Developing a validated methodology for identifying clozapine treatment periods in electronic health records.

BACKGROUND: Clozapine is the only recommended antipsychotic medication for individuals diagnosed with treatment-resistant schizophrenia. Unfortunately, its wider use is hindered by several possible adverse effects, some of which are rare but potentially life threatening. As such, there is a growing interest in studying clozapine use and safety in routinely collected healthcare data. However, previous attempts to characterise clozapine treatment have had low accuracy. AIM: To develop a methodology for identifying clozapine treatment dates by combining several data sources and implement this on a large clinical database. METHODS: Non-identifiable electronic health records from a large mental health provider in London and a linked database from a national clozapine blood monitoring service were used to obtain information regarding patients' clozapine treatment status, blood tests and pharmacy dispensing records. A rule-based algorithm was developed to determine the dates of starting and stopping treatment based on these data, and more than 10% of the outcomes were validated by manual review of de-identified case note text. RESULTS: A total of 3,212 possible clozapine treatment periods were identified, of which 425 (13.2%) were excluded due to insufficient data to verify clozapine administration. Of the 2,787 treatments remaining, 1,902 (68.2%) had an identified start-date. On evaluation, the algorithm identified treatments with 96.4% accuracy; start dates were 96.2% accurate within 15 days, and end dates were 85.1% accurate within 30 days. CONCLUSIONS: The algorithm produced a reliable database of clozapine treatment periods. Beyond underpinning future observational clozapine studies, we envisage it will facilitate similar implementations on additional large clinical databases worldwide.

Recording of intellectual disability in general hospitals in England 2006-2019: Cohort study using linked datasets.

BACKGROUND: Accurate recognition and recording of intellectual disability in those who are admitted to general hospitals is necessary for making reasonable adjustments, ensuring equitable access, and monitoring quality of care. In this study, we determined the rate of recording of intellectual disability in those with the condition who were admitted to hospital and factors associated with the condition being unrecorded. METHODS AND FINDINGS: Retrospective cohort study using 2 linked datasets of routinely collected clinical data in England. We identified adults with diagnosed intellectual disability in a large secondary mental healthcare database and used general hospital records to investigate recording of intellectual disability when people were admitted to general hospitals between 2006 and 2019. Trends over time and factors associated with intellectual disability being unrecorded were investigated. We obtained data on 2,477 adults with intellectual disability who were admitted to a general hospital in England at least once during the study period (total number of admissions = 27,314; median number of admissions = 5). People with intellectual disability were accurately recorded as having the condition during 2.9% (95% CI 2.7% to 3.1%) of their admissions. Broadening the criteria to include a nonspecific code of learning difficulty increased recording to 27.7% (95% CI 27.2% to 28.3%) of all admissions. In analyses adjusted for age, sex, ethnicity, and socioeconomic deprivation, having a mild intellectual disability and being married were associated with increased odds of the intellectual disability being unrecorded in hospital records. We had no measure of quality of hospital care received and could not relate this to the presence or absence of a record of intellectual disability in the patient record. CONCLUSIONS: Recognition and recording of intellectual disability in adults admitted to English general hospitals needs to be improved. Staff awareness training, screening at the point of admission, and data sharing between health and social care services could improve care for people with intellectual disability.

Ethnic differences in physical and mental multimorbidity in working age adults with a history of depression and/or anxiety.

BACKGROUND: The current study used data from an ethnically diverse population from South London to examine ethnic differences in physical and mental multimorbidity among working age (18-64 years) adults in the context of depression and anxiety. METHOD: The study included 44 506 patients who had previously attended Improving Access to Psychological Therapies services in the London Borough of Lambeth. Multinomial logistic regression examined cross-sectional associations between ethnicity with physical and mental multimorbidity. Patterns of multimorbidity were identified using hierarchical cluster analysis. RESULTS: Within 44 056 working age adults with a history of depression or anxiety from South London there were notable ethnic differences in physical multimorbidity. Adults of Black Caribbean ethnicity were more likely to have physical multimorbidity [adjusted relative risk ratio (aRRR) = 1.25, 95% confidence interval (CI) 1.15-1.36] compared to adults of White ethnicity. Relative to adults of White ethnicity, adults of Asian ethnicity were more likely to have physical multimorbidity at higher thresholds only (e.g. 4 + conditions; aRRR = 1.53, 95% CI 1.17-2.00). Three physical (atopic, cardiometabolic, mixed) and three mental (alcohol/substance use, common/severe mental illnesses, personality disorder) multimorbidity clusters emerged. Ethnic minority groups with multimorbidity had a higher probability of belonging to the cardiometabolic cluster. CONCLUSION: In an ethnically diverse population with a history of common mental health disorders, we found substantial between- and within-ethnicity variation in rates of physical, but not mental, multimorbidity. The findings emphasised the value of more granular definitions of ethnicity when examining the burden of physical and mental multimorbidity.

