematic analysis to identify which studies have been conducted for individuals seeking treatment in the UK. The authors examined the settings, research designs, outcome measures used to assess gambling treatments, and gaps in the research. The authors used a robust methodology, including searching key databases and publications involving research into gambling treatment conducted in the UK.

Studies were included if they evaluated the effectiveness of an intervention or treatment designed to improve symptoms of harmful or problematic gambling, reported outcomes of interventions on treatment adherence, gambling symptoms, or behaviours using standardised measures, were conducted in the UK, and were published since 2000 and ending 2023 (Seel et al., 2024).

Results

Their findings are very worrying.

Only eight studies in the reviewed literature met the authors’ inclusion criteria. These studies primarily employed retrospective reviews, case reports, or cross-sectional designs, and none utilised rigorous experimental methodologies such as randomised controlled trials (RCTs). The outcome follow-up periods for the studies ranged from 18 months to three years, except for one study examining the predictors of treatment dropout, which provided clinical data over 16 years. All but one of the studies were published within the last decade, and none were published after the COVID-19 pandemic.

Four studies employed the most frequently used retrospective chart review design. Additionally, one study utilised a retrospective case series, two focused on single-participant case reports, and one used a cross-sectional survey design. Case reports were then used to inform policy advice rather than encourage more rigorous research (Jones & George, 2011). No experimental research designs were identified in the review.

Gambling treatment clinics were the most frequently reported settings, appearing in five studies. The other three studies took place in locations such as Gamblers Anonymous (GA) meetings, residential care facilities, or unspecified sites.

Cognitive-behavioural therapy (CBT) is the most extensively studied intervention for gambling harm. While CBT has shown promise in tackling gambling-related issues, the review highlighted the significant lack of research into alternative approaches, including pharmacological treatments, self-guided internet interventions, and broader psychosocial interventions.

The review found no evidence that interventions for harmful gambling followed recognised best-practice experimental designs, such as randomised controlled trials. Instead, they overrelied on retrospective reviews of outcomes, standard data, or subjective case reports.

Additionally, even the definition of gambling disorder was inconsistent. Most researchers inferred severity using the Problem Gambling Severity Index (PGSI) scoring criteria or from self-reports. However, the PGSI does not provide a formal diagnosis of gambling disorder, and its accuracy and validity in identifying issues can vary. Self-reporting is often also inconsistent and, as with the PGSI, does not offer a formal diagnosis of gambling disorder suitable for research purposes. Seel et al. recommend utilising more robust criteria, such as the DSM-5 or ICD-11. Only one of the studies employed the latest DSM-based diagnostic instrument.

Studies rarely offered details about recruitment criteria and often consisted solely of secondary analysis of internal clinical audits. Only one study noted conflicts of interest, and funding information was presented in only two.

Conclusions

This review highlights the urgent need for comprehensive research to build a strong evidence base for effective gambling harm interventions in the UK.

Without research, clinicians are working in the dark, extrapolating from the treatment of other non-behavioural addictions or from international research, which might not be immediately applicable to a UK cohort of patients. By adopting a more methodologically rigorous approach, the field can more effectively address gambling-related harms’ complex and far-reaching impacts.

The authors say there is:

an urgent need to establish new research priorities to support the treatment of harmful gambling.

Strengths and limitations

There are several limitations which the authors acknowledge in their review. For example, they did not conduct a risk of bias assessment, as this is not typically part of standard practice for scoping reviews aimed at mapping evidence. However, such an assessment might have been beneficial in evaluating the robustness of each included study in terms of their methodological and reporting quality. Additionally, the small number of included studies limited the possibility of a more detailed examination of potential biases.

Moreover, the review focused exclusively on UK-based treatment literature, as the primary objective was to explore this area for the first time, particularly in developing the NICE guidelines for harmful gambling treatment. Consequently, it excluded studies from countries with different policy and legislative frameworks on gambling treatment.

Future research would benefit from examining the global literature to identify common approaches, practical strategies, and potential gaps in treating harmful gambling across various settings. Expanding the scope to include international studies could offer a broader perspective and enhance the generalisability of findings, ultimately leading to the development of more comprehensive treatment frameworks.

However, the limitations arise not primarily from the paper itself, a thorough analysis and well-conducted scoping review, but rather from the content of what they were exploring: the lack of quality studies originating from the UK. The authors suggest that this may stem from issues related to funding for research, which has come mainly from voluntary levies imposed by the gambling industry and fines levied by the Gambling Commission on gambling providers. This funding source could have discouraged researchers from applying for funds due to concerns about being perceived as under the influence of the industry or potential conflicts of interest.

