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.

BJPsych Open: a summary of growth and vision for my second innings as editor-in-chief.

As my second 5-year term as its editor-in-chief begins, it is important to review what BJPsych Open has accomplished, its areas of growth and what should be our future vision for the Journal. The keyword throughout this editorial is growth, with emphasis on growth in quality, for meaningful growth can only exist with increased quality. The original remit remains the correct long-term direction for the Journal, with the important modifier 'relevance' added to ensure quality - a general psychiatric journal with high-quality, methodologically rigorous and relevant publications, with relevance to the advancement of clinical care, patient outcomes, the scientific literature, research and policy. During this second term, I desire to expand the editorial board to fill expertise and diversity gaps; increase editorials and commentaries highlighting specific articles and timely events with psychiatric themes; focus on thematic series driven by the editorial board; and address under-represented topics.

A systematic review and meta-analysis of treatments for rapid cycling bipolar disorder.

OBJECTIVES: Rapid cycling is a common and disabling phenomenon in individuals with bipolar disorders. In the absence of a recent literature examination, this systematic review and meta-analysis aimed to synthesise the evidence of efficacy, acceptability and tolerability of treatments for individuals with rapid cycling bipolar disorder (RCBD). METHOD: A systematic search was conducted to identify randomised controlled trials assigning participants with RCBD to pharmacological and/or non-pharmacological interventions. Study inclusion and data extraction were undertaken by two reviewers independently. The primary outcome was continuous within-subject RCBD illness severity before and after treatment. Pre-post random effects meta-analyses were conducted for each outcome/intervention arm studied, generating a standardised effect size (hedge's g) and 95% confidence interval (CI). RESULTS: A total of 34 articles describing 30 studies were included. A total of 16 separate pharmacological treatments were examined in contrast to 1 psychological therapy study. Only quetiapine and lamotrigine were assessed in >5 studies. By assessing 95% CI overlap of within-subject efficacy effects compared to placebo, the only interventions suggesting significant depression benefits (placebo g = 0.60) were olanzapine (with/without fluoxetine; g = 1.01), citalopram (g = 1.10) and venlafaxine (g = 2.48). For mania, benefits were indicated for quetiapine (g = 1.01), olanzapine (g = 1.19) and aripiprazole (g = 1.09), versus placebo (g = 0.33). Most of these effect sizes were from only one trial per treatment. Heterogeneity between studies was variable, and 20% were rated to have a high risk of bias. CONCLUSIONS: While many interventions appeared efficacious, there was a lack of robust evidence for most treatments. Given the limited and heterogeneous evidence base, the optimal treatment strategies for people with RCBD are yet to be established.

The integrity of the research record: a mess so big and so deep and so tall.

SUMMARY: Poor research integrity is increasingly recognised as a serious problem in science. We outline some evidence for this claim and introduce the Royal College of Psychiatrists (RCPsych) journals' Research Integrity Group, which has been created to address this problem.

Narrative review of the COVID-19, healthcare and healthcarers thematic series.

This review covers the thematic series of 22 papers selected from among manuscripts published by BJPsych Open concerning coronavirus disease 2019 (COVID-19) and healthcare. We report nine papers that cover concepts and epidemiology relating to the public and patients. We review 11 papers about the impact of COVID-19 on healthcare services and their staff in 15 countries. Two papers consider the psychosocial impact on staff working in mental health services in the UK. Most papers report cross-sectional analyses of data collected from convenience samples by self-reported surveys conducted at single times. They have limitations of generalisability, do not enable conclusions about diagnosis or causality, and many are likely to have attendant bias and noise. BJPsych Open published these papers to meet requirements for early indications of the mental health impact of COVID-19 on the public and on healthcare staff. They claim high prevalence of symptoms of anxiety, depression and post-traumatic stress. We contrast these findings with selected reports of studies with different methodologies published elsewhere. We emphasise the need for longitudinal clinical studies with refined sampling and methodological rigour. We identify several longitudinal research programmes; two in this series. We advocate tuning advice offered about caring for the public and healthcare staff to the realities of their circumstances and their perceptions of need in the context of findings from further longitudinal studies. We draw attention to the importance of the social, relationship and environmental circumstances of the public and healthcare staff in order to understand their distress and their risks of developing mental health disorders.

