The macro-social and environmental conditions in which people live, such as the level of a country’s development or inequality, are associated with brain-related disorders. However, the relationship between these systemic environmental factors and the brain remains unclear. We aimed to determine the association between the level of development and inequality of a country and the brain structure of healthy adults.

We conducted a cross-sectional study pooling brain imaging (T1-based) data from 145 magnetic resonance imaging (MRI) studies in 7,962 healthy adults (4,110 women) in 29 different countries. We used a meta-regression approach to relate the brain structure to the country’s level of development and inequality.

Higher human development was consistently associated with larger hippocampi and more expanded global cortical surface area, particularly in frontal areas. Increased inequality was most consistently associated with smaller hippocampal volume and thinner cortical thickness across the brain.

Our results suggest that the macro-economic conditions of a country are reflected in its inhabitants’ brains and may explain the different incidence of brain disorders across the world. The observed variability of brain structure in health across countries should be considered when developing tools in the field of personalized or precision medicine that are intended to be used across the world.

It remains unclear which individuals with subthreshold depression benefit most from psychological intervention, and what long-term effects this has on symptom deterioration, response and remission.

To synthesise psychological intervention benefits in adults with subthreshold depression up to 2 years, and explore participant-level effect-modifiers.

Randomised trials comparing psychological intervention with inactive control were identified via systematic search. Authors were contacted to obtain individual participant data (IPD), analysed using Bayesian one-stage meta-analysis. Treatment–covariate interactions were added to examine moderators. Hierarchical-additive models were used to explore treatment benefits conditional on baseline Patient Health Questionnaire 9 (PHQ-9) values.

IPD of 10 671 individuals (50 studies) could be included. We found significant effects on depressive symptom severity up to 12 months (standardised mean-difference [s.m.d.] = −0.48 to −0.27). Effects could not be ascertained up to 24 months (s.m.d. = −0.18). Similar findings emerged for 50% symptom reduction (relative risk = 1.27–2.79), reliable improvement (relative risk = 1.38–3.17), deterioration (relative risk = 0.67–0.54) and close-to-symptom-free status (relative risk = 1.41–2.80). Among participant-level moderators, only initial depression and anxiety severity were highly credible (P > 0.99). Predicted treatment benefits decreased with lower symptom severity but remained minimally important even for very mild symptoms (s.m.d. = −0.33 for PHQ-9 = 5).

Psychological intervention reduces the symptom burden in individuals with subthreshold depression up to 1 year, and protects against symptom deterioration. Benefits up to 2 years are less certain. We find strong support for intervention in subthreshold depression, particularly with PHQ-9 scores ≥ 10. For very mild symptoms, scalable treatments could be an attractive option.

Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not ‘excessive’ relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement.

Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates.

Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms.

Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Chemsex refers to the use of drugs, typically stimulants and/or psychoactive substances, in a sexual context, often in the context of casual or group sex encounters. Currently, the practice of chemsex focuses on men who have sex with men (MSM). On the other hand, Pre-exposure prophylaxis (PrEP) is a biomedical method that has proven effective in preventing HIV transmission, particularly among individuals at a heightened risk, including those who engage in chemsex. MSM account for two thirds of new HIV cases in the US. It is estimated that in 70% of cases seroconversion occurs through “condomless anal sex” (CAS). According to the CDC, one in six MSM will be infected with HIV during their lifetime. The consumption of methamphetamine (MA) has been identified as the main driver of the practice of CAS, alteration of rectal immunological function and faster seroconversion. One in three new HIV infections have been associated with MA consumption. (Grov C et al. JAIDS 2020; 85 272-279).

The primary goal of this study is to describe the prevalence of chemsex engagement among PrEP users, delineate user characteristics and requirements, gain deeper insights into this phenomenon within the Barcelona region, and formulate customized strategies accordingly.

This study conducts a literature review to explore the current correlation between engaging in chemsex and the utilization of PrEP. We identified research articles published between January 2020 and December 2022, that discussed the utilization of chemsex drugs prior to or during sexual activities. The findings were synthesised using a narrative approach and conceptualised using a behavioural analysis framework.

