Protecting and promoting editorial independence.

We argue that editorial independence, through robust practice of publication ethics and research integrity, promotes good science and prevents bad science. We elucidate the concept of research integrity, and then discuss the dimensions of editorial independence. Best practice guidelines exist, but compliance with these guidelines varies. Therefore, we make recommendations for protecting and strengthening editorial independence.

The role of social support in reducing the long-term burden of cumulative childhood adversity on adulthood internalising disorder.

PURPOSE: Previous research indicates that social support is protective for the mental health outcomes of exposure to childhood adversity. However, the impact of social support as a protective factor following exposure to cumulative childhood adversity is understudied with prospective longitudinal data. The aim of this present study was to examine how social support mediates the impact of cumulative exposure to childhood adversity on internalising disorder in adulthood. METHODS: The Christchurch Health and Development Study (CHDS) is a general population birth cohort, born in 1977 and representative of Christchurch, New Zealand at the time of the cohort members' birth. The present study used a generalised estimating equations (GEE) framework to analyse direct associations between a cumulative measure of childhood adversity (CA) and internalising disorders (major depression, and any anxiety disorder), and indirect associations through social support. RESULTS: Results indicated a dose-dependent relationship between increased exposure to CA and worsened odds of a diagnosis for major depression and any anxiety disorder, respectively. There was also a significant mediating effect of social support on the direct associations between CA and both major depression (OR (95%CI) =0 .98 (0.97, 0.99), p < 001) and any anxiety disorder (OR (95%CI) = .98 (0.97, 0.99), p < 001). CONCLUSION: The findings indicate that social support reduces the impact of childhood adversity on adult mental health, and is therefore a target for future work examining potential interventions following CA.

Suicide and self-harm.

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Methamphetamine use and psychotic symptoms: findings from a New Zealand longitudinal birth cohort.

BACKGROUND: This study examined the association between methamphetamine use and psychotic symptoms in a New Zealand general population birth cohort (n = 1265 at birth). METHODS: At age 18, 21, 25, 30, and 35, participants reported on their methamphetamine use and psychotic symptoms in the period since the previous interview. Generalized estimating equations modelled the association between methamphetamine use and psychotic symptoms (percentage reporting any symptom, and number of symptoms per participant). Confounding factors included childhood individual characteristics, family socioeconomic circumstances and family functioning. Long term effects of methamphetamine use on psychotic symptoms were assessed by comparing the incidence of psychotic symptoms at age 30-35 for those with and without a history of methamphetamine use prior to age 30. RESULTS: After adjusting for confounding factors and time-varying covariate factors including concurrent cannabis use, methamphetamine use was associated with a modest increase in psychosis risk over five waves of data (adjusted odds ratio (OR) 1.33, 95% confidence interval (CI) 1.03-1.72 for the percentage measure; and IRR 1.24, 95% CI 1.02-1.50 for the symptom count measure). The increased risk of psychotic symptoms was concentrated among participants who had used at least weekly at any point (adjusted OR 2.85, 95% CI 1.21-6.69). Use of methamphetamine less than weekly was not associated with increased psychosis risk. We found no evidence for a persistent vulnerability to psychosis in the absence of continuing methamphetamine use. CONCLUSION: Methamphetamine use is associated with increased risk of psychotic symptoms in the general population. Increased risk is chiefly confined to people who ever used regularly (at least weekly), and recently.

Epistemic problems with mental health legislation in the doctor-patient relationship.

Mental health legislation that requires patients to accept 'care' has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor-patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation.

Variation in the use of compulsory community treatment orders between district health boards in New Zealand.

OBJECTIVE: To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability. METHODS: The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions. RESULTS: The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Maori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe. CONCLUSIONS: CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated.

Many mental disorders are linked to personality, but this is rarely recognised in clinical practice. It is suggested here that when the links are very close, the two can be joined. Galenic syndromes are so named because Galen was the first physician to recognise the links between personality and disease.

A Novel Graphical Method for Data Presentation in Alcohol Systematic Reviews: The Interactive Harvest Plot.

