Differences in the impact of the COVID-19 pandemic in the long-term trajectories of life satisfaction by sex in the UK: a prospective cohort study.

BACKGROUND: The COVID-19 pandemic has disproportionately affected women's mental health, with most evidence focused on mental ill-health outcomes. Previous research suggests that differences in time-use might explain this disparity, as women generally spent more time doing psychologically taxing activities than men. We investigated (1) sex differences in the impact of the pandemic in the long-term trajectories of life satisfaction and (2) whether time-use differences partly explained that differential impact. METHODS: In this prospective cohort study, we used the 1970 British Cohort Study, a birth cohort representing people born in Great Britain in 1970. Since 1970, information has been collected for all cohort members every 4-10 years (ten sweeps). Additional data were collected at three timepoints during the pandemic (May 2020, September-October 2020, February-March 2021) as part of the COVID-19 Survey. Response rates within the target population ranged between 23·6% (May, 2020) and 32·5% (March, 2021) in the COVID-19 Survey. We used non-response weights to restore sample representativeness to the target population (cohort members alive and residing in the UK during the pandemic). Life satisfaction was prospectively assessed at ages 26 (1996), 30, 34, 42, 46, 50, 50·5, and 51 years (2021) using a single question with responses ranging from 0 (lowest life satisfaction) to 10 (highest life satisfaction). We used multiple-group piecewise latent growth curve models grouped by sex assigned at birth. Additional models were adjusted for self-reported number of hours spent working, volunteering, home-schooling children, taking care of children and other people, and doing housework during the pandemic. Participants provided verbal informed consent. Ethics approval was not sought as non-sensitive, open-access data with minimal risk of identification was used. FINDINGS: We analysed data from 6766 adults (3799 [56·2%] women and 2967 [43·8%] men). Compared with men, women had consistently higher levels of life satisfaction before the pandemic (Δintercept,unadjusted = 0·213, 95% CI 0·087 to 0·340, p=0·0009), and experienced a more accelerated decline with its onset (Δquad2,unadjusted = -0·018, -0·026 to -0·011; p<0·0001), even after accounting for time use (Δquad2,adjusted = -0·016, -0·031 to -0·001; p=0·0348). Results were robust to adjustment for concurrent financial and occupational situation (Δquad2,adjustedfull = -0·019, -0·035 to -0·004; p=0·0158). INTERPRETATION: Our study shows sex inequalities in the impact of the pandemic on the long-term life satisfaction trajectories of adults in their 50s. Self-reported time-use differences did not account for these inequalities. One of the limitations is that we relied on self-reported time-use and were not able to include factors like the so-called mental load (being responsible for organising or monitoring activities, regardless of being involved in their execution), which might partly explain these results. FUNDING: Economic and Social Research Council (ESRC) Centre for Society and Mental Health at King's College London.

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews.

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

A quantitative approach to the intersectional study of mental health inequalities during the COVID-19 pandemic in UK young adults.

PURPOSE: Mental health inequalities across social identities/positions during the COVID-19 pandemic have been mostly reported independently from each other or in a limited way (e.g., at the intersection between age and sex or gender). We aim to provide an inclusive socio-demographic mapping of different mental health measures in the population using quantitative methods that are consistent with an intersectional perspective. METHODS: Data included 8,588 participants from two British cohorts (born in 1990 and 2000-2002, respectively), collected in February/March 2021 (during the third UK nationwide lockdown). Measures of anxiety and depressive symptomatology, loneliness, and life satisfaction were analysed using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) models. RESULTS: We found evidence of large mental health inequalities across intersectional strata. Large proportions of those inequalities were accounted for by the additive effects of the variables used to define the intersections, with some of the largest gaps associated with sexual orientation (with sexual minority groups showing substantially worse outcomes). Additional inequalities were found by cohort/generation, birth sex, racial/ethnic groups, and socioeconomic position. Intersectional effects were observed mostly in intersections defined by combinations of privileged and marginalised social identities/positions (e.g., lower-than-expected life satisfaction in South Asian men in their thirties from a sexual minority and a disadvantaged childhood social class). CONCLUSION: We found substantial inequalities largely cutting across intersectional strata defined by multiple co-constituting social identities/positions. The large gaps found by sexual orientation extend the existing evidence that sexual minority groups were disproportionately affected by the pandemic. Study implications and limitations are discussed.