According to a recent cross-sectional study performed at Hospital Clínic de Barcelona, SUD among patients who are being followed-up in the outpatient clinic of PrEP was higher (89%) compared with other European regions such as England (38.5%) or Amsterdam (41%). Moreover, according to data collected in the EMIS 2017 survey, Barcelona is the city with the highest prevalence of chemsex in Spain. (De La Mora L et al. AIDS Beh. 2022; 26: 4055-4062).

The frequency of chemsex practice among individuals using PrEP in Barcelona surpasses what has been observed in other groups. Nearly 25% of the participants express worries and a requirement for assistance regarding the management of drug use, matters associated with their sexuality, and sexually transmitted infections (STIs). MSM who suffers from substance use disorder may experience difficulty achieving effective daily oral PrEP adherence prevention levels that may serve as early indicators of increased risk of disengagement from PrEP care and discontinuation the PrEP. These results highlight the importance of adopting aninterdisciplinary approach that incorporates education about substances and the implementation of risk mitigation strategies within the context of riskier sexual behaviors.

None Declared

In Spain and other European countries, patients coming to the emergency room (ER) are usually classified as “organic” or “psychiatric” on arrival, but this may be complicated when psychiatric history is present as the focus can be misplaced (Leeman. IJPM 1975;6(4):544-40; Alam et al. Psychiatr. Clin. North Am. 2017;40(3):425–33).

To describe three cases seen in the psychiatric emergency room (PER) in which triage errors occurred and to review whether it is widespread for psychiatric patients with organic pathology or in need of medical care to be wrongly triaged.

We retrospectively reviewed three cases seen in the PER of Hospital Clínic in July 2023 in which triage errors happened. Triage error was considered when patients triaged directly to the PER presented symptoms that either needed medical treatment or required medical clearance before being considered purely psychiatric.

Case 1: A 27-year-old woman with history of depressive syndrome was triaged for a speech disturbance that had occurred fifteen minutes after intercourse. After being evaluated, she was referred to neurology where she was diagnosed with an acute ischaemic stroke in left middle cerebral artery territory, requiring thrombectomy and posterior admission to neurology.

Case 2: A 50-year-old man with history of alcohol use disorder was brought to the PER after saying that “he was seeing people doing magic” at home. When evaluated, significant distal tremor, tachycardia and hypertension were observed, being compatible with withdrawal symptoms, so he was transferred to the ER. There he was monitored and treated, finally requiring admission to internal medicine due to persistent symptoms.

Case 3: A 26-year-old man with history of substance use disorder was triaged for loss of consciousness and “spasms”. After evaluation, he was transferred to the ER, where organic screening was carried out, being oriented as a probable tonic-clonic seizure and discharged with outpatient follow-up.

The cases presented are instances in which somatic diseases in patients pre-labelled with psychiatric histories were wrongly assumed to be recurrences of their psychiatric disorders. In all cases, they needed to be re-examined by the corresponding medical specialty and required diagnostic tests, in two cases hospital admission was needed. Emergency physicians and emergency psychiatrists often disagree on how to medically clear patients (Alam et al. Psychiatr. Clin. North Am. 2017;40(3):425–33; Janiak et al. JEM. 2012;43(5):866–70), some authors have even proposed protocols for doing this in a more systematic way (Shah et al. JEM. 2012;43(5):871–5). To avoid a delay in diagnosis and treatment and the consequences that may result from it, establishing guidelines for proper triage of patients with psychiatric history should be considered.

None Declared

The Acute Organic Change of Character (AOCC) is an organic mental disorder subtype in which perception, thought, mood and personality impairment predominate. It consists in a change in the individual’s general behaviour or attitude, which is shown to be closely associated with or caused by an underlying organic process, and which is rapidly resolved when the organic noxious agent is eliminated (Pintor et al. Journal of Psychiatry and Psychiatric Disorders 4 (2020): 354-358).

To describe the importance of taking AOCC diagnosis into consideration and the role of liaison psychiatrists in AOCC management by presenting two AOCC cases admitted to the Hospital Clinic of Barcelona.