Implications for practice

The authors recommend a comprehensive overhaul of the UK research approach to gambling harm interventions. This includes more significant investment in experimental research, developing standardised treatment protocols, and broader recruitment strategies to ensure representative samples. They also emphasise the importance of addressing systemic barriers, such as limited funding and insufficient collaboration among researchers, clinicians, and policymakers. The good news is that the UK government’s introduction of a statutory levy on gambling operators is poised to enhance research into gambling-related harms significantly. Aiming to start in April 2025, this levy is expected to generate approximately £100 million annually, with 20%—around £20 million—explicitly allocated for research purposes. With this levy in place, research efforts can be more strategically planned and executed, fostering a deeper understanding of gambling behaviours, the effectiveness of interventions, and the development of evidence-based policies.

A better evidence base for treating individuals suffering from gambling-related harms ensures that interventions are effective and account for a diversity of needs, including different patient populations. This is especially evident due to the social, psychological, and financial effects that families, communities, the broader society, and the individual can subsequently experience. For example, an important area for research is whether different treatment approaches might need to consider gender. Due to stigma and stereotypes primarily associating gambling with men, it’s possible that gambling-related harms in women may go unrecognised. Women may not seek gambling treatment due to many reasons, including stigma, shame, fear of judgment, childcare responsibilities, co-occurring mental health issues, or distrust in treatment. Addressing these requires women-centric, trauma-informed, accessible services, reducing stigma, and offering flexible, affordable, and supportive interventions (Hing et al., 2016). Effective solutions require ongoing research.

Furthermore, prisoners represent a high-risk group for problem gambling, with engagement often exacerbating substance misuse, mental health issues, and recidivism. Evidence-based interventions within correctional settings can address underlying causes, helping to break the cycle of harm and thus increase the likelihood of rehabilitation.

There are many unique challenges faced by minority groups that add complexity to developing these evidence-based treatments, such as cultural stigmas, discrimination, and barriers to accessing necessary treatment. These complexities are crucial to consider providing culturally sensitive and inclusive care.

Without strong evidence to support the development of these treatments, the risk of ineffective care is heightened, leading to an increased likelihood of harm and the perpetuation of inequalities. Therefore, employing this rigorous research can ensure that relevant interventions tackle the root causes of gambling-related harms while reducing stigma and remaining person-centred. Developing these strategies is vital for improving treatment outcomes for individuals and addressing health disparities between demographics, which would foster healthier communities. This is truly an area where “more research is needed”.

Statement of interests

Both RW and CG are funded to deliver care via the Primary Care Gambling Service through a grant from Gamble Aware.

Links

Primary paper

Seel, C. J., Jones, M., Christensen, D. R., May, R., Hoon, A. E., & Dymond, S. (2024). Treatment of harmful gambling: A scoping review of United Kingdom-based intervention research. BMC Psychiatry, 24(1), 392. https://doi.org/10.1186/s12888-024-05843-8

Other references

Bijker, R., Booth, N., Merkouris, S. S., Dowling, N. A., & Rodda, S. N. (2022). Global prevalence of help-seeking for problem gambling: A systematic review and meta-analysis. Addiction (Abingdon, England), 117(12), 2972–2985. https://doi.org/10.1111/add.15952

Hing, N., Russell, A., Tolchard, B., & Nower, L. (2016). Risk Factors for Gambling Problems: An Analysis by Gender. Journal of Gambling Studies, 32(2), 511–534. https://doi.org/10.1007/s10899-015-9548-8

Jones, H. B., & George, S. (2011). ‘You never told me I would turn into a gambler’: A first person account of dopamine agonist – induced gambling addiction in a patient with restless legs syndrome. BMJ Case Reports, 2011, bcr0720114459. https://doi.org/10.1136/bcr.07.2011.4459

Karlsson, A., & Håkansson, A. (2018). Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study. Journal of Behavioral Addictions, 7(4), 1091–1099. https://doi.org/10.1556/2006.7.2018.112

Livingstone, C., & Rintoul, A. (2021). Gambling-related suicidality: Stigma, shame, and neglect. The Lancet Public Health, 6(1), e4–e5. https://doi.org/10.1016/S2468-2667(20)30257-7

May-Chahal, C., Humphreys, L., Clifton, A., Francis, B., & Reith, G. (2017). Gambling Harm and Crime Careers. Journal of Gambling Studies, 33(1), 65–84. https://doi.org/10.1007/s10899-016-9612-z

Public Health England. (2019). Gambling Related Harms Evidence Review.