Understanding social and clinical associations with unemployment for people with schizophrenia and bipolar disorders: large-scale health records study.

PURPOSE: People with severe mental illness (SMI) experience high levels of unemployment. We aimed to better understand the associations between clinical, social, and demographic inequality indicators and unemployment. METHODS: Data were extracted from de-identified health records of people with SMI in contact with secondary mental health services in south London, UK. A Natural Language Processing text-mining application was applied to extract information on unemployment in the health records. Multivariable logistic regression was used to assess associations with unemployment, in people with SMI. RESULTS: Records from 19,768 service users were used for analysis, 84.9% (n = 16,778) had experienced unemployment. In fully adjusted models, Black Caribbean and Black African service users were more likely to experience unemployment compared with White British service users (Black Caribbean: aOR 1.62, 95% CI 1.45-1.80; Black African: 1.32, 1.15-1.51). Although men were more likely to have experienced unemployment relative to women in unadjusted models (OR 1.36, 95% CI 1.26-1.47), differences were no longer apparent in the fully adjusted models (aOR 1.05, 95% CI 0.97-1.15). The presence of a non-affective (compared to affective) diagnosis (1.24, 1.13-1.35), comorbid substance use (2.02, 1.76-2.33), previous inpatient admissions (4.18, 3.71-4.70), longer inpatient stays (78 + days: 7.78, 6.34-9.54), and compulsory admissions (3.45, 3.04-3.92) were associated with unemployment, in fully adjusted models. CONCLUSION: People with SMI experience high levels of unemployment, and we found that unemployment was associated with several clinical and social factors. Interventions to address low employment may need to also address these broader inequalities.

Long-term psychological distress trajectories and the COVID-19 pandemic in three British birth cohorts: A multi-cohort study.

BACKGROUND: Growing evidence suggests that population mental health outcomes have worsened since the pandemic started. The extent that these changes have altered common age-related trends in psychological distress, where distress typically rises until midlife and then falls after midlife in both sexes, is unknown. We aimed to analyse whether long-term pre-pandemic psychological distress trajectories were disrupted during the pandemic, and whether these changes have been different across cohorts and by sex. METHODS AND FINDINGS: We used data from three nationally representative birth cohorts comprising all people born in Great Britain in a single week of 1946 (National Survey of Health and Development, NSHD), 1958 (National Child Development Study, NCDS), or 1970 (British Cohort Study, BCS70). The follow-up data used spanned 39 years in NSHD (1982 to 2021), 40 years in NCDS (1981 to 2001), and 25 years in BCS70 (1996 to 2021). We used psychological distress factor scores, as measured by validated self-reported questionnaires (NSHD: Present State Examination, Psychiatric Symptoms Frequency, and 28- and 12-item versions of General Health Questionnaire; NCDS and BCS70: Malaise Inventory; all: 2-item versions of Generalized Anxiety Disorder scale and Patient Health Questionnaire). We used a multilevel growth curve modelling approach to model the trajectories of distress across cohorts and sexes and obtained estimates of the differences between the distress levels observed during the pandemic and those observed at the most recent pre-pandemic assessment and at the peak in the cohort-specific pre-pandemic distress trajectory, located at midlife. We further analysed whether pre-existing cohort and sex inequalities had changed with the pandemic onset using a difference-in-differences (DiD) approach. The analytic sample included 16,389 participants. By September/October 2020, distress levels had reached or exceeded the levels of the peak in the pre-pandemic life-course trajectories, with larger increases in younger cohorts (standardised mean differences [SMD] and 95% confidence intervals of SMDNSHD,pre-peak = -0.02 [-0.07, 0.04], SMDNCDS,pre-peak = 0.05 [0.02, 0.07], and SMDBCS70,pre-peak = 0.09 [0.07, 0.12] for the 1946, 1958, and 1970 birth cohorts, respectively). Increases in distress were larger among women than men, widening pre-existing sex inequalities (DiD and 95% confidence intervals of DiDNSHD,sex,pre-peak = 0.17 [0.06, 0.28], DiDNCDS,sex,pre-peak = 0.11 [0.07, 0.16], and DiDBCS70,sex,pre-peak = 0.11 [0.05, 0.16] when comparing sex inequalities in the pre-pandemic peak in midlife to those observed by September/October 2020). As expected in cohort designs, our study suffered from high proportions of attrition with respect to the original samples. Although we used non-response weights to restore sample representativeness to the target populations (those born in the United Kingdom in 1946, 1958, and 1970, alive and residing in the UK), results may not be generalisable to other sections within the UK population (e.g., migrants and ethnic minority groups) and countries different than the UK. CONCLUSIONS: Pre-existing long-term psychological distress trajectories of adults born between 1946 and 1970 were disrupted during the COVID-19 pandemic, particularly among women, who reached the highest levels ever recorded in up to 40 years of follow-up data. This may impact future trends of morbidity, disability, and mortality due to common mental health problems.