We retrospectively reviewed two AOCC cases in patients followed by our hospital’s liaison psychiatry unit during the summer of 2023. We also searched for previous case reports of AOCC using a PubMed query.

Case 1: A 50-year-old male who suffered a polytrauma with diffuse axonal injury (DAI). His relatives and the referring medical team observed a change in his behaviour consisting in irritability, suspicion, hostility and impatience. No cognitive impairment nor fluctuation in the described symptoms were observed. At the time of discharge character changes were still present due to DAI slow and unpredictable clinical course. Symptomatic treatment with risperidone 6mg/day and quetiapine 100mg/day was administered achieving a satisfactory clinical response.

Case 2: A 47-year-old woman with type 2 diabetes who suffered an infectious cellulitis that spread causing sepsis. The patient began to appear disruptive with verbose and tangential speech during her admission. No cognitive impairment nor fluctuation in the described symptoms were observed. Symptomatic treatment with risperidone 10mg/day and olanzapine 5mg/day was administered achieving a satisfactory clinical response. At the time of discharge character changes described before were almost resolved.

The clinical presentation of both cases suggested organic mental disorders in which a change in general behaviour predominates. Liaison psychiatrists play a key role in AOCC management by recognizing the clinical pattern, helping if needed with psychopharmacological treatment and ensuring a good understanding of the disorder both by the referring medical team and the patient’s relatives. To our knowledge, it would be of great importance to achieve a better understanding of this clinical condition which to date we consider to be underdiagnosed.

None Declared

Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation.

Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months.

10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation.

Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

The coronavirus infectious disease 2019 (COVID-19) pandemic has had a deleterious impact in many areas. Given this, efforts have focused on developing effective vaccines and vaccination campaigns have been carried out prioritizing population at risk. This should include mental health patients since they are at higher risk of developing complications or ending up in a critical status. Since it may be sometimes difficult for these patients to access vaccination, hospitalization may be a window of opportunity to evaluate and offer vaccination.

This study aims to retrospectively assess vaccination status and offer during admission of psychiatry inpatients at Hospital Clínic of Barcelona during a 6-month period, in order to determine if there are differences regarding vaccination rates compared to general population and between main diagnostic categories.

We retrospectively evaluated all admitted patients to the acute psychiatry ward. The main collected variables included age, gender, main psychiatric diagnosis, presence of organic comorbidities, vaccination status at admission and vaccination offer during admission. We used descriptive statistics to extract most of the information. A binary logistic regression was also conducted to evaluate whether the main diagnosis, age and gender had some influence upon vaccination status at admission.

Between January 1st and June 30th of 2022, 216 patients were admitted to the psychiatry ward. A total of 42% were female, with a mean age for the whole sample of 42.8 years (SD 14.7). More than half were current smokers (55%), and 46% of the patients had at least one significant organic comorbidity. The percentages of main diagnosis were as follows: addiction 21.3%; bipolar disorder 18.5%; schizophrenia 18.1%; non-specified psychosis 14.4%; depression 7.4%; cognitive impairment 0.9%; personality disorders 6.9%.

Vaccination status was available for 187 patients (86.6%). Of these, 78 patients were fully vaccinated, 68 had an incomplete vaccination status and 41 patients had not received any dose. No differences on the vaccination status were seen based on the psychiatric diagnosis. Among patients with incomplete or no vaccination, 19 patients (17.4%) were offered a vaccination dose. A total of 11 patients accepted and received it (57.9%). In the logistic regression model, the only significant variable predicting an increase in the likelihood of being fully vaccinated was age, with every year of age increasing the probability of full vaccination by 6%.

Our data suggest that routine screening of vaccination status during psychiatric admission and improved strategies for vaccination offer and acceptance should become a priority in psychiatric wards. Given the impact of the pandemics, and the likelihood of new waves or even new pandemics, more research on vaccination strategies among mental health patients is warranted.

None Declared

We summarize what we assess as the past year's most important findings within climate change research: limits to adaptation, vulnerability hotspots, new threats coming from the climate–health nexus, climate (im)mobility and security, sustainable practices for land use and finance, losses and damages, inclusive societal climate decisions and ways to overcome structural barriers to accelerate mitigation and limit global warming to below 2°C.