Catatonia: demographic, clinical and laboratory associations.

BACKGROUND: Catatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia. METHODS: Electronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case-control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality. RESULTS: We identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 µmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45-0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29-1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment. CONCLUSIONS: In the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.

Multimorbidity and fit note receipt in working-age adults with long-term health conditions.

BACKGROUND: Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. METHODS: Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017. RESULTS: We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95). CONCLUSIONS: Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

Ethnic inequalities in clozapine use among people with treatment-resistant schizophrenia: a retrospective cohort study using data from electronic clinical records.

PURPOSE: Clozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder. METHODS: A retrospective cohort study, using information from 11 years of clinical records (2007-2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use. RESULTS: Among 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine. CONCLUSION: Black service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.

Association between air pollution exposure and mental health service use among individuals with first presentations of psychotic and mood disorders: retrospective cohort study.

BACKGROUND: Growing evidence suggests that air pollution exposure may adversely affect the brain and increase risk for psychiatric disorders such as schizophrenia and depression. However, little is known about the potential role of air pollution in severity and relapse following illness onset. AIMS: To examine the longitudinal association between residential air pollution exposure and mental health service use (an indicator of illness severity and relapse) among individuals with first presentations of psychotic and mood disorders. METHOD: We identified individuals aged ≥15 years who had first contact with the South London and Maudsley NHS Foundation Trust for psychotic and mood disorders in 2008-2012 (n = 13 887). High-resolution (20 × 20 m) estimates of nitrogen dioxide (NO2), nitrogen oxides (NOx) and particulate matter (PM2.5 and PM10) levels in ambient air were linked to residential addresses. In-patient days and community mental health service (CMHS) events were recorded over 1-year and 7-year follow-up periods. RESULTS: Following covariate adjustment, interquartile range increases in NO2, NOx and PM2.5 were associated with 18% (95% CI 5-34%), 18% (95% CI 5-34%) and 11% (95% CI 3-19%) increased risk for in-patient days after 1 year. Similarly, interquartile range increases in NO2, NOx, PM2.5 and PM10 were associated with 32% (95% CI 25-38%), 31% (95% CI 24-37%), 7% (95% CI 4-11%) and 9% (95% CI 5-14%) increased risk for CMHS events after 1 year. Associations persisted after 7 years. CONCLUSIONS: Residential air pollution exposure is associated with increased mental health service use among people recently diagnosed with psychotic and mood disorders. Assuming causality, interventions to reduce air pollution exposure could improve mental health prognoses and reduce healthcare costs.

Effect of trazodone on cognitive decline in people with dementia: Cohort study using UK routinely collected data.

OBJECTIVES: Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants. METHODS: Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis. RESULTS: We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses. CONCLUSIONS: There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.

What gets recorded, counts: dementia recording in primary care compared with a specialist database.

BACKGROUND: databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care. METHODS: a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared. RESULTS: 3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06). DISCUSSION: there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Mental health consequences of urban air pollution: prospective population-based longitudinal survey.