Sanju, G., & Gerada, C. (2011). Problem gamblers in primary care: Can GPs do more? The British Journal of General Practice,61(585), 248–249. https://doi.org/10.3399/bjgp11X567027

Photo credits

Racial and ethnic disparities in mental health remain a contentious topic of political initiatives, researchers, theorists and activists.  There have been many initiatives by successive governments in the United Kingdom, to improve race equality in mental health.  These include Delivering Race Equality in Mental Health (Department of Health 2005) (hereinafter, “DRE“),  and the current Patient and Carers Race Equality Framework (PCREF) (NHS England 2023), which began to be rolled out in 2023.

However, overall patterns in tangible action remain intransigent. Local services produce reports on what needs to be done, many of which gather dust on the shelf. Studies and academic papers often set out to identify what causes higher uptake of services than average for many racialised groups. However, as Barnet et al (2019) identified in their meta-analysis, there is little primary research into the underlying causation of disparity.

Citation bias results in newer academic research papers citing previous papers and the hypotheses about causation as if they were fact. Consequently, while there is much known about the dominant narratives around causes for racial disparities, (primarily the higher than average rates of involuntary admissions) critical and iterative exploration based on a scientific examination of causality is limited. There is also a dearth of patient representation and co-production to explain such causality from the perspective of people most affected by it.

The term ‘racial disparities’ can also homogenise, and potentially obscure the severity of the variations between population groups. To put this into perspective, rates of diagnosis for psychosis vary widely across demographics: 3.2% for black men compared with 0.3% for white men, and 1.3% for Asian men (McManus et al. 2016).

This recent paper by Knight and Jarvis (2024) contributes to the knowledge in this arena with a scoping review of literature with definite parameters: focusing specifically on psychosis, and the experiences of English-speaking Afro Caribbean people in North America and the United Kingdom.

Methods

The research focused on attitudes and beliefs, giving a voice to how the target research group consider their experience of psychosis, so that services can better adapt to meet their needs. As this was not an explicitly comparative study, it is not possible to empirically identify points of divergence with the majority white populations. However by reference to large-scale population studies such as Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) in the UK, the European Network of National Schizophrenia Networks Studying Gene–Environment Interactions (EU-GEI) across Europe and the National Survey of American Life (NSAL) in America – the paper identifies that mental healthcare services are poorly designed to serve Afro Carribean populations in North America and the UK.

Of note, the research identified notable challenges faced by this population in accessing and utilising services for mental wellbeing:

• reduced familial caregiver involvement,
• associated stigma, and distrust of services,
• greater societal exposure to poverty and social disadvantages,
• societal discrimination, threat, hostility and violence,
• discrimination in access to all healthcare,
• diagnostic error due to cultural bias in mental healthcare,
• in more recent studies, explicit links to racism in healthcare.

To gain a deeper understanding of the challenges faced by this population, the researchers conducted a focused keyword search of Medline, PsychINFO and Scopus databases to identify 296 articles spanning English-speaking Afro-Caribbean populations, of a variety of research methodologies. A further grey literature search was conducted, to “identify and integrate Afro-Caribbean attitudes and beliefs that may not be highlighted in mainstream sources or found through traditional peer-reviewed research”.

Articles exclusively evaluating Haitians (French-Creole), Dominicans (Spanish), or non-Afro Carribean cultural or language groups were excluded. Only English-language full-text articles were included, yielding a final evidence base of 220 studies.

The researchers proceeded with a thematic analysis, including sub-thematic analysis, coding the information in each article in relation to emergent attitudes and views of English speaking Afro Caribbean people in North America and the United Kingdom.

Results

Five themes were identified through this thematic analysis:

• Colonisation: This theme encompassed not only historical, but current geographically located administrations. It encapsulated the ways in which the legacies of colonialism present today, such as ideas about cultural superiority and inferiority, and material inequalities arising from the consequences of colonial exploitation.
• Adaptation: This theme cited the particular challenges of migrants assimilating into a new culture and society, in aspects such as language, cultural norms, foods, values and even climate.  Thematic characteristics of the new societies included the experience of being unwelcome in an unwelcoming environment, and there was exploration of the personal challenges of immersion in new societies, to the point that original values and cultural norms were overtaken. A common analogy utilised in the paper, was the sense of being ‘black on the outside (i.e. racialised as black) but effectively being white’, in terms of behaviours and values.
• Cultural mistrust: This theme explored the ongoing social mistrust linked to specific historical breaches of trust in the US, with one such example being the unethical Tuskegee experiments where African American men were made to continue being hosts to syphilis despite treatment options being available, so that ‘researchers’ could see the course of the illness.
• Collectivism: This theme covered the cultural norms of the study communities, to gather and operate within the context of group identities. Afro Caribbean societies were found to be more collectivist, however the experience of migration was found to disrupt this collective identity. The paper cites specific examples of the consequences of disruptions, which may even present at the intra-familial level, e.g. to mother and grandmother relationships. Larger sociocultural value disruption was also captured, such as the experience of ties to ancestors being disrupted, that can be misunderstood in clinical assessment settings.
• Religion and Spirituality: This theme spoke to powerful cultural values and traditions. A wide scope of belief systems were cited, included Christian religion, Rastafarian beliefs, and engagement with African heritage beliefs and practices such as Obeah and voodoo.