Let us do better: learning lessons for recovery of healthcare professionals during and after COVID-19.

The COVID-19 pandemic emphasises the need to rethink and restructure the culture of healthcare organisations if we are to ensure the long-term well-being and mental health of healthcare provider organisations and their staff. In this paper, we recognise the high levels of stress and distress among staff of healthcare services before the COVID-19 pandemic began. We identify lessons for care of healthcare staff and illustrate the paths by which support mobilises and later deteriorates. Although this paper focuses on NHS staff in the UK, we contend that similar effects are likely in most healthcare systems.

Double stigma in mental health: epilepsy and mental illness.

BACKGROUND: Epilepsy and mental illness share similar problems in terms of stigma, as a result of centuries of superstition, ignorance and misbeliefs. Stigma leads not only to discrimination and civil and human rights violations but also to poor access to healthcare and non-adherence or decreased adherence to treatment, ultimately increasing morbidity and mortality. Despite continuous efforts in fighting stigma in these conditions, there is very limited knowledge on the phenomenon of double stigma, meaning the impact of having two stigmatised conditions at the same time. AIMS: To discuss double stigma in mental health with special reference to epilepsy. METHOD: Articles were identified through searches in PubMed up to 31 October 2019 using the search terms 'epilepsy', 'psychiatric disorders', 'stigma' and additional material was identified from the authors' own files and from chosen bibliographies. RESULTS: Double stigma is gaining attention for other stigmatised medical conditions, such as HIV, however, the literature on epilepsy is almost non-existent and this is quite astonishing given that one in three people with epilepsy have a lifetime diagnosis of a psychiatric condition. Felt (perceived) stigma and psychiatric disorders, particularly depression, create a vicious circle in epilepsy maintaining both, as depression correlates with stigma and vice versa as well as epilepsy and depression serving as bidirectional risk factors. This phenomenon has no geographical and economic boundaries as similar data have been reported for low-income and high-income countries. CONCLUSIONS: Governments and policymakers as well as health services, patients' organisations, families and the general public need to be aware of the phenomenon of double stigma in order to develop campaigns and interventions tailored for these patients.

BJPsych Open fifth anniversary editorial: history, accomplishments, trajectory and passion.

BJPsych Open has come of age. This editorial celebrates the journal's fifth anniversary by reviewing the history of BJPsych Open, what we have accomplished, where we strive to go (our planned trajectory) and the passion of being an Editor-in-Chief.

A global needs assessment in times of a global crisis: world psychiatry response to the COVID-19 pandemic.

The COVID-19 pandemic has stunned the global community with marked social and psychological ramifications. There are key challenges for psychiatry that require urgent attention to ensure mental health well-being for all - COVID-19-positive patients, healthcare professionals, first responders, people with psychiatric disorders and the general population. This editorial outlines some of these challenges and research questions, and serves as a preliminary framework of what needs to be addressed. Mental healthcare should be an integral component of healthcare policy and practice towards COVID-19. Collaborative efforts from psychiatric organisations and their members are required to maximise appropriate clinical and educational interventions while minimising stigma.

Generating value with mental health apps.

