Comorbidity has profound implications in both the clinical field and research, yet little is known about the prevalence and structure of comorbid mental disorders. This article aims not only to present data on the prevalence of mental disorders and comorbidity, but also to explore relationships between comorbid mental disorders by using a network approach.

Data used in this cross-sectional study are part of a prospective cohort study within penitentiary psychiatric centers (PPCs) in the Netherlands. It includes DSM diagnoses of 5,257 unique male patients incarcerated in one of the PPC's. Prevalence rates of mental disorders and comorbidity were calculated, the network of comorbid DSM diagnoses was constructed using regression coefficients.

Schizophrenia spectrum and substance-related disorders were most prevalent within this sample (56.7 and 43.1%, respectively), and over half of all patients were diagnosed with a comorbid disorder (56.9%). Four distinctive groups of disorders emerged from the network analysis of DSM diagnoses: substance use, impulsivity, poor social skills, and disruptive behaviors. Psychotic disorders were considered as a separate group as it was unconnected to other disorders.

Comorbid mental disorders can be described, at least in part, as connected networks. Underlying attributes as well as direct influences of mental disorders on one another seem to be affecting the presence of comorbidity. Results could contribute to the understanding of a possible causal relation between psychopathology and criminal behavior and the development of treatment programs targeting groups of disorders.

Social anxiety symptoms (SAS) are among the most common mental health problems during adolescence, and it has been shown that parenting influences the adolescent’s level of social anxiety. In addition, it is now widely assumed that most mental health problems, including social anxiety, originate from a complex interplay between genes and environment. However, to date, gene–environment (G × E) interactions studies in the field of social anxiety remain limited. In this study, we have examined how 274 genes involved in different neurotransmission pathways interact with five aspects of perceived parenting as environmental exposure (i.e., support, proactive control, psychological control, punitive control, and harsh punitive control) to affect SAS during adolescence.

We have applied an analytical technique that allows studying genetic information at the gene level, by aggregating data from multiple single-nucleotide-polymorphisms within the same gene and by taking into account the linkage disequilibrium structure of the gene. All participants were part of the STRATEGIES cohort of 948 Flemish adolescents (mean age = 13.7), a population-based study on the development of problem behaviors in adolescence. Relevant genes were preselected based on prior findings and neurotransmitter-related functional protein networks.

The results suggest that genes involved in glutamate (SLC1A1), glutathione neurotransmission (GSTZ1), and oxidative stress (CALCRL), in association with harsh punitive parenting, may contribute to social anxiety in adolescence. Isolated polymorphisms in these genes have been related to anxiety and related disorders in earlier work.Conclusions: Taken together, these findings provide new insights into possible biological pathways and environmental risk factors involved in the etiology of social anxiety symptoms’ development.

Taken together, these findings provide new insights into possible biological pathways and environmental risk factors involved in the etiology of social anxiety symptoms’ development.

The COVID-19 outbreak required the significantly increased working time and intensity for health professionals in China, which may cause stress signs.

From March 2–13 of 2020, 4,618 health professionals in China were included in an anonymous, self-rated online survey regarding their concerns on exposure to the COVID-19 outbreak. The questionnaires consisted of five parts: basic demographic information and epidemiological exposure; occupational and psychological impact; concerns during the episode; coping strategies; and the Huaxi Emotional-Distress Index (HEI).

About 24.2% of respondents experienced high levels of anxiety or/and depressive symptoms since the COVID-19 outbreak. Respondents who worried about their physical health and those who had COVID-19 infected friends or close relatives were more likely to have high HEI levels, than those without these characteristics. Further, family relationship was found to have an independent protective effect against high HEI levels. Their main concerns were that their families would not be cared for and that they would not be able to work properly. Compared to respondents with clear emotional problems, those with somewhat hidden emotional issues adopted more positive coping measures.

About a quarter of medical staff experienced psychological problems during the pandemic of COVID-19. The psychological impact of stressful events was related to worrying about their physical health, having close COVID-19 infected acquaintances and family relationship issues. Therefore, the psychological supprot for medical staff fighting in the COVID-19 pandemic may be needed.