The authors also specifically outlined their own positionality, as belonging to racialised communities.

Each theme is discussed as it relates to potential ways in which they influence the relationships of individuals with clinical staff and also with the diagnostic process of psychosis. Verbatim experiences recorded add a rich textual base of lived-experience evidence, to contextualise presentations which may be medically and diagnostically framed as psychosis: from participants experiencing anything from, “nerves” as an emotional state, to religious and supernatural ideas such as being “possessed” or “cursed“.

The discussion section makes links between the views and attitudes to psychosis, of the study group (i.e. English speaking Afro Caribbean people in North America and the United Kingdom) and possible developments in service approaches and design. These include seeking a greater recognition of the impact of historic colonialism and its legacy in society and psychiatry, and the need to decolonise and increase the plurality of understandings about psychosis, including Caribbean sociocultural and collectivist influences on the individual experience.

The authors further identify a need for professionals in mental health services to avoid invalidating experiences of racism described by intended service users from marginalised communities, and to increase cultural understanding by using cultural formulations and paying attention to language and meanings.

Conclusions

The authors recognised the heterogeneity between and within Caribbean societies in the Northern Hemisphere, while highlighting the impacts of shared experience of colonialism and social discrimination and its consequences at large, and within populations seeking mental health services.

The presentations of English speaking Afro Caribbean people in North America and the United Kingdom need to be seen in the context of historic and current experiences of discrimination. The authors were explicit in stating that sometimes the experiences of the study group were not solely omissions in practice, which are themselves problematic, but also the discrimination in society that shows up in individual practice, as well as within the models and frameworks employed in the delivery of treatment and care.

Strengths and limitations

This scoping review provided a focused insight into the beliefs and attitudes of the research subjects, enabling a specific thematic analysis of individuals’ experiences, and examination of the misalignments between these and the underlying assumptions and approaches in psychiatry and psychology. Frontline staff are often interested in the ‘how to’ aspects of these topics and though the authors do not offer a toolkit approach, the paper provides concrete examples for improving practice.

The authors excellently avoided presenting the research as being entirely about cultural understanding.  Individual racism and discrimination as well as systemic racism are spotlighted. However, a limitation in the study is the absence of a comparator group, making it difficult to identify whether the themes that emerged were causally linked with racialised inequalities.

Further, the paper refers to misdiagnosis as a possible consequence of the divergence of attitudes, beliefs and perspectives of services and service users. It may have been helpful for the authors to highlight the domains where impact might be achieved, for example in experience of using services and also designing culturally sensitive and specific outcome measures, to contextualise the rates of psychosis diagnosis.

The paper made some reference to intergenerational trauma, without explicitly naming this or providing its theoretical framing. The work of Carter and Pieterse (2020) on what they term ‘race-based traumatic stress’ states that an understanding of the role of intergenerational trauma in race based traumatic stress is essential. Given the emergence of the theme of collectivism and themes of destruction in intra-familial relationships within this paper, the authors may have benefited from using the intergeneration trauma framework for thematic analysis. Considering the greater awareness and inclusion of trauma-informed approaches in psychiatry at large, this may be another helpful lens for designing future inclusive clinical practice.

Implications for practice

This is an innovative study that makes clear that a failure to take account of the wider context of racialised lives is not benign, but rather causes harm through invalidation, at the practice level.

Critical texts such as Suman Fernando’s Institutional Racism in Psychiatry and Clinical Psychology (2017) provide one perspective of re-examination of the ways in which evolution of disciplines, particularly those with a coercive and liberty-limiting element in ‘care’, replicate racism. Knight and Jarvis (2024) add to this message, that being non-discriminatory whist utilising processes that lead to racist outcomes is not a neutral end-outcome.