AIMS: To demonstrate a novel method for presenting and exploring data in systematic reviews of the alcohol literature. METHODS: Harvest plots are a graphical method for displaying data on the overall pattern of evidence from a systematic review. They can display the direction of effects and risk of bias within studies for multiple outcomes in a single graphical chart. Using data from our previous meta-analysis on the association between personality disorder and alcohol treatment outcome, we extended the application of harvest plots by developing an interactive online harvest plot application. RESULTS: Studies included in the review were heterogeneous in design. There were many different primary outcomes, and similar outcomes were often defined differently across studies. The interactive harvest plot allows readers to explore trends in the data across multiple outcomes, including the impact of within-study bias and year of publication. In contrast, meta-analysis on the same data was hampered by a lack of consistency in the way outcomes were measured, and incomplete reporting of effect sizes and their variance. This meant many studies included in the systematic review could not be meta-analysed. CONCLUSIONS: Interactive harvest plots are a novel graphical method to present data from systematic reviews. They can supplement or even replace meta-analysis when the studies included in a systematic review use heterogeneous designs and measures, as is often the case in the alcohol literature.

Risk-relativity is still a nonsense.

In this short response to Gray's article Capacity and Decision Making we double down on our argument that risk-relativity is a nonsense. Risk relativity is the claim that we should set a higher standard of competence for a person to make a risky choice than to make a safe choice. Gray's response largely involves calling attention to the complexities, ramifications and multiple value implications of decision-making, but we do not deny any of this. Using the notion of quality of care mentioned by Gray, we construct an argument that might be used to support risk relativity. But it is no more persuasive than the arguments put forward by risk-relativists.

Risk-related standards of competence are a nonsense.

If a person is competent to consent to a treatment, is that person necessarily competent to refuse the very same treatment? Risk relativists answer no to this question. If the refusal of a treatment is risky, we may demand a higher level of decision-making capacity to choose this option. The position is known as asymmetry. Risk relativity rests on the possibility of setting variable levels of competence by reference to variable levels of risk. In an excellent 2016 article in Journal of Medical Ethics (JME), Rob Lawlor defends asymmetry of this kind by defending risk relativity, using and developing arguments and approaches found in earlier work such as that of Wilks. He offers what we call the two-scale approach: a scale of risk is to be used to set a standard of competence on a scale of decision-making difficulty. However, can this be done in any rational way? We argue it cannot, and in this sense, and to this extent, risk relativity is a nonsense.

Harmful Choices, the Case of C, and Decision-Making Competence.

In this paper, we make the case that a person who is considering or has already made a decision that appears seriously harmful to that person should in some cases be judged incapable of making that decision because of the harmfulness of the decision. We focus on the English case of C of 2015. C refused life-saving dialysis. The hospital wanted her declared incompetent to make this decision under the English Mental Capacity Act of 2005. The Judge argued that the consequences for a person's welfare of their decision are irrelevant to the assessment of competence, a position labeled "internalism." This aligns with an assessment of decision-making competence on a strictly cognitivist model. However, internalism misrepresents decision-making. The outcomes of decision-making processes should be part and parcel of judgments of decision-making competence, and in some cases are necessary for any judgment of incompetence to be made.

Supported Decision making teaching in New Zealand postgraduate psychiatry trainees.

OBJECTIVE: To examine psychiatric trainees teaching of supported decision-making (SDM). METHOD: New Zealand psychiatric trainees were surveyed about teaching regarding SDM using a novel tool. The analysis strategy examined the latent structure of the questionnaire and correlates of teaching in these areas. RESULTS: Forty nine trainees participated. Questions related to support from others and consistency of engagement were most highly endorsed while the concept of experiential learning was most poorly endorsed. Three latent factors were identified: 'enabling personhood', 'decision autonomy' and 'experiential learning'. Only gender correlated with the total summed score of the questionnaire, and two latent factors. CONCLUSIONS: Teaching about SDM occurs to some degree throughout New Zealand. The questionnaire captures the experience of learning in this area with a three-factor structure; enabling personhood, enhancing decisional autonomy and experiential learning.