Clients and therapists often have different perspectives on their therapeutic alliance (TA), affecting the process and outcome of therapy. The aim of the present meta-analysis was to assess the mean differences between clients’ and therapists’ estimations of TA among clients with severe disturbances, while focusing on two potential moderators: client diagnosis and alliance instrument.

We conducted a systematic literature search of studies examining both client perspective and therapist perspective on TA in psychotherapy among people with schizophrenia spectrum disorders, personality disorders, and substance misuse disorders. We then analyzed the data using a random-effects meta-analytic model with Cohen’s d standardized mean effect size.

Heterogeneity analyses (k = 22, Cohen’s d = −.46, 95% confidence interval = .31–1.1) produced a significant Q-statistic (Q = 94.96) and indicated high heterogeneity, suggesting that moderator analyses were appropriate.

Our findings show that the type of TA instrument moderates the agreement on TA between client and therapist, but there was no indication of the client’s diagnosis moderating the effect. The agreement between client and therapist estimations seems to be dependent on the instrument that is used to assess TA. Specific setting-related instruments seem to result in higher agreement between clients’ and therapists’ estimations than do more general instruments that are applied to assess TA.

We investigated whether adults with attention-deficit/hyperactivity disorder (ADHD) show pseudoneglect—preferential allocation of attention to the left visual field (LVF) and a resulting slowing of mean reaction times (MRTs) in the right visual field (RVF), characteristic of neurotypical (NT) individuals —and whether lateralization of attention is modulated by presentation speed and incentives.

Fast Task, a four-choice reaction-time task where stimuli were presented in LVF or RVF, was used to investigate differences in MRT and reaction time variability (RTV) in adults with ADHD (n = 43) and NT adults (n = 46) between a slow/no-incentive and fast/incentive condition. In the lateralization analyses, pseudoneglect was assessed based on MRT, which was calculated separately for the LVF and RVF for each condition and each study participant.

Adults with ADHD had overall slower MRT and increased RTV relative to NT. MRT and RTV improved under the fast/incentive condition. Both groups showed RVF-slowing with no between-group or between-conditions differences in RVF-slowing.

Adults with ADHD exhibited pseudoneglect, a NT pattern of lateralization of attention, which was not attenuated by presentation speed and incentives.

Impairments in social and nonsocial cognition have been demonstrated in both patients suffering from bipolar disorder (BD) and their unaffected relatives and might therefore represent a heritable marker of risk. This study investigated the relevance of emotional intelligence (EI) as part of the emotion processing domain of social cognition in this regard.

A total of 54 outpatients suffering from BD, 54 unaffected siblings, and 80 control subjects were investigated using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Brief Assessment of Cognition in Schizophrenia (BACS). Analyses of covariance (ANCOVAs) were performed with adjustment for the BACS composite score. The three groups were compared by one-way analysis of variance or chi-square test, depending on the variable type. As the three groups differed significantly in their level of education, additional ANCOVAs with adjustment for education were performed.

Patients achieved significantly lower levels of overall EI and overall nonsocial cognitive functioning compared to unaffected siblings and controls, whereas performance of the latter two groups was comparable in both domains.

Due to comparable levels of EI in unaffected siblings of patients suffering from BD and control subjects, EI assessed by means of the MSCEIT does not represent an endophenotype for BD.

The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural areas. We examined population density and suicide in the Italian population in the last 30 years.

The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985–2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.

Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval [CI]:1.08–1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20–1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994–2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82–1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85–1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.

A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.

Around 30% of patients with schizophrenia are considered treatment resistant (TRS). Only around 40% of TRS patients respond to clozapine. Long acting injectable antipsychotics could be a useful augmentation strategy for nonresponders.

We conducted a multicenter, observational, naturalistic, retrospective, 6-month mirror-image study to evaluate the efficacy and tolerability of clozapine and paliperidone palmitate association in 50 patients with TRS and other psychotic disorders. Clinical outcomes and side effects were systematically assessed.

Six months after starting the combined treatment, participants showed a significant relief of symptoms, decreasing the Brief Psychiatric Rating Scale total score from 18.32 ± 7.71 to 7.84 ± 5.16 (p < 0.001). The number of hospitalizations, the length of hospital stays and the number of visits to emergency services also decreased, while an increase of the functionality was observed (Personal and Social Performance total score increased from 46.06 ± 118.7 to 60.86 ± 18.68, p < 0.001). There was also a significant decrease in the number and severity of side effects with the combination therapy, decreasing the Udvalg for Kliniske Undersogelser total score from 10.76 ± 8.04 to 8.82 ± 6.63 (p = 0.004).

