The complexity of treatment-resistant depression: A data-driven approach.

BACKGROUND: Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample. METHODS: As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events. RESULTS: Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience. LIMITATIONS: Potential for recall bias, not examining possible interactions, and absence of a control group. CONCLUSIONS: Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

A cross-sectional investigation into the role of intersectionality as a moderator of the relation between youth adversity and adolescent depression/anxiety symptoms in the community.

BACKGROUND: Adolescents exposed to adversity show higher levels of depression and anxiety, with the strongest links seen in socially/societally disadvantaged individuals (e.g., females, low socioeconomic status [SES]), as well as neurodivergent individuals. The intersection of these characteristics may be important for the differential distribution of adversity and mental health problems, though limited findings pertain to the extent to which intersectional effects moderate this association. METHODS: Combined depression/anxiety symptoms were measured using the emotional problems subscale of the Strengths and Difficulties Questionnaire in 13-14-year-olds in Cornwall, United Kingdom in 2017-2019. In a cross-sectional design (N = 11,707), multiple group structural equation modeling was used to estimate the effects of youth adversity on depression/anxiety symptoms across eight intersectionality profiles (based on gender [female/male], SES [lower/higher], and traits of hyperactivity/inattention [high/low]). Moderation effects of these characteristics and their intersections were estimated. RESULTS: Youth adversity was associated with higher levels of depression/anxiety (compared to an absence of youth adversity), across intersectional profiles. This effect was moderated by gender (stronger in males; ß = 0.22 [0.11, 0.36]), and SES (stronger in higher SES; ß = 0.26 [0.14,0.40]); with indications of moderation attributable to the intersection between gender and hyperactivity/inattention (ß = 0.21 [-0.02,0.44]). CONCLUSIONS: Youth adversity is associated with heightened depression/anxiety across intersectional profiles in 13-14-year-olds. The stronger effects observed for males, and for higher SES, may be interpreted in terms of structural privilege. Preliminary findings suggest that vulnerability and resilience to the effects of youth adversity may partially depend on specific intersectional effects. Importantly, the current results invite further investigation in this emerging line of inquiry.

Brief Educational Workshops in Secondary Schools Trial (BESST trial), a school-based cluster randomised controlled trial of the DISCOVER workshop for 16-18-year-olds: recruitment and baseline characteristics.

BACKGROUND: The Brief Educational Workshops in Secondary Schools Trial (BESST) is an England-wide school-based cluster randomised controlled trial assessing the clinical and cost-effectiveness of an open-access psychological workshop programme (DISCOVER) for 16-18-year-olds. This baseline paper describes the self-referral and other recruitment processes used in this study and the baseline characteristics of the enrolled schools and participants. METHOD: We enrolled 900 participants from 57 Secondary schools across England from 4th October 2021 to 10th November 2022. Schools were randomised to receive either the DISCOVER day-long Stress workshop or treatment as usual which included signposting information. Participants will be followed up for 6 months with outcome data collection at baseline, 3-month, and 6-month post randomisation. RESULTS: Schools were recruited from a geographically and ethnically diverse sample across England. To reduce stigma, students were invited to self-refer into the study if they wanted help for stress. Their mean age was 17.2 (SD = 0.6), 641 (71%) were female and 411 (45.6%) were from ethnic minority groups. The general wellbeing of our sample measured using the Mood and Feelings Questionnaire (MFQ) found 314 (35%) of students exhibited symptoms of depression at baseline. Eighty percent of students reported low wellbeing on the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) suggesting that although the overall sample mean is below the cut-off for depression, the self-referral approach used in this study supports distressed students in coming forward. CONCLUSION: The BESST study will continue to follow up participants to collect outcome data and results will be analysed once all the data have been collected. TRIAL REGISTRATION: ISRCTN registry ISRCTN90912799. Registered on 28 May 2020.

Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK.