Severe mental illness, race/ethnicity, multimorbidity and mortality following COVID-19 infection: nationally representative cohort study.

BACKGROUND: The association of COVID-19 with death in people with severe mental illness (SMI), and associations with multimorbidity and ethnicity, are unclear. AIMS: To determine all-cause mortality in people with SMI following COVID-19 infection, and assess whether excess mortality is affected by multimorbidity or ethnicity. METHOD: This was a retrospective cohort study using primary care data from the Clinical Practice Research Database, from February 2020 to April 2021. Cox proportional hazards regression was used to estimate the effect of SMI on all-cause mortality during the first two waves of the COVID-19 pandemic. RESULTS: Among 7146 people with SMI (56% female), there was a higher prevalence of multimorbidity compared with the non-SMI control group (n = 653 024, 55% female). Following COVID-19 infection, the SMI group experienced a greater risk of death compared with controls (adjusted hazard ratio (aHR) 1.53, 95% CI 1.39-1.68). Black Caribbean/Black African people were more likely to die from COVID-19 compared with White people (aHR = 1.22, 95% CI 1.12-1.34), with similar associations in the SMI group and non-SMI group (P for interaction = 0.73). Following infection with COVID-19, for every additional multimorbidity condition, the aHR for death was 1.06 (95% CI 1.01-1.10) in the SMI stratum and 1.16 (95% CI 1.15-1.17) in the non-SMI stratum (P for interaction = 0.001). CONCLUSIONS: Following COVID-19 infection, patients with SMI were at an elevated risk of death, further magnified by multimorbidity. Black Caribbean/Black African people had a higher risk of death from COVID-19 than White people, and this inequity was similar for the SMI group and the control group.

Lack of fit with the neighbourhood social environment as a risk factor for psychosis - a national cohort study.