BACKGROUND: Although apps are increasingly being used to support the diagnosis, treatment and management of mental illness, there is no single means through which costs associated with mental apps are being reimbursed. Furthermore, different apps are amenable to different means of reimbursement as not all apps generate value in the same way. AIMS: To provide insights into how apps are currently generating value and being reimbursed across the world, with a particular focus on the situation in the USA. METHOD: An international team performed secondary research on how apps are being used and on common pathways to remuneration. RESULTS: The uses of apps today and in the future are reviewed, the nature of the value delivered by apps is summarised and an overview of app reimbursement in the USA and other countries is provided. Recommendations regarding how payments might be made for apps in the future are discussed. CONCLUSIONS: Currently, apps are being reimbursed through channels with other original purposes. There may be a need to develop an app-specific channel for reimbursement which is analogous to the channels used for devices, drugs and laboratory tests.

When a corrigendum is not sufficient.

We present the reasoning behind a retraction noting that even small, honest errors can result in significant changes in findings.

Aspirin misuse: a case report.

Aspirin-use disorder is an underreported condition. Identification of the signs and symptoms of aspirin misuse are important in light of prevalent non-prescribed medicine/over-the-counter medication (NPM/OTC) misuse. We discuss here the case of a patient with a history of chronic aspirin misuse who presented to the emergency department with salicylate intoxication and described elation secondary to deliberate aspirin consumption. This case highlights the importance of screening for NPM/OTC medication misuse in at-risk populations.

Ensuring research integrity: setting standards for robust and ethical conduct and reporting of research.

We present an account of why we decided to retract a paper. We discovered a lack of adherence to conventional trials registration, execution, interpretation and reporting, and consequently, with the authors, needed to correct the scientific record. We set out our responses in general to strengthen research integrity.Declaration of interestK.S.B. is Editor-in-Chief of the British Journal of Psychiatry. W.L., K.R.K. and S.M.L. are members of the senior editorial committee and the research integrity committee for the journal. In the past three years, S.M.L. has received research support from Janssen and Lundbeck, and personal support from Janssen, Otsuka and Sunovion.

Alprazolam-induced dose-dependent anorgasmia: case analysis.

BACKGROUND: Sexual dysfunctions are associated with multiple medical and psychiatric disorders, as well as pharmacotherapies used to treat these disorders. Although sexual dysfunctions negatively affect both quality of life and treatment adherence, patients infrequently volunteer these symptoms and clinicians do not pose directed questions to determine their presence or severity. This issue is especially important in psychiatric patients, for whom most common psychotropics may cause sexual dysfunctions (antidepressants, antipsychotics, anxiolytics and mood-stabilising agents). There is limited literature addressing benzodiazepines, and alprazolam in particular. AIMS: To report dose-dependent alprazolam anorgasmia. METHOD: Case analysis with PubMed literature review. RESULTS: A 30-year-old male psychiatric patient presented with new-onset anorgasmia in the context of asymptomatic generalised anxiety disorder, social anxiety, panic disorder with agoraphobia, obsessive-compulsive disorder, major depression in remission, and attention-deficit hyperactivity disorder treated with escitalopram 10 mg q.a.m., gabapentin 1000 mg total daily dose, lisdexamfetamine dimesylate 70 mg q.a.m., nortriptyline 60 mg q.h.s. and alprazolam extended-release 2.5 mg total daily dose. All psychotropic doses had been constant for >6 months excluding alprazolam, which was titrated from 1 mg to 2.5 mg total daily dose. The patient denied any sexual dysfunction with alprazolam at 1 mg q.d. and 1 mg b.i.d. Within 1 week of increasing alprazolam to 2.5 mg total daily dose, the patient reported anorgasmia. Anorgasmia was alprazolam dose-dependent, as anorgasmia resolved with reduced weekend dosing (1 mg b.i.d. Saturday/1.5 mg total daily dose Sunday). CONCLUSIONS: Sexual dysfunction is an important adverse effect negatively influencing therapeutic outcome. This case reports alprazolam-induced dose-dependent anorgasmia. Clinicians/patients should be aware of this adverse effect. Routine sexual histories are indicated. DECLARATION OF INTEREST: None.

Bipolar disorder, comorbid anxiety disorders, gynecomastia and dental pain: case analysis with literature review.