PURPOSE: The World Health Organisation (WHO) recently ranked air pollution as the major environmental cause of premature death. However, the significant potential health and societal costs of poor mental health in relation to air quality are not represented in the WHO report due to limited evidence. We aimed to test the hypothesis that long-term exposure to air pollution is associated with poor mental health. METHODS: A prospective longitudinal population-based mental health survey was conducted of 1698 adults living in 1075 households in South East London, from 2008 to 2013. High-resolution quarterly average air pollution concentrations of nitrogen dioxide (NO2) and oxides (NOx), ozone (O3), particulate matter with an aerodynamic diameter < 10 µm (PM10) and < 2.5 µm (PM2.5) were linked to the home addresses of the study participants. Associations with mental health were analysed with the use of multilevel generalised linear models, after adjusting for large number of confounders, including the individuals' socioeconomic position and exposure to road-traffic noise. RESULTS: We found robust evidence for interquartile range increases in PM2.5, NOx and NO2 to be associated with 18-39% increased odds of common mental disorders, 19-30% increased odds of poor physical symptoms and 33% of psychotic experiences only for PM10. These longitudinal associations were more pronounced in the subset of non-movers for NO2 and NOx. CONCLUSIONS: The findings suggest that traffic-related air pollution is adversely affecting mental health. Whilst causation cannot be proved, this work suggests substantial morbidity from mental disorders could be avoided with improved air quality.

Demographic variation in fit note receipt and long-term conditions in south London.

OBJECTIVES: Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, 'maybe fit' use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the 'maybe fit' option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt. METHODS: Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis. RESULTS: In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. 'Maybe fit' recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use. CONCLUSIONS: For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

Co-occurring obsessive-compulsive disorder and autism spectrum disorder in young people: prevalence, clinical characteristics and outcomes.

Obsessive-compulsive disorder (OCD) and autism spectrum disorders (ASD) commonly co-occur and are considered challenging to manage when they co-occur in youth. However, clinical characteristics and prognosis of this group remain poorly understood. This study examined the prevalence, clinical correlates and outcomes of paediatric OCD co-occurring with ASD (OCD + ASD) in a large clinical cohort. Data were extracted from electronic clinical records of young people aged 4-17 years who had attended a mental health trust in South London, United Kingdom. We identified young people with diagnoses of OCD + ASD (n = 335), OCD without ASD (n = 1010), and ASD without OCD (n = 6577). 25% of youth with OCD had a diagnosis of ASD, while 5% of those with ASD had a diagnosis of OCD. At diagnosis, youth with OCD + ASD had lower psychosocial functioning scores on the clinician-rated Child Global Assessment Scale (CGAS) compared to those with either OCD or ASD. Youth with OCD + ASD were equally likely to receive CBT compared to those with OCD but were more likely to be prescribed medication and use services for longer than either comparison group. Youth with OCD + ASD showed significant improvements in functioning (CGAS scores) after service utilisation but their gains were smaller than those with OCD. OCD + ASD commonly co-occur, conferring substantial impairment, although OCD may be underdiagnosed in youth with ASD. Young people with co-occurring OCD + ASD can make significant improvements in functioning with routine clinical care but are likely to remain more impaired than typically developing youth with OCD, indicating a need for longer-term support for these young people.

Comparison of Treatment Outcomes Between Lesbian, Gay, Bisexual and Heterosexual Individuals Receiving a Primary Care Psychological Intervention.

BACKGROUND: Lesbian, gay and bisexual individuals experience more anxiety and depression than heterosexual people. Little is known about their comparative treatment response to psychological interventions. AIMS: To compare sociodemographic/clinical characteristics and treatment outcomes across sexual orientation groups, for adults receiving primary care psychological interventions from Improving Access to Psychological Therapies (IAPT) services in London, adjusting for possible confounders. METHOD: Data from 188 lesbian women, 222 bisexual women, 6637 heterosexual women, 645 gay men, 75 bisexual men and 3024 heterosexual men were analysed from pre-treatment and last treatment sessions. Males and females were analysed separately. RESULTS: Before treatment, lesbian and bisexual women were more likely to report clinical levels of impairment (Work and Social Adjustment Scale) than heterosexual women; there were no significant differences in depression (PHQ-9) or anxiety (GAD-7). Bisexual men were more likely to meet depression caseness than gay men but less likely to meet anxiety caseness than gay or heterosexual men. Compared with heterosexual women, lesbian and bisexual individuals showed smaller reductions in depression and impairment, controlling for age, ethnicity, employment, baseline symptoms, number of sessions and intervention type. Bisexual women experienced significantly smaller reductions in anxiety than heterosexual women and were less likely to show recovery or reliable recovery. There were no significant differences in treatment outcomes between gay, bisexual and heterosexual men. CONCLUSIONS: Reasons for poorer outcomes in lesbian and bisexual women require investigation, for example lifetime trauma or stigma/discrimination regarding gender or sexual orientation in everyday life or within therapy services.