BACKGROUND: Many studies report an ethnic density effect whereby psychosis incidence among ethnic minority groups is higher in low co-ethnic density areas. It is unclear whether an equivalent density effect applies with other types of socioeconomic disadvantages. METHODS: We followed a population cohort of 2 million native Danes comprising all those born on 1st January 1965, or later, living in Denmark on their 15th birthday. Socioeconomic disadvantage, based on parents' circumstances at age 15 (low income, manual occupation, single parent and unemployed), was measured alongside neighbourhood prevalence of these indices. RESULTS: Each indicator was associated with a higher incidence of non-affective psychosis which remained the same, or was slightly reduced, if neighbourhood levels of disadvantage were lower. For example, for individuals from a low-income background there was no difference in incidence for those living in areas where a low-income was least common [incidence rate ratio (IRR) 1.01; 95% confidence interval (CI) 0.93-1.10 v. those in the quintile where a low income was most common. Typically, differences associated with area-level disadvantage were the same whether or not cohort members had a disadvantaged background; for instance, for those from a manual occupation background, incidence was lower in the quintile where this was least v. most common (IRR 0.83; 95% CI 0.71-0.97), as it was for those from a non-manual background (IRR 0.77; 95% CI 0.67-0.87). CONCLUSION: We found little evidence for group density effects in contrast to previous ethnic density studies. Further research is needed with equivalent investigations in other countries to see if similar patterns are observed.

Generational, sex, and socioeconomic inequalities in mental and social wellbeing during the COVID-19 pandemic: prospective longitudinal observational study of five UK cohorts.

BACKGROUND: Research suggests that there have been inequalities in the impact of the coronavirus disease 2019 (COVID-19) pandemic and related non-pharmaceutical interventions on population mental health. We explored generational, sex, and socioeconomic inequalities during the first year of the pandemic using nationally representative cohorts from the UK. METHODS: We analysed data from 26772 participants from five longitudinal cohorts representing generations born between 1946 and 2000, collected in May 2020, September-October 2020, and February-March 2021 across all five cohorts. We used a multilevel growth curve modelling approach to investigate generational, sex, and socioeconomic differences in levels of anxiety and depressive symptomatology, loneliness, and life satisfaction (LS) over time. RESULTS: Younger generations had worse levels of mental and social wellbeing throughout the first year of the pandemic. Whereas these generational inequalities narrowed between the first and last observation periods for LS [-0.33 (95% CI -0.51 to -0.15)], they became larger for anxiety [0.22 (0.10, 0.33)]. Generational inequalities in depression and loneliness did not change between the first and last observation periods, but initial depression levels of the youngest cohort were worse than expected if the generational inequalities had not accelerated. Women and those experiencing financial difficulties had worse initial mental and social wellbeing levels than men and those financially living comfortably, respectively, and these gaps did not substantially differ between the first and last observation periods. CONCLUSIONS: By March 2021, mental and social wellbeing inequalities persisted in the UK adult population. Pre-existing generational inequalities may have been exacerbated with the pandemic onset. Policies aimed at protecting vulnerable groups are needed.

Prevalence of common mental disorders and treatment receipt for people from ethnic minority backgrounds in England: repeated cross-sectional surveys of the general population in 2007 and 2014.

BACKGROUND: Concerns persist that some ethnic minority groups experience longstanding mental health inequalities in England. It is unclear if these have changed over time. AIMS: To assess the prevalence of common mental disorders (CMDs) and treatment receipt by ethnicity, and changes over time, using data from the nationally representative probability sample in the Adult Psychiatric Morbidity Surveys. METHOD: We used survey data from 2007 (n = 7187) and 2014 (n = 7413). A Clinical Interview Schedule - Revised score of ≥12 indicated presence of a CMD. Treatment receipt included current antidepressant use; any counselling or therapy; seeing a general practitioner about mental health; or seeing a community psychiatrist, psychologist or psychiatric nurse, in the past 12 months. Multivariable logistic regression assessed CMD prevalence and treatment receipt by ethnicity. RESULTS: CMD prevalence was highest in the Black group; ethnic variation was explained by demographic and socioeconomic factors. After adjustment for these factors and CMDs, odds ratios for treatment receipt were lower for the Asian (0.62, 95% CI 0.39-1.00) and White Other (0.58, 95% CI 0.38-0.87) groups in 2014, compared with the White British group; for the Black group, this inequality appeared to be widening over time (2007 treatment receipt odds ratio 0.68, 95% CI 0.38-1.23; 2014 treatment receipt odds ratio 0.23, 95% CI 0.13-0.40; survey year interaction P < 0.0001). CONCLUSIONS: Treatment receipt was lower for all ethnic minority groups compared with the White British group, and lowest among Black people, for whom inequalities appear to be widening over time. Addressing socioeconomic inequality could reduce ethnic inequalities in mental health problems, but this does not explain pronounced treatment inequalities.