We synthesize 10 topics within climate research where there have been significant advances or emerging scientific consensus since January 2021. The selection of these insights was based on input from an international open call with broad disciplinary scope. Findings concern: (1) new aspects of soft and hard limits to adaptation; (2) the emergence of regional vulnerability hotspots from climate impacts and human vulnerability; (3) new threats on the climate–health horizon – some involving plants and animals; (4) climate (im)mobility and the need for anticipatory action; (5) security and climate; (6) sustainable land management as a prerequisite to land-based solutions; (7) sustainable finance practices in the private sector and the need for political guidance; (8) the urgent planetary imperative for addressing losses and damages; (9) inclusive societal choices for climate-resilient development and (10) how to overcome barriers to accelerate mitigation and limit global warming to below 2°C.

Science has evidence on barriers to mitigation and how to overcome them to avoid limits to adaptation across multiple fields.

Cardiovascular events (CVE) are infrequent adverse effects in patients receiving electroconvulsive therapy (ECT). Nonetheless, it constitutes a threat for patient’s life and may compromise continuing ECT.

To describe a case of acute-onset atrial fibrillation under combined therapy with ECT and venlafaxine.

We present a 76-year-old man diagnosed of delusional disorder and without any previous CVE, who was hospitalized in our acute psychiatric unit by major depressive episode with psychotic symptoms resistant to pharmacological treatment (valproic-acid 100mg/d, haloperidol 6mg/d, venlafaxine 300mg/d). ECT was initiated presenting atrial fibrillation after first session of ECT, requiring amiodarone and anticoagulant treatment for stabilization. Second session of ECT was delayed for three-weeks, worsening the psychiatric symptoms. Haloperidol was discontinued initiating lurasidone with better cardiovascular profile.

CVE occur in 2% of the patients receiving ECT, being acute arrhythmia the most frequent one. Among them, few cases of atrial fibrillation (AF) under ECT have been reported. It has been hypothesised that initial vagal response followed by catecholamine surge secondary to ECT could facilitate the development of AF. In addition venlafaxine, an antidepressant drug, may also predispose to arrhythmia in high-risk individuals. High doses of venlafaxine (>300mg/d) combined with ECT have been related with an increment of CVE.

Although clinically effective for the treatment of major depression disorder, combined therapy of ECT and venlafaxine could precipitate the start of a CVE in genetically susceptible individuals. Therefore, identify and clarify potential risk factors other than previous history of CVE is critical to reduce morbidity and mortality in these patients.

No significant relationships.

Major depressive disorder (MDD) is characterised by a recurrent course and high comorbidity rates. A lifespan perspective may therefore provide important information regarding health outcomes. The aim of the present study is to examine mental disorders that preceded 12-month MDD diagnosis and the impact of these disorders on depression outcomes.

Data came from 29 cross-sectional community epidemiological surveys of adults in 27 countries (n = 80 190). The Composite International Diagnostic Interview (CIDI) was used to assess 12-month MDD and lifetime DSM-IV disorders with onset prior to the respondent's age at interview. Disorders were grouped into depressive distress disorders, non-depressivedistress disorders, fear disorders and externalising disorders. Depression outcomes included 12-month suicidality, days out of role and impairment in role functioning.

Among respondents with 12-month MDD, 94.9% (s.e. = 0.4) had at least one prior disorder (including previous MDD), and 64.6% (s.e. = 0.9) had at least one prior, non-MDD disorder. Previous non-depressive distress, fear and externalising disorders, but not depressive distress disorders, predicted higher impairment (OR = 1.4–1.6) and suicidality (OR = 1.5–2.5), after adjustment for sociodemographic variables. Further adjustment for MDD characteristics weakened, but did not eliminate, these associations. Associations were largely driven by current comorbidities, but both remitted and current externalising disorders predicted suicidality among respondents with 12-month MDD.

These results illustrate the importance of careful psychiatric history taking regarding current anxiety disorders and lifetime externalising disorders in individuals with MDD.