BACKGROUND: Depression and anxiety are increasingly prevalent in adolescents. The Brief Educational Workshops in Secondary Schools Trial investigated the effectiveness of a brief accessible stress workshop programme for 16-18-year-olds. We aimed to investigate the clinical effectiveness and cost-effectiveness of the DISCOVER cognitive behavioural therapy (CBT) workshop on symptoms of depression in 16-18-year-olds at 6 months compared with treatment-as-usual. METHODS: We conducted a multicentre, cluster randomised controlled trial in UK schools or colleges with sixth forms to evaluate clinical effectiveness and cost-effectiveness of a brief CBT workshop (DISCOVER) compared with treatment-as-usual. We planned to enrol 60 schools and 900 adolescents, using a self-referral system to recruit participants. Schools were randomised in a 1:1 ratio for participants to receive either the DISCOVER workshop or treatment-as-usual, stratified by site and balanced on school size and index of multiple deprivation. Participants were included if they were 16-18 years old, attending for the full school year, seeking help for stress, and fluent in English and able to provide written informed consent. The outcome assessors, senior health economist, senior statistician, and chief investigator were masked. People with lived experience were involved in the study. The primary outcome was depression symptoms measured with the Mood and Feelings Questionnaire (MFQ) at 6-month follow-up, in the intention-to-treat population of all participants with full covariate data. The trial was registered with the ISRCTN registry (ISRCTN90912799). FINDINGS: 111 schools were invited to participate in the study, seven were deemed ineligible, and 47 did not provide consent. Between Oct 4, 2021, and Nov 10, 2022, 933 students at 57 schools were screened for eligibility, seven were not eligible for inclusion, and 26 did not attend the baseline meeting and assessment, resulting in 900 adolescents participating in the study. The DISCOVER group included 443 participants (295 [67%] female and 136 [31%] male) and the treatment-as-usual group included 457 participants (346 [76%] female and 92 [20%] male). 468 (52%) of the 900 participants were White, and the overall age of the participants was 17·2 years (SD 0·6). 873 (97%) adolescents were followed up in the intention-to-treat population. The primary intention-to-treat analysis (n=854) found an adjusted mean difference in MFQ of -2·06 (95% CI -3·35 to -0·76; Cohen's d=-0·17; p=0·0019) at the 6-month follow-up, indicating a clinical improvement in the DISCOVER group. The probability that DISCOVER is cost- effective compared with treatment-as-usual ranged from 61% to 78% at a £20 000 to £30 000 per quality-adjusted life-year threshold. Nine adverse events (two of which were classified as serious) were reported in the DISCOVER group and 14 (two of which were classified as serious) were reported in the treatment-as-usual group. INTERPRETATION: Our findings indicate that the DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools. Given the importance of addressing mental health needs early in this adolescent population, additional research is warranted to explore this intervention. FUNDING: National Institute for Health and Care Research Health Technology Assessment Programme.

The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders.

BACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Youth adversity and trajectories of depression/anxiety symptoms in adolescence in the context of intersectionality in the United Kingdom.

BACKGROUND: Youth adversity is associated with persistence of depression and anxiety symptoms. This association may be greater for disadvantaged societal groups (such as females) compared with advantaged groups (e.g. males). Given that persistent symptoms are observed across a range of disadvantaged, minoritized, and neurodivergent groups (e.g. low compared with high socio-economic status [SES]), the intersection of individual characteristics may be an important moderator of inequality. METHODS: Data from HeadStart Cornwall (N = 4441) was used to assess the effect of youth adversity on combined symptoms of depression and anxiety (Strengths and Difficulties Questionnaire emotional problems subscale) measured at three time-points in 11-14-year-olds. Latent trajectories and regressions were estimated for eight intersectionality profiles (based on gender, SES, and hyperactivity/inattention), and moderating effects of the individual characteristics and their intersections were estimated. RESULTS: Youth adversity was associated with higher average depression/anxiety symptoms at baseline (11-12-years) across all intersectionality profiles. The magnitude of effects differed across profiles, with suggestive evidence for a moderating effect of youth adversity on change over time in depression/anxiety symptoms attributable to the intersection between (i) gender and SES; and (ii) gender, SES, and hyperactivity/inattention. CONCLUSIONS: The detrimental effects of youth adversity pervade across intersectionality profiles. The extent to which these effects are moderated by intersectionality is discussed in terms of operational factors. The current results provide a platform for further research, which is needed to determine the importance of intersectionality as a moderator of youth adversity on the development of depression and anxiety symptoms in adolescence.

Clinical effectiveness of the psychological therapy Mental Health Intervention for Children with Epilepsy in addition to usual care compared with assessment-enhanced usual care alone: a multicentre, randomised controlled clinical trial in the UK.