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.

Explaining ethnic variations in adolescent mental health: a secondary analysis of the Millennium Cohort Study.

PURPOSE: The relationship between ethnicity and adolescent mental health was investigated using cross-sectional data from the nationally representative UK Millennium Cohort Study. METHODS: Parental Strengths and Difficulties Questionnaire reports identified mental health problems in 10,357 young people aged 14 (n = 2042 from ethnic minority backgrounds: Mixed n = 492, Indian n = 275, Pakistani n = 496, Bangladeshi n = 221, Black Caribbean n = 102, Black African n = 187, Other Ethnic Group n = 269). Univariable logistic regression models investigated associations between each factor and outcome; a bivariable model investigated whether household income explained differences by ethnicity, and a multivariable model additionally adjusted for factors of social support (self-assessed support, parental relationship), participation (socialising, organised activities, religious attendance), and adversity (bullying, victimisation, substance use). Results were stratified by sex as evidence of a sex/ethnicity interaction was found (P = 0.0002). RESULTS: There were lower unadjusted odds for mental health problems in boys from Black African (OR 0.15, 95% CI 0.04-0.61) and Indian backgrounds (OR 0.42, 95% CI 0.21-0.86) compared to White peers. After adjustment for income, odds were lower in boys from Black African (OR 0.10, 95% CI 0.02-0.38), Indian (OR 0.40, 95% CI 0.21-0.77), and Pakistani (OR 0.49, 95% CI 0.27-0.89) backgrounds, and girls from Bangladeshi (OR 0.18, 95% CI 0.05-0.65) and Pakistani (OR 0.63, 95% CI 0.41-0.99) backgrounds. After further adjustment for social support, participation, and adversity factors, only boys from a Black African background had lower odds (OR 0.16, 95% CI 0.03-0.71) of mental health problems. CONCLUSIONS: Household income confounded lower prevalence of mental health problems in some young people from Pakistani and Bangladeshi backgrounds; findings suggest ethnic differences are partly but not fully accounted for by income, social support, participation, and adversity. Addressing income inequalities and socially focused interventions may protect against mental health problems irrespective of ethnicity.

A comparison of single and intersectional social identities associated with discrimination and mental health service use: data from the 2014 Adult Psychiatric Morbidity Survey in England.

Inequities in mental health service use (MHSU) and treatment are influenced by social stratification processes linked to socially contextualised interactions between individuals, organisations and institutions. These complex relations underpin observed inequities and their experience by people at the intersections of social statuses. Discrimination is one important mechanism influencing such differences. We compared inequities in MHSU/treatment through single and intersectional status analyses, accounting for need. We assessed whether past-year discrimination differentially influences MHSU/treatment across single and intersecting statuses. Data came from a population survey (collected 2014-2015) nationally representative of English households (N = 7546). We used a theory and datadriven approach (latent class analysis) which identified five intersectional groups in the population comprising common combinations of social statuses. Single status analyses identified characteristics associated with MHSU/treatment (being a sexual minority (adjusted odds ratio (AOR) 1.65 95% CI:1.09-2.50), female (AOR 1.71, 95% CI:1.45-2.02), economically inactive (AOR 2.02, 95% CI:1.05-3.90), in the most deprived quintile (AOR 1.33, 95% CI:1.02-1.74), and Black (AOR 0.36 95% CI:0.20-0.66)). Intersectional analyses detected patterns not apparent from single status analyses. Compared to the most privileged group ("White British, highly educated, employed, high social class"), "Retired White British" had greater odds of MHSU/treatment (AOR 1.88, 95% CI:1.53-2.32) while "Employed migrants" had lower odds (AOR 0.39, 95% CI:0.27-0.55). Past-year discrimination was associated with certain disadvantaged social statuses and greater MHSU/treatment but-except for sexual minorities-adjusting for discrimination had little influence using either analytic approach. Observing patterns only by single social statuses masks potentially unanticipated and contextually varying inequities. The latent class approach offers policy-relevant insights into patterns and mechanisms of inequity but may mask other key intersectional patterns by statuses less common or under represented in surveys (e.g. UK-born ethnic minority groups). We propose multiple, context-relevant, theory-driven approaches to intersectional understanding of mental health inequalities.