This paper reflects that despite a variety of individual experiences represented in research into mental disorders, there still exists a challenge to uproot established approaches, where there is a partial if impactful evidence base of effectiveness. It is also worth noting that the experience of ‘professionalisation’ itself, as practitioners become experts in a field, leads to a personal investment and identitarian legitimisation of a framework or model with continued practice, which may undermine individuals’ ability to be self-critical, as any attempt to critique or dismantle can feel personal.

At the practice level then, cultural humility and working effectively cross-culturally is important.  Effective practice therefore requires some form of collective action, to address and alter systemic discrimination within professions that are ultimately about serving vulnerable communities, and to be prepared to co-produce any change with current and intended service users.

Statement of Interests

None.

Links

Primary paper

Knight, S., Yang, X.Q., & Jarvis, G.E. (2024). “Dem sey mi mad”: A scoping review of the attitudes and beliefs of English-speaking Afro-Caribbeans about psychosis. Frontiers in Psychiatry, 15, 1385525. https://doi.org/10.3389/fpsyt.2024.1385525

Other references

Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) Study, United Kingdom

Barnett P, Mackay E, Matthews H, Gate R, Greenwood H, Ariyo K, Bhui K, Halvorsrud K, Pilling S, Smith S. (2019) Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Lancet Psychiatry. 2019 Apr;6(4):305-317. Open Access Published: March 04, 2019 DOI: https://doi.org/10.1016/S2215-0366(19)30027-6

Carter, R & Pieterse, A. (2020) Measuring the Effects of Racism: Guidelines for the Assessment and Treatment of Race-Based Traumatic Stress Injury.  New York. Columbia University Press

Department of Health (2005) Delivering Race Equality in Mental Health Care.  Crown: London

European Network of National Schizophrenia Networks Studying Gene–Environment Interactions (EU-GEI), Europe

Fernando, S. (2017) Institutional Racism in Psychiatry and Clinical Psychology. London: Palgrave.

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Attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) are highly prevalent mental health conditions with many overlapping symptoms (Biederman, 2005). The idea that ADHD shares features with other psychiatric disorders is well-established, with early discussions dating back to Millberger et al. (1995). Some of the key shared symptoms between ADHD and MDD include:

• Difficulty with focus and attention
• Emotional dysregulation
• Low motivation and fatigue
• Irritability
• Low self-esteem
• Sleep disturbances

ADHD is typically diagnosed in childhood, with prevalence estimates ranging from 5–10% in youths and 2–5% in adults. In contrast, MDD is usually diagnosed later in life, with an approximate lifetime prevalence of 12% in adolescents and 16% in adults (Faraone et al., 2021; Fernandez-Pujals et al., 2015). ADHD is also frequently associated with psychiatric comorbidities and longitudinal studies report high rates of antisocial and substance use disorders in individuals with ADHD (Reale et al., 2017). ADHD and MDD frequently co-occur. A substantial genetic correlation between ADHD and MDD has been reported (Powell et al., 2021). However, while this genetic connection is well-established, few prospective studies have directly examined whether having ADHD increases the likelihood of developing MDD later in life. Many existing studies suffer from methodological limitations or small sample sizes, leaving this question only partially addressed.

In their recent publication, Garcia-Argibay et al. (2024) aimed to assess whether ADHD causally increases the risk of subsequent MDD diagnoses.

Methods

The author applied a comprehensive three-pronged genetically informed approach, controlling for sex and birth year in all analyses:

1. Longitudinal sibling cohort analysis

A Swedish sibling cohort of 1,018,489 individuals was analysed, controlling for key confounders such as age, sex, and education level. By leveraging sibling comparisons, this analysis helped isolate the genetic and shared environmental effects relevant to ADHD and MDD while reducing bias introduced by confounders.

2. Child and adolescent twin cohort analysis

Using data from the Child and Adolescent Twin Study in Sweden (CATSS), a co-twin control analysis was conducted, a method designed to assess causality by comparing twins discordant for ADHD exposure. Specifically, they investigated whether the twin diagnosed with ADHD had a higher likelihood of developing MDD compared to their non-exposed co-twin, while controlling for shared genetic and environmental influences.

3. Mendelian randomization (MR) analysis

MR was used to leverage genome-wide association study (GWAS) summary statistics, which link common genetic variations to specific traits, to explore whether ADHD plays a causal role in the development of MDD. By using genetic variants as instrumental variables, MR analysis helps mitigate the influence of confounding factors that often affect observational studies.