This study provides the first evidence that combining clozapine with paliperidone palmitate in patients with TRS and other psychotic disorders could be effective and safe, suggesting further research with randomized controlled trials of augmentation strategies for clozapine nonresponder patients.

Patients with psychotic disorders such as schizophrenia show a variable response to antipsychotic treatments. Around 30% of patients are considered treatment resistant, indicated by insufficient symptom control to at least two different drugs. In these resistant cases, clozapine should be indicated, as it has shown to be superior to other options. However, only 40% of patients respond to clozapine, being necessary to establish which treatments could best potentiate clozapine action. Combining clozapine with long acting injectable antipsychotics, and particularly paliperidone palmitate, could be a useful strategy. We conducted a multicenter study of 50 patients with treatment-resistant schizophrenia and other psychotic disorders comparing the efficacy and tolerability in the 6 month-period prior and after starting the clozapine and paliperidone palmitate association. Our study suggests that this combination could be effective and safer, laying the groundwork for future clinical trials with this combination.

Abnormalities in the semantic and syntactic organization of speech have been reported in individuals at clinical high-risk (CHR) for psychosis. The current study seeks to examine whether such abnormalities are associated with changes in brain structure and functional connectivity in CHR individuals.

Automated natural language processing analysis was applied to speech samples obtained from 46 CHR and 22 healthy individuals. Brain structural and resting-state functional imaging data were also acquired from all participants. Sparse canonical correlation analysis (sCCA) was used to ascertain patterns of covariation between linguistic features, clinical symptoms, and measures of brain morphometry and functional connectivity related to the language network.

In CHR individuals, we found a significant mode of covariation between linguistic and clinical features (r = 0.73; p = 0.003), with negative symptoms and bizarre thinking covarying mostly with measures of syntactic complexity. In the entire sample, separate sCCAs identified a single mode of covariation linking linguistic features with brain morphometry (r = 0.65; p = 0.05) and resting-state network connectivity (r = 0.63; p = 0.01). In both models, semantic and syntactic features covaried with brain structural and functional connectivity measures of the language network. However, the contribution of diagnosis to both models was negligible.

Syntactic complexity appeared sensitive to prodromal symptoms in CHR individuals while the patterns of brain-language covariation seemed preserved. Further studies in larger samples are required to establish the reproducibility of these findings.

Birth weight influences not only brain development, but also mental health outcomes, including depression, but the underlying mechanism is unclear.

The phenotypic data of 12,872–91,009 participants (59.18–63.38% women) from UK Biobank were included to test the associations between the birth weight, depression, and brain volumes through the linear and logistic regression models. As birth weight is highly heritable, the polygenic risk scores (PRSs) of birth weight were calculated from the UK Biobank cohort (154,539 participants, 56.90% women) to estimate the effect of birth weight-related genetic variation on the development of depression and brain volumes. Finally, the mediation analyses of step approach and mediation analysis were used to estimate the role of brain volumes in the association between birth weight and depression. All analyses were conducted sex stratified to assess sex-specific role in the associations.

We observed associations between birth weight and depression (odds ratio [OR] = 0.968, 95% confidence interval [CI] = 0.957–0.979, p = 2.29 × 10−6). Positive associations were observed between birth weight and brain volumes, such as gray matter (B = 0.131, p = 3.51 × 10−74) and white matter (B = 0.129, p = 1.67 × 10−74). Depression was also associated with brain volume, such as left thalamus (OR = 0.891, 95% CI = 0.850–0.933, p = 4.46 × 10−5) and right thalamus (OR = 0.884, 95% CI = 0.841–0.928, p = 2.67 × 10−5). Additionally, significant mediation effects of brain volume were found for the associations between birth weight and depression through steps approach and mediation analysis, such as gray matter (B = –0.220, p = 0.020) and right thalamus (B = –0.207, p = 0.014).