Does a comprehensive service user-led education programme effect more positive attitudes towards recovery and less stigmatising attitudes towards people with lived experience of mental distress in medical students? A comparative cohort study.

OBJECTIVE: This study sought to investigate the impact of a service user-led anti-stigma and discrimination education programme, encompassing numerous interventions focused on facilitating multiple forms of social contact, the promotion of recovery, and respect for human rights, on medical student attitudes. METHOD: A comparison cohort study was used to compare the attitudes of two cohorts of medical students who received this programme as part of their fifth (the fifth-year cohort) or sixth (the sixth-year cohort) year psychological medical education attachment (programme cohorts) with two cohorts of equivalent students who received a standard psychological medical attachment (control cohorts). Attitudes to recovery (using the Recovery Attitudes Questionnaire) and stigma (using the Opening Minds Scale for Healthcare Providers) were measured at the beginning and end of the attachments for each year and compared both within and between the cohorts using Wilcoxon signed-rank or Wilcoxon rank-sum tests. RESULTS: With sample sizes ranging from 46 to 70 across all cohorts, after their psychological medicine attachment both the programme and control cohorts showed more positive attitudes towards recovery and less stigmatising attitudes towards people with lived experience of mental distress. Significant differences between the programme cohorts and the control cohorts were found for recovery attitudes (median difference of 2, p < 0.05 in both fifth and sixth year), with particularly large differences being found for the 'recovery is possible and needs faith' subdomain of the Recovery Attitudes Questionnaire. There were no significant between cohort differences in terms of stigmatising attitudes as measured by the Opening Minds Scale for Healthcare Providers. CONCLUSION: The introduction of a comprehensive service user-led anti-stigma and education programme resulted in significant improvements in recovery attitudes compared to a control cohort. However, it was not found to be similarly superior in facilitating less stigmatising attitudes. Various possible reasons for this are discussed.

Personality disorder prevalence and correlates in a whole of nation dataset.

PURPOSE: The epidemiology of personality disorder is poorly understood. This study aims to describe the population in contact with mental health services with a diagnosis of personality disorder and compare service use between this group and those with a diagnosis of depression. METHODS: Investigation of a routinely collected clinical data set across New Zealand was conducted. We used data from 2008 to 2017 and 1-year data from 2016, the most complete dataset. This allowed for variation over the years and confirmation within a 1-year prevalence. These data were analysed focusing on patients with a primary diagnosis of any personality disorder and the subset with borderline personality disorder (BPD). BPD was chosen as the most common clinical personality disorder diagnosis and that most researched. RESULTS: 8884 (2.8%) of the population in contact with mental health services carried a primary diagnosis of personality disorder. Personality diagnosis other than antisocial personality disorder (ASPD) in men and borderline personality disorder (BPD) in either gender was negligible. Rates of personality pathology increased with social deprivation and were commonest in young adults. Multi-morbidity was the norm, with internalising disorder common. Maori diagnosed with PD were over-represented both in the patient group and by population. CONCLUSION: Borderline personality disorder and antisocial personality disorder are routinely diagnosed in routine clinical practice in New Zealand; however, other categorical diagnoses are not made. Patients with PD are significant users of resources in comparison to depressed patients. Resource utilisation was significantly greater in those with PD, in particular use of inpatient services compared to those with depression.

A comparative analysis of two alternative programmes to counter stigma and discrimination associated with mental illness delivered to medical students.

OBJECTIVE: To assess and compare attitudes of medical students in response to two service-user-led anti-stigma and discrimination education programmes. METHOD: Two programmes, consistent with the key elements of effective contact-based anti-stigma and discrimination education programmes for healthcare providers, were delivered to medical students in their penultimate and final year: a more intensive version of the programme in 2015/2016 and a briefer programme in 2016/2017. Attitudes were assessed using the Recovery Attitudes Questionnaire (RAQ) and the Opening Minds Stigma Scale for Health Care Providers (OMS-HC-20) at the beginning and end of their final year. RESULTS: There were no significant differences between the years in initial scores on either scale. Both cohorts showed statistically significant reductions in scores on both scales after completion of the programme, indicating overall improvements in students' attitudes with reductions in stigma, and more positive attitudes towards recovery of those in mental distress. The more intensive programme led to significantly greater improvement in reductions in stigma than the less intensive programme. CONCLUSION: Findings support the need for contact-based anti-stigma and discrimination education programmes for medical students that are both intensive and repeated over time.

