Lithium has a narrow therapeutic index with a risk of toxicity and potential to increase morbidity and mortality, particularly in the elderly with co-morbid illness and polypharmacy. Lithium therapy and monitoring of lithium levels require precision and several guidelines have been issued including recommendations for strict control of lithium levels in the elderly population.

We evaluated the effect of implementation of a multifaceted management programme on the compliance with international practice standards for lithium monitoring in patients under the care of Psychiatry of Old Age (POA), Sligo Leitrim Mental Health Services in the North West of Ireland.

Results from a prior audit performed in February 2020 involving a cohort of 18 patients prescribed lithium under the care of POA were analysed and compared to accepted standards. The guideline used as the benchmark for compliance was the National Institute for Clinical Excellence (NICE) guidelines on the use and monitoring of lithium therapy, as published in 2014. Several deficits were found and therefore a designated Lithium Management Programme was established. A subsequent audit, performed using a simplified audit tool incorporating the NICE guidelines, delivered results which were directly compared to the initial findings and analysed to evaluate the effect of the implemented management programme.

In comparison with findings from 2020, there had been a significant improvement in most facets of lithium management and compliance to practice standards. Of particular note was the improvement of biochemical monitoring, side effect screening, polypharmacy surveillance, patient education and interdisciplinary communication.

The launch of a dedicated Lithium Management Programme with specific features aimed at identifying and addressing poor compliance with monitoring guidelines has led to improved adherence to accepted international practice standards. Our model provides a dynamic, multi-layered system which paves the way for better patient outcomes, timely access to care and furthering education for patients and staff members.

Disturbances in Pavlovian valuation systems are reported to follow traumatic stress exposure. However, motivated decisions are also guided by instrumental mechanisms, but to date the effect of traumatic stress on these instrumental systems remain poorly investigated. Here, we examine whether a single episode of severe traumatic stress influences flexible instrumental decisions through an impact on a Pavlovian system.

Twenty-six survivors of the 2011 Norwegian terror attack and 30 matched control subjects performed an instrumental learning task in which Pavlovian and instrumental associations promoted congruent or conflicting responses. We used reinforcement learning models to infer how traumatic stress affected learning and decision-making. Based on the importance of dorsal anterior cingulate cortex (dACC) for cognitive control, we also investigated if individual concentrations of Glx (=glutamate + glutamine) in dACC predicted the Pavlovian bias of choice.

Survivors of traumatic stress expressed a greater Pavlovian interference with instrumental action selection and had significantly lower levels of Glx in the dACC. Across subjects, the degree of Pavlovian interference was negatively associated with dACC Glx concentrations.

Experiencing traumatic stress appears to render instrumental decisions less flexible by increasing the susceptibility to Pavlovian influences. An observed association between prefrontal glutamatergic levels and this Pavlovian bias provides novel insight into the neurochemical basis of decision-making, and suggests a mechanism by which traumatic stress can impair flexible instrumental behaviours.

Obsessive–compulsive disorder (OCD) has been linked to functional abnormalities in fronto-striatal networks as well as impairments in decision making and learning. Little is known about the neurocognitive mechanisms causing these decision-making and learning deficits in OCD, and how they relate to dysfunction in fronto-striatal networks.

We investigated neural mechanisms of decision making in OCD patients, including early and late onset of disorder, in terms of reward prediction errors (RPEs) using functional magnetic resonance imaging. RPEs index a mismatch between expected and received outcomes, encoded by the dopaminergic system, and are known to drive learning and decision making in humans and animals. We used reinforcement learning models and RPE signals to infer the learning mechanisms and to compare behavioural parameters and neural RPE responses of the OCD patients with those of healthy matched controls.

Patients with OCD showed significantly increased RPE responses in the anterior cingulate cortex (ACC) and the putamen compared with controls. OCD patients also had a significantly lower perseveration parameter than controls.

Enhanced RPE signals in the ACC and putamen extend previous findings of fronto-striatal deficits in OCD. These abnormally strong RPEs suggest a hyper-responsive learning network in patients with OCD, which might explain their indecisiveness and intolerance of uncertainty.