Bipolar disorder with comorbid anxiety disorders frequently requires rational polypharmacy, including use of serotonergic psychotropics. These may result in adverse effects, influencing adherence, complicating treatment and confounding diagnoses. Serotonergic non-adherence is associated with discontinuation syndromes. In this complex case with an on/off/on/off design, both dose-dependent buspirone-induced gynecomastia and buspirone discontinuation syndrome with dental pain are reported. Clinicians and patients should consider these findings to maximise treatment adherence, minimise any unnecessary interventions and address unusual adverse effects. Since patients may not voluntarily disclose specific adverse effects and often do not acknowledge non-adherence, clinician-directed questions are required. This case further emphasises the importance of medication and symptom timelines to guide determination of causation for adverse effects. Although findings from this case cannot be generalised, they suggest the need for continued clinician and patient education, as well as the benefit from detailed case reports. DECLARATION OF INTEREST: None.

BJPsych Open editorial transition: opportunity, challenge and vision.

BJPsych Open enters its fourth year with a transition in leadership and a new Editor-in-Chief (EIC). This editorial summarises the Journal's metrics through its first 36 months, provides insights into the Journal's history and growth, and shares the aspirations of the new EIC for BJPsych Open. DECLARATION OF INTEREST: K.R.K. is Editor-in-Chief of BJPsych Open; he took no part in the peer-review of this work.

Trastornos de bipolares y comorbilidades - consideraciones éticas en deportes / Bipolar disorders and comorbid conditions - Ethical considerations in sports

Introducción: El objetivo de la intervención farmacológica es el resultado terapéutico: máxima eficacia con mínimos efectos adversos. Esto resulta difícil a la hora de tratar el trastorno bipolar, debido a las comorbilidades y/o fármacos complementarios necesarios para abordar los efectos adversos. La polifarmacia racional óptima puede maximizar el resultado terapéutico, aunque podría crear cuestiones éticas en los deportes competitivos. El Código Mundial Antidopaje (WADC) y la Lista de Sustancias Prohibidas de la Agencia Mundial Antidopaje, publicada anualmente, tienen como objetivo disuadir y sancionar a los atletas que utilicen agentes para mejorar el rendimiento, y promover un marco de igualdad para todos los competidores. Este documento presenta tres ejemplos hipotéticos (TDAH/temblor secundario al litio/dolor) en los que la contravención no deliberada de la Lista de Sustancias Prohibidas derivaría en descalificación por violación de la norma antidopaje sin aprobación de las Exenciones por Uso Terapéutico (TUEs). Método: Análisis de caso hipotético con revisión de la literatura. Resultados: TDAH Comórbido: la Lista de Sustancias Prohibidas excluye los psicoestimulantes (metilfenidato/anfetaminas) en la competición (S6) pero permite guanfacina/atomoxetina. En los casos en que los psicoestimulantes constituyeran un tratamiento eficaz para el TDAH en los atletas con trastorno bipolar, a diferencia de guanfacina/atomoxetina, estos pacientes-atletas deberán presentar TUEs, junto con la certificación y documentación de respaldo del clínico. Temblor secundario al Litio: a menudo se prescriben beta-bloqueantes para controlar el temblor secundario al litio, pero que no están autorizados para deportes específicos (P2). En caso de que los fármacos alternativos (primidona) resulten ineficaces, serán necesarias las TUEs. Dolor: el manejo del dolor crónico es difícil en atletas, ya que los analgésicos narcóticos (S7) y cannabinoides (S8) están prohibidos en la competición. Cuando el dolor comórbido no se controla con fármacos autorizados, son necesarias las TUEs. Conclusión: Los pacientes-atletas con trastorno bipolar y comorbilidades precisan enfoques holísticos, con reconocimiento tanto del WADC como de la Lista de Sustancias Prohibidas. Los atletas deberían realizar un listado de todos los fármacos incluyendo diagnósticos/obtener TUEs/verificar el estado de la medicación propuesta (prohibido/restringido/permitido) con las Federaciones Internacionales adecuadas y/u Organizaciones Olímpicas. Los clínicos deberán ser conocedores de estas cuestiones a la hora de tratar a los pacientes-atletas