A systematic review of the label accuracy of cannabinoid-based products in regulated markets: is what's on the label what's in the product?

OBJECTIVES: To review the literature regarding label accuracy and contamination of medical cannabinoid-based products. METHODS: A systematic review with meta-analysis following PRISMA guidelines. This study is registered with PROSPERO (CRD42019131565). RESULTS: Five studies reported label accuracy data ranging between 17% and 86%. Four studies reported contaminants, including pesticides, solvents and AB-FUBINACA. Meta-analysis was limited to the proportion of pesticide-contaminated samples found in two studies (0.25 (95% CI [0.10, 0.40])) and displayed significant heterogeneity. CONCLUSIONS: Label inaccuracies and contaminants are found across a spectrum of cannabinoid-based products. The review highlights the paucity and heterogeneity of research relating to cannabinoid-based products in light of changing global legislation. Further robust research is required to support ongoing pharmacovigilance and patient safety.

Who controls your future: The convention on the rights of persons with disabilities from a service user focused perspective.

Although notions of personal autonomy are increasingly enshrined as the primary principle of ethical medical practice, psychiatry appears to have real difficulty in applying this. Notions such as compulsory treatment and mental health legislation serve to reinforce paternalism. This may not be in the interests of either the patient or the doctor. The Convention on the Rights of Persons with Disabilities (CRPD), although providing no new rights to mental health patients, has led to guidance as to what existing rights entail and how they should be applied. While service users were involved in the drafting of the Convention on the Rights of Persons with Disabilities, what is lacking is service user focused perspectives in the critique and debate that has ensued in response to the Convention on the Rights of Persons with Disabilities committee's informed guidance as to the correct interpretation of the rights. Furthermore, consideration of how to translate the rights into practice is also lacking. This co-produced viewpoint aims to contribute to this debate and provides a brief overview of a novel educational approach to translating the Convention on the Rights of Persons with Disabilities committee's guidance into clinical practice.

Alcohol use in adolescents and adult psychopathology and social outcomes: Findings from a 35-year cohort study.

OBJECTIVE: To examine the consequences of alcohol consumption and symptoms of alcohol use disorder during adolescence and later adulthood psychopathology and social outcomes. METHODS: A longitudinal, prospective birth cohort study, the Christchurch Health and Development Study, was examined across a 35-year period. We estimated the associations between two measures of adolescent alcohol use (volume of alcohol consumed and symptoms of alcohol use disorder) and two later internalising disorders, externalising psychopathology measured by substance use disorders and psychosocial outcomes in adulthood, adjusting for individual and family factors from childhood. RESULTS: The pattern of results indicates alcohol symptoms predict internalising disorder in adulthood. Volume of alcohol used in adolescence predicted adult substance use disorders, lower educational attainment and higher risk of welfare benefit receipt in adulthood in fully adjusted models. CONCLUSION: Early consumption of larger volumes of alcohol led to continuation of this pattern in adult life with resulting poorer educational achievement, increased welfare benefit receipt and substance use disorders. Early symptoms of alcohol use disorder, however, led to increased adult levels of mental health disorders. This relationship persisted within a 20-year study period and after adjustment for statistically significant covariate factors. The study shows that early patterns of alcohol use have a direct and specific impact upon adult outcomes.

Making the World of Difference: a service user-led education programme reshaping the learning environment in psychiatry.

OBJECTIVE: To describe the implementation of a service user-led learning programme implemented within the education of undergraduate medical students and psychiatric registrars. CONCLUSION: This programme has the potential to impact on the learning of those early in their medical career and future consultant psychiatrists. Ongoing research will help to explain the reach and depth of the programme and the elements of greatest benefit.

Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis.

BACKGROUND: Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.AimsOur aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters. METHOD: This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics. RESULTS: Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27-0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43-2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies. CONCLUSIONS: Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.Declaration of interestNone.