BACKGROUND: Mental health difficulties are common in children and young people with chronic health conditions, but many of those in need do not access evidence-based psychological treatments. The study aim was to evaluate the clinical effectiveness of integrated mental health treatment for children and young people with epilepsy, a common chronic health condition known to be associated with a particularly high rate of co-occurring mental health difficulties. METHODS: We conducted a parallel group, multicentre, open-label, randomised controlled trial of participants aged 3-18 years, attending epilepsy clinics across England and Northern Ireland who met diagnostic criteria for a common mental health disorder. Participants were randomised (1:1; using an independent web-based system) to receive the Mental Health Intervention for Children with Epilepsy (MICE) in addition to usual care, or assessment-enhanced usual care alone (control). Children and young people in both groups received a full diagnostic mental health assessment. MICE was a modular psychological intervention designed to treat common mental health conditions in children and young people using evidence-based approaches such as cognitive behaviour therapy and behavioural parenting strategies. Usual care for mental health disorders varied by site but typically included referral to appropriate services. Participants, along with their caregivers, and clinicians were not masked to treatment allocation but statisticians were masked until the point of analysis. The primary outcome, analysed by modified intention-to-treat, was the parent-report Strengths and Difficulties Questionnaire (SDQ) at 6 months post-randomisation. The study is complete and registered with ISRCTN (57823197). FINDINGS: 1401 young people were potentially deemed eligible for study inclusion. Following the exclusion of 531 young people, 870 participants were assessed for eligibility and completed the SDQ, and 480 caregivers provided consent for study inclusion between May 20, 2019, and Jan 31, 2022. Between Aug 28, 2019, and Feb 21, 2022, 334 participants (mean ages 10·5 years [SD 3·6] in the MICE group vs 10·3 [4·0] in control group at baseline) were randomly assigned to an intervention using minimisation balanced by age, primary mental health disorder, diagnosis of intellectual disability, and autistic spectrum disorder at baseline. 168 (50%) of the participants were female and 166 (50%) were male. 166 participants were randomly assigned to the MICE group and 168 were randomly assigned to the control group. At 6 months, the mean SDQ difficulties for the 148 participants in the MICE group was 17·6 (SD 6·3) and 19·6 (6·1) for the 148 participants in the control group. The adjusted effect of MICE was -1·7 (95% CI -2·8 to -0·5; p=0·0040; Cohen's d, 0·3). 14 (8%) patients in the MICE group experienced at least one serious adverse event compared with 24 (14%) in the control group. 68% percent of serious adverse events (50 events) were admission due to seizures. INTERPRETATION: MICE was superior to assessment-enhanced usual care in improving symptoms of emotional and behavioural difficulties in young people with epilepsy and common mental health disorders. The trial therefore shows that mental health comorbidities can be effectively and safely treated by a variety of clinicians, utilising an integrated intervention across ages and in the context of intellectual disability and autism. The evidence from this trial suggests that such a model should be fully embedded in epilepsy services and serves as a model for other chronic health conditions in young people. FUNDING: UK National Institute for Health Research Programme Grants for Applied Research programme and Epilepsy Research UK Endeavour Project Grant.

"You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study.

Introduction: High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement. Method: Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators. Results: The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress. Discussion: The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.

Implementing and evaluating group interpersonal therapy for postnatal depression in Lebanon and Kenya-individually randomised superiority trial.

BACKGROUND: Depression ranks as the foremost mental health concern among childbearing women. Within low- and middle-income countries (LMICs), between 20 and 25% of women encounter depression during pregnancy or soon after delivery. This condition impacts not only the mothers but also their offspring. Offspring of women suffering from postnatal depression (PND) exhibit suboptimal cognitive development and increased emotional and behavioural issues throughout their growth. This scenario becomes more pronounced in LMICs, where numerous adversities further jeopardise children's developmental progress. Despite antenatal services providing a pivotal platform to address women's mental health needs, PND treatment remains inaccessible in many LMICs. The World Health Organization advocates interpersonal psychotherapy (IPT) for treating depression. While research from high-income countries has established the efficacy of IPT and group-IPT (g-IPT) for PND, its effectiveness within the LMIC context and its potential benefits for child development remain uncharted. This study seeks to gauge the potency of g-IPT for women with PND in two LMICs. METHODS: This multi-site randomised controlled trial is a continuation of two preceding phases-conceptual mapping and a feasibility study executed in Lebanon and Kenya. Insights gleaned from these phases underpin this comprehensive RCT, which contrasts the efficacy and cost-effectiveness of high-quality standard care (HQ-SC) augmented with g-IPT against HQ-SC in isolation. The trial, characterised as an individually randomised superiority assessment, targets women with postnatal depression in Beirut, Lebanon, and Nairobi, Kenya. It aims to determine if culturally tailored g-IPT, administered within community settings in both countries, outperforms HQ-SC in influencing child developmental outcomes, maternal depression, and the quality of the mother-child bond. DISCUSSION: The SUMMIT trial, designed with pragmatism, possesses the magnitude to evaluate g-IPT within two LMIC frameworks. It seeks to enlighten policymakers, service commissioners, professionals, and users about g-IPT's potential to alleviate maternal PND and bolster child developmental outcomes in LMICs. Additionally, the trial will generate valuable data on the clinical and economic merits of high-quality standard care. TRIAL REGISTRATION: ISRCTN, ISRCTN15154316. Registered on 27 September 2023, https://doi.org/10.1186/ISRCTN15154316.