Our results showed the associations among birth weight, depression, and brain volumes, and the mediation effect of brain volumes also provide evidence for the sex-specific of associations.

This study aimed to identify clinical and cognitive factors associated with increased risk for difficult-to-treat depression (DTD) or treatment-resistant depression (TRD).

A total of 229 adult outpatients with major depression were recruited from the mental health unit at a public hospital. Participants were subdivided into resistant and nonresistant groups according to their Maudsley Staging Model score. Sociodemographic, clinical, and cognitive (objective and subjective measures) variables were compared between groups, and a logistic regression model was used to identify the factors most associated with TRD risk.

TRD group patients present higher verbal memory impairment than the nonresistant group irrespective of pharmacological treatment or depressive symptom severity. Logistic regression analysis showed that low verbal memory scores (odds ratio [OR]: 2.02; 95% confidence interval [CI]: 1.38–2.95) together with high depressive symptom severity (OR: 1.29; CI95%: 1.01–1.65) were associated with TRD risk.

Our findings align with neuroprogression models of depression, in which more severe patients, defined by greater verbal memory impairment and depressive symptoms, develop a more resistant profile as a result of increasingly detrimental neuronal changes. Moreover, our results support a more comprehensive approach in the evaluation and treatment of DTD in order to improve illness course. Longitudinal studies are warranted to confirm the predictive value of verbal memory and depression severity in the development of TRD.

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

To examine the association between childhood trauma and work functioning, and to elucidate to what extent this association can be accounted for by depression and/or anxiety.

Data of 1,649 working participants were derived from the Netherlands Study of Depression and Anxiety (NESDA, n = 2,981). Childhood trauma (emotional neglect, psychological, physical, and sexual abuse before age 16) was assessed with a structured interview and work functioning, in terms of absenteeism and presenteeism, with the Health and Labor Questionnaire Short Form (SF-HLQ) and the World Health Organization Disability Assessment Schedule II (WHODAS-II), respectively. Depressive and/or anxiety disorders were assessed with the Composite Interview Diagnostic Instrument (CIDI). Mediation analyses were conducted.

At baseline, 44.8% reported to have experienced childhood trauma. Workers with the highest childhood trauma level showed significantly (p < 0.001) more absenteeism as well as more presenteeism. Mediation analyses revealed that indirect effects between the childhood trauma index and both work indices were significantly mediated by current depressive disorder (p = 0.023 and p < 0.001, respectively) and current comorbid depression-anxiety (p = 0.020 and p < 0.001, respectively), with the latter accounting for the largest effects (PM = 0.23 and PM = 0.29, respectively). No significant mediating role in this relationship was found for current anxiety disorder and remitted depressive and/or anxiety disorder.

Persons with childhood trauma have significantly reduced work functioning in terms of absenteeism and presenteeism. This seems to be largely accounted for by current depressive disorders and current comorbid depression-anxiety.

During the outbreak of coronavirus disease 2019 (COVID-19), people are under the dual pressure of interpersonal isolation and concerns about infection. An evaluation of people’s psychological status and risk factors is needed to conduct target interventions.

This was a nationwide, multicenter, cross-sectional study using quota and snowball sampling methods during the COVID-19 epidemic in China. Participants’ characteristics and experiences were obtained by an online questionnaire and telephone review. Psychological distress and sleep problems were measured by the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Insomnia Severity Index.

A total of 23,500 participants were recruited, and 19,372 valid questionnaires were received from 11 centers. Overall, 11.0–13.3% of the participants had anxiety, depression, or insomnia symptoms, and 1.9–2.7% had severe symptoms. The prevalence of psychological and sleep problems has increased. Working as frontline medical staff (Odds Ratio OR = 3.406), living in Hubei Province (OR = 2.237), close contacts with COVID-19 (OR = 1.808), and age 35–49 years (OR = 1.310) were risk factors for anxiety symptoms; no outside activity for 2 weeks (OR = 2.167) and age 35–49 years (OR = 1.198) were risk factors for depression symptoms; and living in Hubei Province (OR = 2.376), no outside activity for 2 weeks (OR = 1.927), and age 35–49 years (OR = 1.262) were risk factors for insomnia symptoms. Only 1.9% of participants received counseling during the epidemic.