Cannabis use and treatment resistance in first episode psychosis: a natural language processing study.

BACKGROUND: Cannabis is frequently used among individuals with first episode psychosis and is associated with poor clinical outcomes. However, little is known about the effect of cannabis use on the response to antipsychotic medications and how use could affect outcomes. Using natural language processing on clinical data from a large electronic case register, we sought to investigate whether resistance to antipsychotic treatment mediated poor clinical outcomes associated with cannabis use. METHODS: Data were obtained from 2026 people with first episode psychosis in south London, UK. Cannabis use documented in free text clinical records was identified with natural language processing. Data for age, sex, ethnicity, marital status, psychotic disorder diagnosis, subsequent hospital admission, and number of unique antipsychotic medications prescribed were obtained using the Clinical Record Interactive Search instrument. The association of these variables with cannabis use was analysed with multivariable regression and mediation analysis. FINDINGS: 939 people (46·3%) with first episode psychosis were using cannabis at first presentation. Cannabis use was most strongly associated with being 16-25 years old, male, and single, and was also associated with an increase in number of hospital admissions (incidence rate ratio 1·50, 95% CI 1·25-1·80), compulsory hospital admission (odds ratio 1·55, 1·16-2·08), and number of days spent in hospital (ß coefficient 35·1 days, 12·1-58·1) over 5 years' follow-up. An increase in number of unique antipsychotic medications mediated an increase in number of hospital admissions (natural indirect effect 1·11, 1·04-1·17; total effect 1·41, 1·22-1·64), compulsory hospital admission (1·27, 1·10-1·45; 1·71, 1·05-2·78), and number of days spent in hospital (16·1, 6·7-25·5; 19·9, 2·5-37·3). INTERPRETATION: We showed that a substantial number of people with first episode psychosis used cannabis and that its use was associated with increased likelihood of hospital admission and number of days spent in hospital. These associations were partly mediated by an increase in number of unique antipsychotic medications prescribed. These findings suggest that cannabis might reduce response to conventional antipsychotic treatment and highlight the importance of strategies to reduce its use. FUNDING: National Institute for Health Research, UK Medical Research Council.

Clinical outcomes and mortality associated with weekend admission to psychiatric hospital.

BACKGROUND: Studies indicate that risk of mortality is higher for patients admitted to acute hospitals at the weekend. However, less is known about clinical outcomes among patients admitted to psychiatric hospitals. AIMS: To investigate whether weekend admission to a psychiatric hospital is associated with worse clinical outcomes. METHOD: Data were obtained from 45 264 consecutive psychiatric hospital admissions. The association of weekend admission with in-patient mortality, duration of hospital admission and risk of readmission was investigated using multivariable regression analyses. Secondary analyses were performed to investigate the distribution of admissions, discharges, in-patient mortality, episodes of seclusion and violent incidents on different days of the week. RESULTS: There were 7303 weekend admissions (16.1%). Patients who were aged between 26 and 35 years, female or from a minority ethnic group were more likely to be admitted at the weekend. Patients admitted at the weekend were more likely to present via acute hospital services, other psychiatric hospitals and the criminal justice system than to be admitted directly from their own home. Weekend admission was associated with a shorter duration of admission (B coefficient -21.1 days, 95% CI -24.6 to -17.6, P<0.001) and an increased risk of readmission in the 12 months following index admission (incidence rate ratio 1.13, 95% CI 1.08 to 1.18, P<0.001), but in-patient mortality (odds ratio (OR) = 0.79, 95% CI 0.51 to 1.23, P = 0.30) was not greater than for weekday admission. Fewer episodes of seclusion occurred at the weekend but there was no significant variation in deaths during hospital admission or violent incidents on different days of the week. CONCLUSIONS: Being admitted at the weekend was not associated with an increased risk of in-patient mortality. However, patients admitted at the weekend had shorter admissions and were more likely to be readmitted, suggesting that they may represent a different clinical population to those admitted during the week. This is an important consideration if mental healthcare services are to be implemented across a 7-day week.

Violent typologies among women inpatients with severe mental illness.