Bayesian Decision-Making Under Uncertainty in Borderline Personality Disorder.

Bayesian decision theory suggests that optimal decision-making should use and weigh prior beliefs with current information, according to their relative uncertainties. However, some characteristics of borderline personality disorder (BPD) patients, such as fast, drastic changes in the overall perception of themselves and others, suggest they may be underrelying on priors. Here, we investigated if BPD patients have a general deficit in relying on or combining prior with current information. We analyzed this by having BPD patients (n = 23) and healthy controls (n = 18) perform a coin-catching sensorimotor task with varying levels of prior and current information uncertainty. Our results indicate that BPD patients learned and used prior information and combined it with current information in a qualitatively Bayesian-like way. Our results show that, at least in a lower-level, nonsocial sensorimotor task, BPD patients can appropriately use both prior and current information, illustrating that potential deficits using priors may not be widespread or domain-general.

Taking stock to move forward: Where the field of developmental psychopathology might be heading.

In this paper, dedicated to Dante Cicchetti's contributions and enduring influence, we explore the prospective directions of developmental psychopathology. Our focus centers on key domains where Cicchetti's significant achievements have continually shaped our evolving thinking about psychological development. These domains include (a) the concepts of equifinality and multifinality, along with the challenges in predicting developmental trajectories, (b) the imperative to integrate wider sociocultural viewpoints into developmental psychopathology frameworks, (c) the interplay of genetic and environmental influences in developmental courses, (d) the significance of mental state language, and (e) the progress, or its absence, in the development of prevention and intervention tactics for children, adolescents, and their caregivers. While many of our forecasts regarding the future of developmental psychopathology may not materialize, we maintain optimistic that the essential ideas presented will influence the research agenda in this field and contribute to its growth over the next fifty years.

Gender, marginalised groups, and young people's mental health: a longitudinal analysis of trajectories.

BACKGROUND: Individuals from marginalised groups experience higher levels of mental health difficulties and lower levels of wellbeing which may be due to the exposure to stress and adversity. This study explores trajectories of mental health over time for young women and girls and young people with other marginalised identities. METHODS: We conducted a secondary analysis on N = 14,215 children and young people (7,501 or 52.8% female, 6,571 or 46.2% male, and 81 or 0.6% non-binary or questioning) who completed a survey at age 11 to 12 years and at least one other annual survey aged 12 to 13 years and/or aged 13 to 14 years. We used group-based trajectory models to examine mental health difficulties. RESULTS: Except for behavioural difficulties, young women's and girls' trajectories showed that they consistently had higher levels of mental health difficulties compared to young men and boys. A similar pattern was shown for non-binary and questioning children and young people. Children and young people with economic disadvantage and/or special education needs, and/or for whom there were welfare concerns, were generally more likely to experience higher levels of mental health difficulties. CONCLUSIONS: This information could inform public policy, guidance and interventions.

A short version of the reflective functioning questionnaire: Validation in a greek sample.