Change in incidence rates for psychosis in different ethnic groups in south London: findings from the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study.

BACKGROUND: A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time. METHODS: We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier. RESULTS: From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6-55.3) to 63.1 (95% CI 57.3-69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4-8.3) to 2.8 (2.1-3.6) and the 'mixed' group from 2.7 (1.8-4.2) to 1.4 (0.9-2.1). In the black African group, there was a negligible difference from 4.1 (3.2-5.3) to 3.5 (2.8-4.5). CONCLUSIONS: We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.

How do ethnicity and deprivation impact on life expectancy at birth in people with serious mental illness? Observational study in the UK.

BACKGROUND: Across international contexts, people with serious mental illnesses (SMI) experience marked reductions in life expectancy at birth. The intersection of ethnicity and social deprivation on life expectancy in SMI is unclear. The aim of this study was to assess the impact of ethnicity and area-level deprivation on life expectancy at birth in SMI, defined as schizophrenia-spectrum disorders, bipolar disorders and depression, using data from London, UK. METHODS: Abridged life tables to calculate life expectancy at birth, in a cohort with clinician-ascribed ICD-10 schizophrenia-spectrum disorders, bipolar disorders or depression, managed in secondary mental healthcare. Life expectancy in the study population with SMI was compared with life expectancy in the general population and with those residing in the most deprived areas in England. RESULTS: Irrespective of ethnicity, people with SMI experienced marked reductions in life expectancy at birth compared with the general population; from 14.5 years loss in men with schizophrenia-spectrum and bipolar disorders, to 13.2 years in women. Similar reductions were noted for people with depression. Across all diagnoses, life expectancy at birth in people with SMI was lower than the general population residing in the most deprived areas in England. CONCLUSIONS: Irrespective of ethnicity, reductions in life expectancy at birth among people with SMI are worse than the general population residing in the most deprived areas in England. This trend in people with SMI is similar to groups who experience extreme social exclusion and marginalisation. Evidence-based interventions to tackle this mortality gap need to take this into account.

Time of referral to older adult liaison psychiatry service and other factors affecting length of stay in the general hospital.

OBJECTIVES: To explore the relationship between social and clinical factors with (1) Time to referral to an older adult liaison psychiatry service, and (2) Length of stay (LOS), in a sample of older adults admitted to an acute general medical hospital receiving liaison psychiatry intervention, in London, United Kingdom, over a 3-year period. METHODS: Information on patients referred to liaison psychiatry for older adults between January 2013 and December 2015 was collected using structured forms, with clinical diagnoses determined according to International Classification of Mental Disorders-10. The association of social and clinical factors with the time taken to refer to liaison psychiatry and LOS was assessed using Cox proportional hazards regression and zero-truncated Poisson regression, respectively. RESULTS: Compared with people who were diagnosed with depression, older adults with psychotic and alcohol use disorders had higher rates of referral to liaison psychiatry (adjusted hazard ratios [aHRs] 1.83 [95% CI: 1.30, 2.59] and aHR 1.69 [95% CI: 1.01, 2.83]) respectively. In adjusted models, LOS was increased in older adults with delusional disorders and shorter in people with alcohol use disorders, personality disorders and learning disabilities, compared to people with depressive diagnoses. Within this cohort, a new definite dementia diagnosis and longer time to refer to liaison psychiatry were both associated with a longer length of general hospital in-patient stay. CONCLUSIONS: In older adults admitted to general medical hospitals, and needing liaison psychiatry input, timely referral may be associated with a shorter LOS.