Psychological and sleep problems increased during interpersonal isolation due to COVID-19. Current psychological interventions are far from sufficient.

Although evidence from psychosis patients demonstrates the adverse effects of cannabis use (CU) at a young age and that the rate of CU is high in subgroups of young violent patients with psychotic disorders, little is known about the possible effect of the age of onset of CU on later violent behaviors (VB). So, we aimed to explore the impact of age at onset of CU on the risk of displaying VB in a cohort of early psychosis patients.

Data were collected prospectively over a 36-month period in the context of an early psychosis cohort study. A total of 265 patients, aged 18–35 years, were included in the study. Logistic regression was performed to assess the link between age of onset of substance use and VB.

Among the 265 patients, 72 had displayed VB and 193 had not. While violent patients began using cannabis on average at age 15.29 (0.45), nonviolent patients had started on average at age 16.97 (0.35) (p = 0.004). Early-onset CU (up to age 15) was a risk factor for VB (odds ratio = 4.47, confidence interval [CI]: 1.13–20.06) when the model was adjusted for age group, other types of substance use, being a user or a nonuser and various violence risk factors and covariates. History of violence and early CU (until 15) were the two main risk factors for VB.

Our results suggest that early-onset CU may play a role in the emergence of VB in early psychosis.

Schizotypy is a multidimensional construct that is linked to the vulnerability for psychosis. Positive schizotypy includes having paranormal beliefs. Negative schizotypy includes social anhedonia. Disorganized schizotypy includes social anxiety and communication disorder. Schizotypy relates to depression and aggression. Family stress from high expressed emotion (EE; a rating of criticism, hostility, and emotional overinvolvement in a close relative toward a person showing signs of mental disorder) may mediate the link between schizotypy, depression and aggression. This study tested, using path analyses, the hypotheses that schizotypy predicts depression and aggression through high perceived EE as criticism and irritability (hypothesis 1) and praise and intrusiveness in a close relative (hypothesis 2).

One hundred and four healthy participants listened to and rated the self-relevance of standard criticism and standard praise that denote EE. Participants rated their level of schizotypy, depression, aggression, and perceived EE in self-report questionnaires. Two path models tested the hypotheses.

Disorganized schizotypy, more than positive schizotypy, predicted the path to depression and aggression when perceived criticism and perceived EE-irritability were mediators. Disorganised schizotypy, more than negative schizotypy, predicted the path to depression and aggression when perceived praise and perceived EE-intrusiveness were mediators.

Greater perceived criticism and less perceived praise in family communication explain the path from disorganized schizotypy (more so than positive or negative schizotypy) to depression and aggression. These findings indicate a need to consider the thought disorder-EE link as a potential contributor to depression and aggression in people with schizophrenia.

The presence of subthreshold psychotic symptoms in adolescents with eating disorders is poorly described. This study provides a detailed characterization of adolescents affected by eating disorders in the absence or presence of subthreshold psychotic symptoms, taking into account a wide set of sociodemographic, psychological, and clinical variables.

Ninety-four adolescents diagnosed with eating disorders were interviewed, focusing on clinical anamnesis and sociodemographic data collection. The Comprehensive Assessment of At-Risk Mental States (CAARMS) was used to assess the presence (HR+) or absence (HR−) of subthreshold psychosis. The clinicians completed a questionnaire on eating disorders severity, whereas patients provided self-report measures of global social functioning and psychological symptoms associated with eating disorders.

Attenuated psychotic symptoms were highly frequent (84% of subjects). HR+ patients experienced more frequently purging behaviors and dysmorphophobia and received a greater amount of antipsychotic drugs. Compared to HR− counterparts, HR+ patients reported higher eating disorders severity and psychological symptoms (i.e., ineffectiveness, interpersonal and affective problems) associated with eating disorders. Finally, a significant correlation between global social functioning and eating disorders severity emerged only for HR− subjects.

These descriptive data are warranted to identify a potential psychotic core in eating disorders, mainly concerning body image and weight as well as specific psychological features. The availability of reliable and valid markers of risk can further increase our capacity to detect the early emergence of psychosis in adolescents with eating disorders, whose outcome might be worsened by the presence of psychotic symptoms.