PURPOSE: Extant severe mental illness (SMI) and physical violence literature focus disproportionately on community-based men samples. To address this empirical imbalance, the current study explored violence towards others and oneself among women inpatients with SMI. As those with SMI are more likely to be victims than perpetrators of violence, victimisation was also an important factor assessed in this study. METHODS: The study used a quantitative within-subject cross-sectional design. Data were extracted from 5675 inpatient women cases between 2009 and 2013. RESULTS: Women with a manic disorder (without psychotic features) were 4.5 times, whilst those with psychotic disorders were 2 times, more likely to be physically violent to others compared to those with major mood disorders. Conversely, women with a major mood disorders were 4.8 times and 7.5 times more likely to engage in violence towards oneself (deliberate self-harm), compared to those with psychotic disorder and manic disorders, respectively. The past victimisation increased the likelihood of later physical violence. CONCLUSION: The data illuminate differential risk factors among women inpatients with SMI that may help predict violence occurring towards others and oneself and allow gender comparisons with the established literature.

Mental health service responses to human trafficking: a qualitative study of professionals' experiences of providing care.

BACKGROUND: Human trafficking is a global crime and human rights violation. Although research has demonstrated a high prevalence of mental disorder among trafficked people and that trafficked people are in contact with mental health services, little is known about mental health professionals' experiences of identifying and providing care for trafficked people. This study aimed to understand how people are identified as trafficked within mental health services and the challenges professionals experience in responding to trafficked people's mental health needs. METHOD: Qualitative study of electronic health records of trafficked people in contact with secondary mental health services in South East London, England. Comprehensive clinical electronic health records for over 200,000 patients in contact with secondary mental health services in South London were searched and retrieved to identify trafficked patients. Content analysis was used to establish how people were identified as trafficked, and thematic analysis was used to explore the challenges experienced in responding to mental health needs. RESULTS: The sample included 130 trafficked patients, 95 adults and 35 children. In 43 % (41/95) of adult cases and 63 % (22/35) child cases, mental health professionals were informed that their patient was a potential victim of trafficking by another service involved in their patient's care. Cases were also identified through patients disclosing their experiences of exploitation and abuse. Key challenges faced by staff included social and legal instability, difficulties ascertaining history, patients' lack of engagement, availability of services, and inter-agency working. CONCLUSIONS: Training to increase awareness, encourage helpful responses, and inform staff about the available support options would help to ensure the mental health needs of trafficked people are met. Further research is needed to establish if these challenges are similar in other health settings.

The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses.

BACKGROUND: Most women with psychotic disorders and bipolar disorders have children but their pregnancies are at risk of adverse psychiatric and fetal outcome. The extent of modifiable risk factors - both clinical and socio-demographic - is unclear as most studies have used administrative data or recruited from specialist tertiary referral clinics. We therefore aimed to investigate the socio-demographic and clinical characteristics of an epidemiologically representative cohort of pregnant women with affective and non-affective severe mental illness. METHODS: Women with severe mental illness were identified from a large electronic mental health case register in south London, and a data linkage with national maternity Hospital Episode Statistics identified pregnancies in 2007-2011. Data were extracted using structured fields, text searching and natural language processing applications. RESULTS: Of 456 pregnant women identified, 236 (51.7%) had schizophrenia and related disorders, 220 (48.3%) had affective psychosis or bipolar disorder. Women with schizophrenia and related disorders were younger, less likely to have a partner in pregnancy, more likely to be black, to smoke or misuse substances and had significantly more time in the two years before pregnancy in acute care (inpatient or intensive home treatment) compared with women with affective disorders. Both groups had high levels of domestic abuse in pregnancy (recorded in 18.9%), were from relatively deprived backgrounds and had impaired functioning measured by the Health of the Nation Outcome Scale. Women in the affective group were more likely to stop medication in the first trimester (39% versus 25%) whereas women with non-affective psychoses were more likely to switch medication. CONCLUSIONS: A significant proportion of women, particularly those with non-affective psychoses, have modifiable risk factors requiring tailored care to optimize pregnancy outcomes. Mental health professionals need to be mindful of the possibility of pregnancy in women of childbearing age and prescribe and address modifiable risk factors accordingly.