Differences in survival and mortality in minority ethnic groups with dementia: A systematic review and meta-analysis.

OBJECTIVES: Although there are disparities in both risk of developing dementia and accessibility of dementia services for certain minority ethnic groups in the United States and United Kingdom, disparities in survival after a dementia diagnosis are less well-studied. Our objective was to systematically review the literature to investigate racial/ethnic differences in survival and mortality in dementia. METHODS: We searched Embase, Ovid MEDLINE, Global Health and PsycINFO from inception to November 2018 for studies comparing survival or mortality over time in at least two race/ethnicity groups. Studies from any country were included but analysed separately. We used narrative synthesis and random-effects meta-analysis to synthesise findings. The Newcastle-Ottawa Scale was used to assess quality and risk of bias in individual studies. RESULTS: We identified 22 articles, most from the United States (n = 17), as well as the United Kingdom (n = 3) and the Netherlands (n = 1). In a meta-analysis of US studies, hazard of mortality was lower in Black/African American groups (Pooled Hazard Ratio = 0.86, 95% CI = 0.82-0.91, I2  = 17%, from four studies) and Hispanic/Latino groups (Pooled HR = 0.65, 95% CI = 0.50-0.84, I2  = 86%, from four studies) versus comparison groups. However, study quality was mixed, and in particular, quality of reporting of race/ethnicity was inconsistent. CONCLUSION: Literature indicates that Black/African American and Hispanic/Latino groups may experience lower mortality in dementia versus comparison groups in the United States, but further research, using clearer and more and consistent reporting of race/ethnicity, is necessary to understand what drives these patterns and their implications for policy and practice.

The association of migration and ethnicity with use of the Improving Access to Psychological Treatment (IAPT) programme: a general population cohort study.

BACKGROUND: Common mental disorders (CMD), such as depression and anxiety, are an important cause of morbidity, economic burden and public mental health need. The UK Improving Access to Psychological Therapies (IAPT) programme is a national effort to reduce the burden and impact of CMD, available since 2008. AIMS: To examine ethnic and migration-related differences in use of IAPT-based psychological treatment using a novel epidemiological dataset with linkage to de-identified IAPT records. METHOD: Data from a psychiatric morbidity survey of two South East London boroughs (2008-2010) were individually-linked to data on IAPT services serving those boroughs. We used Poisson regression to estimate association between ethnicity and migration status (including years of UK residence), with rate of subsequent use of psychological treatment. RESULTS: The rate of psychological treatment use was 14.4 cases per thousand person years [cases/1000 pyrs, 95% confidence intervals (95% CI) 12.4, 16.7]. There was strong statistical evidence that compared to non-migrants, migrants residing in the UK for less than 10 years were less likely to use psychological treatment after adjustment for probable sociodemographic predictors of need, life adversity, and physical/psychiatric morbidity at baseline [rate ratio (RR) 0.4 (95% CI 0.20, 0.75]. This difference was not explained by migration for asylum/political reasons, or English language proficiency, and was evident for both self- and GP referrals. CONCLUSIONS: Lower use of IAPT among recent migrants is unexplained by sociodemographics, adversity, and baseline morbidity. Further research should focus on other individual-level and societal barriers to psychological treatment use among recent migrants to the UK, including in categories of intersecting migration and ethnicity.

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.

BACKGROUND: People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD. METHODS: Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines. RESULTS: One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings. CONCLUSIONS: These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda. GUIDELINES: https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.

Correction to: Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.

An amendment to this paper has been published and can be accessed via the original article.