Results

1. Longitudinal sibling cohort

The sibling cohort was nearly evenly split between biological males (51%) and biological females (49%), with a median age of 14 years at their last follow-up.  The prevalence of ADHD and depression were as follows:

• 3.53% of individuals had an ADHD diagnosis
• 1.20% were diagnosed with depression
• Depression rates were significantly higher among those with ADHD
• 12.07 events per 10,000 person-years in individuals without ADHD
• 62.37 events per 10,000 person-years in individuals with ADHD

The big takeaway? At the population level, individuals diagnosed with ADHD had a 7.4 times higher risk of developing depression compared to those without ADHD. This risk remained elevated even after adjusting for shared familial factors in sibling-stratified analyses, though it was slightly reduced.

2. Child and adolescent twin cohort

The Child and Adolescent Twin Cohort in Sweden included 16,477 twins (5,084 monozygotic [MZ] and 11,393 dizygotic [DZ]) born between 1992 and 2004. The sample consisted of 53% biological females and 47% biological males.

The findings? In monozygotic twins, ADHD factor scores—based on parental reports—were linked to higher depression scores at ages 15 and 18. Even after accounting for unmeasured shared familial factors, the association remained large, though somewhat weaker.

This suggests that while shared genetics and family environment play a role, ADHD itself still uniquely contributes to depression risk.

3. Mendelian randomization (MR)

Finally, researchers turned to MR to test whether ADHD might cause depression at a genetic level. They found a moderate-to-strong genetic correlation between ADHD and major depressive disorder (rg = 0.52). MR analyses also provided evidence of a causal relationship, with ADHD genetic liability increasing the risk of depression (OR = 1.15). Using a stricter MDD definition led to slightly stronger results (OR = 1.26).

Conclusions

Taken together, these findings paint a compelling picture:

• ADHD is strongly associated with a higher risk of depression, as seen in both population-wide and sibling-controlled analyses.
• Genetics and shared family environments contribute to this link, but ADHD itself appears to be a driving factor.
• Genetic analyses suggest a causal relationship, reinforcing the idea that ADHD is not just correlated with depression—it may increase the risk.

This research highlights the importance of early intervention and mental health support for individuals with ADHD. Understanding these connections can help clinicians and researchers develop better prevention and treatment strategies, ultimately improving long-term outcomes for those affected.

Strengths and limitations

Like any well-designed research, this study comes with notable strengths as well as some limitations. By using a three-way, genetically-informed design, the authors were able to examine the potential causal relationship between ADHD and major depressive disorder (MDD) from multiple angles.

Key strengths

One major advantage of this study is its longitudinal design, which allowed the authors to account for shared but unmeasured familial factors in their sibling analysis. This means they could better separate genetic influences from environmental ones when evaluating the link between ADHD and MDD and assess temporality (i.e., the order in which events occurred).

In the twin study, standardised and well-validated clinical scales were used, ensuring a reliable assessment of symptoms. Additionally, the MR analysis leveraged the largest and most recent GWAS for ADHD, further strengthening the case for a causal relationship between ADHD and MDD.

A frequent challenge in genetic studies on ADHD is the overrepresentation of males, since ADHD tends to be underdiagnosed in females. This can result in underpowered analyses when investigating sex-specific effects. However, this study was more balanced in sex representation (51% males, 49% females), helping to mitigate this issue.

Limitations to consider

The authors used symptom-based questionnaires to diagnose cases and this could have led to some misclassification between ADHD and MDD. Since these disorders share overlapping symptoms, the observed associations may have been inflated due to measurement errors.

There are several generalisability issues also to consider:

• The study focused on young/adolescent populations, which means the findings may not necessarily apply to adults.
• The cohorts were restricted to European (specifically Swedish) populations, limiting the ability to generalise results to other populations.
• The participants ranged from early childhood to adolescence, potentially missing critical developmental stages that could further shape the ADHD-MDD relationship.
• Higher-functioning individuals may have been more likely to participate and less likely to drop out, skewing the findings (i.e., selection bias).

A final limitation relates to the “streetlight effect”—the tendency to find what one is specifically looking for, even if the broader reality is more complex (Evans et al., 2020). While this study tested the causal link between ADHD and MDD, expanding the analysis to a wider range of mental health conditions might reveal that the effect is not as specific as initially thought.

Research suggests that many mental health disorders share transdiagnostic features (Caspi & Moffitt, 2018; Sprooten et al., 2022). Over time, specific correlations once thought to be unique have been found to apply across multiple disorders. This raises an important question:

Is the ADHD-MDD relationship truly distinct, or part of a broader pattern of psychiatric comorbidity?