Introduction: The goal of pharmacologic intervention is therapeutic outcome: maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD/lithium-tremor/pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs). Method: Hypothetical case analyses with literature review. Results: Comorbid ADHD: the Prohibited List precludes psychostimulants (methylphenidate/amphetamines) in competition (S6) but permits guanfacine/atomoxetine. When psychostimulants effectively treat ADHD in athletes with bipolar disorder but guanfacine/atomoxetine do not, these patient-athletes, with clinician’s certification and supportive documentation, should file TUEs. Lithium-tremor: beta-blockers are frequently prescribed to control lithium-tremor but are not permitted for specific sports (P2). If alternatives (primidone) are ineffective, TUEs are indicated. Pain: chronic pain management is difficult in athletes as narcotic analgesics (S7) and cannabinoids (S8) are prohibited in competition. When comorbid pain is not controlled with approved medications, TUEs are required. Conclusion: Patient-athletes with bipolar disorder and comorbidities require holistic approaches with appreciation of both the WADC and Prohibited List. Athletes should list all medications with diagnoses/obtain TUEs/verify proposed medication status (banned/restricted/permitted) with appropriate International Federations and/or Olympic organizations. Clinicians should be cognizant of these issues when treating patient-athletes

Lamotrigine-induced sexual dysfunction and non-adherence: case analysis with literature review.

BACKGROUND: Optimal anti-epileptic drug (AED) treatment maximises therapeutic response and minimises adverse effects (AEs). Key to therapeutic AED treatment is adherence. Non-adherence is often related to severity of AEs. Frequently, patients do not spontaneously report, and clinicians do not specifically query, critical AEs that lead to non-adherence, including sexual dysfunction. Sexual dysfunction prevalence in patients with epilepsy ranges from 40 to 70%, often related to AEDs, epilepsy or mood states. This case reports lamotrigine-induced sexual dysfunction leading to periodic non-adherence. AIMS: To report lamotrigine-induced sexual dysfunction leading to periodic lamotrigine non-adherence in the context of multiple comorbidities and concurrent antidepressant and antihypertensive pharmacotherapy. METHOD: Case analysis with PubMed literature review. RESULTS: A 56-year-old male patient with major depression, panic disorder without agoraphobia and post-traumatic stress disorder was well-controlled with escitalopram 20 mg bid, mirtazapine 22.5 mg qhs and alprazolam 1 mg tid prn. Comorbid conditions included complex partial seizures, psychogenic non-epileptic seizures (PNES), hypertension, gastroesophageal reflux disease and hydrocephalus with patent ventriculoperitoneal shunt that were effectively treated with lamotrigine 100 mg tid, enalapril 20 mg qam and lansoprazole 30 mg qam. He acknowledged non-adherence with lamotrigine secondary to sexual dysfunction. With lamotrigine 300 mg total daily dose, he described no libido with impotence/anejaculation/anorgasmia. When off lamotrigine for 48 h, he described becoming libidinous with decreased erectile dysfunction but persistent anejaculation/anorgasmia. When off lamotrigine for 72 h to maximise sexual functioning, he developed auras. Family confirmed patient's consistent monthly non-adherence for 2-3 days during the past year. CONCLUSIONS: Sexual dysfunction is a key AE leading to AED non-adherence. This case describes dose-dependent lamotrigine-induced sexual dysfunction with episodic non-adherence for 12 months. Patient/clinician education regarding AED-induced sexual dysfunction is warranted as are routine sexual histories to ensure adherence. DECLARATION OF INTEREST: No financial interests. K.R.K. is Editor of BJPsych Open; he took no part in the peer-review of this work. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.