This study aims to validate the Greek version of the 54-item Reflective Functioning Questionnaire (RFQ), a measure designed to assess an individual's capacity for understanding themselves and others based on internal mental states. This capacity, also known as Reflective Functioning (RF) or mentalizing, is believed to play a significant role in both typical and atypical development. The validation process examined the factor structure of the RFQ and its relationship with a variety of psychosocial and clinical constructs that have theoretical and empirical links to RF. Additionally, this research investigated the factor structure's invariance across gender and age groups to determine the robustness of the instrument. A unique contribution of this work lies in examining the application of the RFQ to attachment classifications through the use of cluster analysis. The sample consisted of 875 Greek adults from the general community with a mean age of 28.5 and a median age of 22. Participants completed the Greek RFQ along with a series of self-report questionnaires assessing psychosocial constructs, including attachment, epistemic trust, emotion regulation, and psychological mindedness, as well as clinical variables such as anxiety, depression, and borderline personality traits. Our findings suggest that a shorter, 31-item version of the questionnaire provides a robust three-factor structure across a non-clinical Greek adult population. The three identified subscales are (a) excessive certainty, (b) interest/curiosity, and (c) uncertainty/confusion, all demonstrating satisfactory reliability and construct validity. The uncertainty subscale was found to be associated with insecure attachment styles, epistemic mistrust and credulity, emotional suppression, and low psychological mindedness. In contrast, the certainty and curiosity subscales were linked to secure attachment, epistemic trust, emotion reappraisal, and psychological mindedness. Uncertainty was further shown to differ significantly across probable clinical and non-clinical groups, as distinguished by cut-off scores for anxiety, depression, and borderline personality disorder (BPD). However, the certainty and interest/curiosity subscales only varied between the two BPD groups. Our results provide the first evidence supporting the use of a 31-item version of the RFQ with three validated subscales to reliably assess reflective functioning in the Greek population, demonstrating stronger psychometric properties compared to other RFQ versions reported in previous studies. Findings suggest that impaired mentalizing capacity, as measured by the RFQ, is linked to insecure attachment, epistemic mistrust and credulity, poor emotion regulation, and low psychological mindedness, and potentially plays a role in adult mental health symptoms.

Commentary: Special Issue on Interpersonal Trust.

This commentary reviews the Journal of Personality Disorders special issue "Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research," published in Volume 37, Number 5, October 2023.

University students' access to mental health services: A qualitative study of the experiences of health service professionals through the lens of candidacy in England.

OBJECTIVES: In order to develop a better understanding of students' access to mental health services, we explored the experiences of health care professionals interacting with university students with mental health problems. METHODS: We interviewed 23 professionals working across university advice and counselling services, NHS general practice, crisis, and psychological services in North and East London between June 2022 and January 2023. Our approach drew on reflexive thematic analysis and the principles of abductive analysis. The notion of candidacy - that is, how different needs are deemed deserving of health service attention - was particularly helpful to our understanding of the ongoing phenomenon of interest in the data. RESULTS: Each student's access to mental health support was highly contingent on the student's dynamic social context and the pressures and organisation of the local health system. Professionals described how different students viewed different needs as deserving of health service attention. Which students reached the professional's service depended on the resources and relationships a student could draw upon, and the service's relative permeability. Once there, what action professionals took was strongly influenced by the professional's service expertise, resource constraints, the relationships the professional's service had with other organisations, the students' wishes, and whether students regarded treatment offers as acceptable. CONCLUSIONS: Candidacy offers a useful lens to view university students' access to mental health support. Access appears to be an increasingly intricate task for students, given the fragmented service landscape, surging demand for mental health care and challenges of emerging adulthood. Our findings suggest that policy goals to increase use of mental health services are unlikely to improve outcomes for students without policy makers and health systems giving holistic consideration of inter-service relationships and available resources.

'Am I really the priority here?': help-seeking experiences of university students who self-harmed.

BACKGROUND: Self-harm is a significant problem in university students because of its association with emotional distress, physical harm, broader mental health issues and potential suicidality. Research suggests that fewer than half of students who have self-harmed seek professional help when at university. AIMS: This study aimed to explore the help-seeking journeys of university students who had engaged in self-harm, to identify perceived facilitators and barriers to securing both formal and informal support. METHOD: Participants comprised 12 students who had self-harmed during their university tenure. Engaging in two semi-structured interviews over the academic year, they shared insights into their help-seeking behaviours and proposed enhancements to local services. Data underwent reflexive thematic analysis within a critical realist framework. RESULTS: The analysis identified four themes: 'The initial university phase poses the greatest challenge', 'Perceived criteria for "valid" mental health problems', 'Evading external judgements, concerns and consequences' and 'The pivotal role of treatment options and flexibility in recovery'. CONCLUSIONS: Students felt isolated and misunderstood, which amplified self-harming tendencies and diminished inclinations for help-seeking. A prevalent belief was that for self-harm to be deemed 'valid', it must manifest with a certain severity; however, concurrent fears existed around the ramifications of perceived excessive severity. Participants expressed a desire for streamlined pathways to mental health resources, encompassing both university and external mental health services. Insights from this study could guide future research and inform current service paradigms within academic and healthcare systems.

Variation in symptoms of common mental disorders in the general population during the COVID-19 pandemic: longitudinal cohort study.