Genetic–epidemiological studies that estimate the contributions of genetic factors to variation in tic symptoms are scarce. We estimated the extent to which genetic and environmental influences contribute to tics, employing various phenotypic definitions ranging between mild and severe symptomatology, in a large population-based adult twin-family sample.

In an extended twin-family design, we analysed lifetime tic data reported by adult mono- and dizygotic twins (n = 8323) and their family members (n = 7164; parents and siblings) from 7311 families in the Netherlands Twin Register. We measured tics by the abbreviated version of the Schedule for Tourette and Other Behavioral Syndromes. Heritability was estimated by genetic structural equation modeling for four tic disorder definitions: three dichotomous and one trichotomous phenotype, characterized by increasingly strictly defined criteria.

Prevalence rates of the different tic disorders in our sample varied between 0.3 and 4.5% depending on tic disorder definition. Tic frequencies decreased with increasing age. Heritability estimates varied between 0.25 and 0.37, depending on phenotypic definitions. None of the phenotypes showed evidence of assortative mating, effects of shared environment or non-additive genetic effects.

Heritabilities of mild and severe tic phenotypes were estimated to be moderate. Overlapping confidence intervals of the heritability estimates suggest overlapping genetic liabilities between the various tic phenotypes. The most lenient phenotype (defined only by tic characteristics, excluding criteria B, C and D of DSM-IV) rendered sufficiently reliable heritability estimates. These findings have implications in phenotypic definitions for future genetic studies.

Changes in reflexive emotional responses are hallmarks of depression, but how emotional reflexes make an impact on adaptive decision-making in depression has not been examined formally. Using a Pavlovian-instrumental transfer (PIT) task, we compared the influence of affectively valenced stimuli on decision-making in depression and generalized anxiety disorder compared with healthy controls; and related this to the longitudinal course of the illness.

A total of 40 subjects with a current DSM-IV-TR diagnosis of major depressive disorder, dysthymia, generalized anxiety disorder, or a combination thereof, and 40 matched healthy controls performed a PIT task that assesses how instrumental approach and withdrawal behaviours are influenced by appetitive and aversive Pavlovian conditioned stimuli (CSs). Patients were followed up after 4–6 months. Analyses focused on patients with depression alone (n = 25).

In healthy controls, Pavlovian CSs exerted action-specific effects, with appetitive CSs boosting active approach and aversive CSs active withdrawal. This action-specificity was absent in currently depressed subjects. Greater action-specificity in patients was associated with better recovery over the follow-up period.

Depression is associated with an abnormal influence of emotional reactions on decision-making in a way that may predict recovery.

The influence of genetic factors on major depressive disorder is lower than on other psychiatric disorders. Heritability estimates mainly derive from cross-sectional studies, and knowledge on the longitudinal aetiology of symptoms of anxiety and depression (SxAnxDep) across the lifespan is limited. We aimed to assess phenotypic, genetic and environmental stability in SxAnxDep between ages 3 and 63 years.

We used a cohort-sequential design combining data from 49 524 twins followed from birth to age ⩾20 years, and from adolescence into adulthood. SxAnxDep were assessed repeatedly with a maximum of eight assessments over a 25-year period. Data were ordered in 30 age groups and analysed with longitudinal genetic models.

Over age, there was a significant increase during adolescence in mean scores with sex differences (women>men) emerging. Heritability was high in childhood and decreased to 30–40% during adulthood. This decrease in heritability was due to an increase in environmental variance. Phenotypic stability was moderate in children (correlations across ages ~0.5) and high in adolescents (r = 0.6), young adults (r = 0.7), and adults (r = 0.8). Longitudinal stability was mostly attributable to genetic factors. During childhood and adolescence there was also significant genetic innovation, which was absent in adults. Environmental effects contributed to short-term stability.

The substantial stability in SxAnxDep is mainly due to genetic effects. The importance of environmental effects increases with age and explains the relatively low heritability of depression in adults. The environmental effects are transient, but the contribution to stability increases with age.

Healthy older adults report greater well-being and life satisfaction than their younger counterparts. One potential explanation for this is enhanced optimism. We tested the influence of age on optimistic and pessimistic beliefs about the future and the associated structural neural correlates.