Implications for practice

Studies establishing a genetic relationship between ADHD and MDD are not novel. However, these findings underscore the need for effective treatment and assessment of ADHD and a requirement for a deeper understanding of the potential causal mechanisms linking ADHD and MDD. Establishing this relationship can help inform the management and assessment of individuals with ADHD and could lead to an improvement in symptoms and overall well-being for individuals affected by ADHD.

One of the key insights from this study is that the genetic relationship between ADHD and MDD cannot be fully explained by shared genetic and environmental factors. This highlights the role of unique environmental influences, which, crucially, are often modifiable and actionable.

The implications for clinical practice and future research can be distilled into two key recommendations:

1. Expanding the Scope of Psychopathology Research

Traditional research has often focused narrowly on pairwise disorder comparisons, missing broader patterns of mental health interconnectivity. A more comprehensive, multidimensional approach—one that balances both depth and breadth of phenotyping—is needed to capture the full complexity of behavioural and psychiatric traits. Future studies should embrace wider-ranging data collection across multiple disorders rather than limiting themselves to rigid diagnostic labels.

2. Emphasising Modifiable Environmental Factors

While genetic factors play a significant role, environmental influences actively shape the development and progression of mental health conditions. Several potential modifiable pathways warrant further investigation, including:

• Parental treatment differences
• Traumatic experiences
• Peer relationships
• Unique life events not shared with siblings
• Chronic stressors
• Substance misuse-related experiences

Identifying and targeting these factors could lead to more effective prevention and intervention strategies.

Regardless of the lens used—genetic, neuroimaging, sociological, or cultural—understanding the inner workings of mental health disorders remains immensely complex. A truly integrative, multidisciplinary approach is essential for refining psychiatric classification systems and translating research findings into clinically meaningful tools. By adopting more dynamic, biologically and environmentally informed models, the field has the potential to develop more effective, personalized treatment strategies—ultimately improving mental health outcomes for a diverse range of individuals.

Statement of interests

Tim is a PhD candidate with King’s College London and A*STAR Singapore. He researches the genetic relationship between major depressive disorder, schizophrenia and cognitive health and is not involved with research groups investigating the relationship between ADHD and MDD. He has no conflicts of interest to report.

Links

Primary paper

Garcia-Argibay, M., Brikell, I., Thapar, A., Lichtenstein, P., Lundström, S., Demontis, D., & Larsson, H. (2024). Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder: Evidence From Multiple Genetically Informed Designs. Biological Psychiatry, 95(5), 444-452. https://doi.org/10.1016/j.biopsych.2023.07.017

Other references

Biederman, J. (2005). Attention-deficit/hyperactivity disorder: A selective overview. Biological Psychiatry, 57(11), 1215–1220. https://doi.org/10.1016/j.biopsych.2004.10.020

Caspi, A., & Moffitt, T. E. (2018). All for one and one for all: Mental disorders in one dimension. American Journal of Psychiatry, 175(9), 831–844. https://doi.org/10.1176/appi.ajp.2018.17121383

Evans B. J. (2020). The Streetlight Effect: Regulating Genomics Where the Light Is. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics, 48(1), 105–118. https://doi.org/10.1177/1073110520916998

Hindley, G., Frei, O., Ph, D., Shadrin, A. A., Ph, D., Cheng, W., Ph, D., Connell, K. S. O., & Ph, D. (n.d.). Charting the Landscape of Genetic Overlap Between Mental Disorders and Related Traits Beyond Genetic Correlation. 14, 1–11. https://doi.org/10.1176/appi.ajp.21101051

Kotov, R., Waszczuk, M. A., Krueger, R. F., Forbes, M. K., Watson, D., Clark, L. A., Achenbach, T. M., Althoff, R. R., Ivanova, M. Y., Michael Bagby, R., Brown, T. A., Carpenter, W. T., Caspi, A., Moffitt, T. E., Eaton, N. R., Forbush, K. T., Goldberg, D., Hasin, D., Hyman, S. E., … Zimmerman, M. (2017). The hierarchical taxonomy of psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454–477. https://doi.org/10.1037/abn0000258

Milberger, S., Biederman, J., Faraone, S. V., Murphy, J., & Tsuang, M. T. (1995). Attention deficit hyperactivity disorder and comorbid disorders: issues of overlapping symptoms. The American journal of psychiatry, 152(12), 1793–1799. https://doi.org/10.1176/ajp.152.12.1793

Powell, V., Martin, J., Thapar, A., Rice, F., & Anney, R. J. L. (2021). Investigating regions of shared genetic variation in attention deficit/hyperactivity disorder and major depressive disorder: a GWAS meta-analysis. Scientific Reports, 11(1). https://doi.org/10.1038/s41598-021-86802-1