BACKGROUND: A significant rise in mental health disorders was expected during the COVID-19 pandemic. However, referrals to mental health services dropped for several months before rising to pre-pandemic levels. AIMS: To identify trajectories of incidence and risk factors for common mental disorders among the general population during 14 months of the COVID-19 pandemic, to inform potential mental health service needs. METHOD: A cohort of 33 703 adults in England in the University College London COVID-19 Social Study provided data from March 2020 to May 2021. Growth mixture modelling was used to identify trajectories based on the probability of participants reporting symptoms of depression (Patient Health Questionnaire-9) or anxiety (Generalised Anxiety Disorder-7) in the clinical range, for each month. Sociodemographic and personality-related characteristics associated with each trajectory class were explored. RESULTS: Five trajectory classes were identified for depression and anxiety. Participants in the largest class (62%) were very unlikely to report clinically significant symptom levels. Other trajectories represented participants with a high likelihood of clinically significant symptoms throughout, early clinically significant symptoms that reduced over time, clinically significant symptoms that emerged as the pandemic unfolded and a moderate likelihood of clinically significant symptoms throughout. Females, younger adults, carers, those with existing mental health diagnoses, those that socialised frequently pre-pandemic and those with higher neuroticism scores were more likely to experience depression or anxiety. CONCLUSIONS: Nearly 40% of participants followed trajectories indicating risk of clinically significant symptoms of depression or anxiety. The identified risk factors could inform public health interventions to target individuals at risk in future health emergencies.

The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research.

Mentalizing is the human capacity to understand actions of others and one's own behavior in terms of intentional mental states, such as feelings, wishes, goals and desires. Mentalizing is a transtheoretical and transdiagnostic concept that has been applied to understanding vulnerability to psychopathology and has attracted considerable research attention over the past decades. This paper reports on a pre-registered systematic review of evidence concerning the role of mentalizing as a moderator and mediator in psychological interventions in adults. Studies in adults were reviewed that address the following questions: (a) does pre-treatment mentalizing predict treatment outcome; (b) do changes in mentalizing across treatment predict outcome; (c) does adherence to the principles or protocol of mentalization-based treatment predict outcome; and (d) does strengthening in-session mentalizing impact the therapeutic process via improved alliance, alleviated symptoms, or improved interpersonal functioning? Results suggest that mentalizing might be a mediator of change in psychotherapy and may moderate treatment outcome. However, the relatively small number of studies (n = 33 papers based on 29 studies, totaling 3124 participants) that could be included in this review, and the heterogeneity of studies in terms of design, measures used, disorders included, and treatment modalities, precluded a formal meta-analysis and limited the ability to draw strong conclusions. Therefore, theoretical and methodological recommendations for future research to improve the quality of existing research in this area are formulated.

To trust or not to trust in the thrall of the COVID-19 pandemic: Conspiracy endorsement and the role of adverse childhood experiences, epistemic trust, and personality functioning.

RATIONALE: Conspiracy endorsement is a public health challenge for the successful containment of the COVID-19 pandemic. While usually considered a societal phenomenon, little is known about the equally important developmental backdrops and personality characteristics like mistrust that render an individual prone to conspiracy endorsement. There is a growing body of evidence implying a detrimental role of adverse childhood experiences (ACEs) - a highly prevalent developmental burden - in the development of epistemic trust and personality functioning. This study aimed to investigate the association between ACEs and conspiracy endorsement in the general population, specifically questioning a mediating role of epistemic trust and personality functioning. METHODS: Based on cross-sectional data from a representative German survey collected during the COVID-19 pandemic (N = 2501), we conducted structural equation modelling (SEM) where personality functioning (OPD-SQS) and epistemic trust (ETMCQ) were included as mediators of the association between ACEs and conspiracy endorsement. Bootstrapped confidence intervals (5000 samples, 95%-CI) are presented for all paths. RESULTS: ACEs were significantly associated with conspiracy endorsement (ß = 0.25, p < 0.001) and explained 6% of its variance. Adding epistemic trust and personality functioning as mediators increased the explained variance of conspiracy endorsement to 19% while the direct association between ACEs and conspiracy endorsement was diminished (ß = 0.12, p < 0.001), indicating an indirect effect of personality functioning and epistemic trust in the association between ACEs and conspiracy endorsement. Fit indices confirmed good model fit. CONCLUSIONS: Establishing an association between ACEs and conspiracy endorsement further increases the evidence for early childhood adversities' far-reaching and detrimental effects. By including epistemic trust and personality functioning, these findings contribute to a deeper understanding of the underlying mechanisms in the way that ACEs may be associated with conspiracy endorsement.