Reale, L., Bartoli, B., Cartabia, M. et al. Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. Eur Child Adolesc Psychiatry 26, 1443–1457 (2017). https://doi.org/10.1007/s00787-017-1005-z

Simmons, J. M., & Quinn, K. J. (2014). The NIMH Research Domain Criteria (RDoC) Project: Implications for genetics research. Mammalian Genome, 25(1–2), 23–31. https://doi.org/10.1007/s00335-013-9476-9

Sprooten, E., Franke, B., & Greven, C. U. (2022). The P-factor and its genomic and neural equivalents: an integrated perspective. In Molecular Psychiatry (Vol. 27, Issue 1, pp. 38–48). Springer Nature. https://doi.org/10.1038/s41380-021-01031-2

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The WHO publishes a report every three years, summarising health data from the 53 member states of the WHO European area, which includes the UK as well as all of continental Europe, Russia and other countries in central Asia.

“Without action the next generation will not only face a high risk of chronic disease, but a growing mental health crisis”

Hans Kluge

The European health report 2024 states that Europe as a global region has made substantial achievements in addressing disease burdens and increasing life expectancy.

However, it also identified key areas where European health systems have been “stagnating” or “backsliding”, including child and adolescent health and dealing with the challenges presented by an ageing population.

According to the report, one in five adolescents in the European region is grappling with a mental health condition, while 15% of adolescents report they have experienced cyberbullying.

Suicide is the leading cause of death among 15-29-year-olds across the countries in the WHO European region, and girls consistently report lower levels of mental wellbeing compared with boys.

Speaking at the launch of the report, regional director for the WHO European region Dr Hans Kluge said: “Childhood sets the foundation for lifelong health and wellbeing, yet key indicators are stagnating or even worsening across the region.”

He said: “Social media, online harassment and digital dependency are increasingly affecting young people’s wellbeing and without action the next generation will not only face a high risk of chronic disease, but a growing mental health crisis.”

He added that although girls consistently reported lower mental wellbeing than boys, at the same time, men die by suicide at a rate four times higher than women.

“And this is sobering,” he said.  “Suicide remains the leading cause of death among young people aged 15-29.”

Data from individual countries in the region included in in the report reveal that the mental health crisis in young people in the UK is even worse than in other European and Asian countries.

According to the report, the UK saw the greatest increase in deaths by suicide of any country in the WHO European region between 2015 and 2021.

The number of deaths from suicide across the European region decreased over this period by more than 16% while in the UK it increased by more than 14%.

In addition, the gender gap in mental wellbeing in 15-year-olds was highest in England of all the countries in the region. Girls in England scored just 39 out of 100 on a screening tool for depression in 2022, which was the lowest for any group of 15-year-olds surveyed, while boys in England scored 57.

The WHO report also found that routine vaccination rates have fallen in many countries in the European region, leading to a resurgence of preventable diseases.

In 2023 there were 58,000 cases of measles across 41 of the WHO Europe member states, which is a 30-fold increase on the figures for 2022.

The data for the UK showed vaccination coverage rates for key childhood illnesses were lower in 2023 than the average across the European region, including for measles, pertussis and pneumococcal disease.

Dr Kluge said: “These diseases should be behind us, yet they are making a comeback due to declining vaccination rates, fuelled by misinformation and gaps in our healthcare.”

The WHO report also highlighted the risks to the health systems of Europe from their ageing populations.

“These diseases should be behind us, yet they are making a comeback due to declining vaccination rates”

Hans Kluge

Dr Kluge said: “In 2024 for the first time there were more people over 65 than under 15 years old in the European region and projections show that there will be three times more people aged 80+ by 2050.”

The report highlighted that although people were living longer, they were spending more years at the end of the lives living with illness and disability. Nearly half of people aged 65 years and over who are unable to fully take care of themselves lack the assistance they require for personal care or household activities.

Dr Kluge said: “There is a 10-year gap between life expectancy and healthy life-expectancy. This means millions of people in our region spend the last decades of life in poor health. They struggle with chronic diseases, disability and lack of access to adequate care.”

The pressure on healthcare systems that will come from increased rates of dementia was also highlighted in the report.

It found that dementia is one of the leading causes of dependency and disability among older people in the European region and that mortality from dementia was higher in the UK in 2021 than in any other country in the European region.

“Over 14 million people in our region are living with dementia. A number set to double by 2030, so if we do not act now, the gap between living longer and living well will continue to widen, so we must change our approach to ensure our populations not only live longer but age in good health,” Dr Kluge said.