Eighteen young and 18 healthy older adults performed a belief updating paradigm, measuring differences in updating beliefs for desirable and undesirable information about future negative events. These measures were related to regional brain volume, focusing on the anterior cingulate cortex (ACC) because this region is strongly linked to a positivity bias in older age.

We demonstrate an age-related reduction in updating beliefs when older adults are faced with undesirable, but not desirable, information about negative events. This greater ‘update bias’ in older age persisted even after controlling for a variety of variables including subjective rating scales and poorer overall memory. A structural brain correlate of this greater ‘update bias’ was evident in greater grey matter volume in the dorsal ACC in older but not in young adults.

We show a greater update bias in healthy older age. The link between this bias and relative volume of the ACC suggests a shared mechanism with an age-related positivity bias. Older adults frequently have to make important decisions relating to personal, health and financial issues. Our findings have wider behavioural implications in these contexts because an enhanced optimistic update bias may skew such real-world decision making.

When challenged with information about the future, healthy participants show an optimistically biased updating pattern, taking desirable information more into account than undesirable information. However, it is unknown how patients suffering from major depressive disorder (MDD), who express pervasive pessimistic beliefs, update their beliefs when receiving information about their future. Here we tested whether an optimistically biased information processing pattern found in healthy individuals is absent in MDD patients.

MDD patients (n = 18; 13 medicated; eight with co-morbid anxiety disorder) and healthy controls (n = 19) estimated their personal probability of experiencing 70 adverse life events. After each estimate participants were presented with the average probability of the event occurring to a person living in the same sociocultural environment. This information could be desirable (i.e. average probability better than expected) or undesirable (i.e. average probability worse than expected). To assess how desirable versus undesirable information influenced beliefs, participants estimated their personal probability of experiencing the 70 events a second time.

Healthy controls showed an optimistic bias in updating, that is they changed their beliefs more toward desirable versus undesirable information. Overall, this optimistic bias was absent in MDD patients. Symptom severity correlated with biased updating: more severely depressed individuals showed a more pessimistic updating pattern. Furthermore, MDD patients estimated the probability of experiencing adverse life events as higher than healthy controls.

Our findings raise the intriguing possibility that optimistically biased updating of expectations about one's personal future is associated with mental health.

The aim of this study was to examine the perceived impact of a community mobilisation intervention programme to reduce alcohol consumption among amateur sportsmen aged 16–34 years.

A qualitative focus group format was used to identify potentially important themes or concepts relating to players’ and coaches’ experiences of the intervention. Six focus groups were conducted (five with four to seven players per focus group and one with six coaches) to elicit participants’ experiences of the intervention.

Three major themes emerged from the analyses: patterns of alcohol consumption and associated factors; perceived impact of the intervention; and suggested changes to the community mobilisation intervention. Excessive binge drinking (i.e. the consumption of six or more standard drinks on any one occasion) was common among players. The perceived impact of the intervention programme among players was low; players and coaches believed that if future programmes were to succeed, a ‘bottom-up’ rather than a ‘top-down’ approach should be adopted.

The findings suggest that players perceived the community mobilisation programme to have had only limited success in changing attitudes or behaviour towards alcohol consumption in this amateur sports setting.

Approximately one-third of children in the USA are either overweight or obese. Understanding the perceptions of children is an important factor in reversing this trend.

An online survey was conducted with children to capture their perceptions of weight, overweight, nutrition, physical activity and related socio-behavioural factors.

Within the USA.

US children (n 1224) aged 8–18 years.

Twenty-seven per cent of children reported being overweight; 47·1 % of children overestimated the rate of overweight/obesity among US children. A higher percentage of self-classified overweight children (81·9 %) worried about weight than did self-classified under/normal weight children (31·1 %). Most children (91·1 %) felt that it was important to not be overweight, for both health-related and social-related reasons. The majority of children believed that if someone their age is overweight they will likely be overweight in adulthood (93·1 %); get an illness such as diabetes or heart disease in adulthood (90·2 %); not be able to play sports well (84·5 %); and be teased or made fun of in school (87·8 %). Children focused more on food/drink than physical activity as reasons for overweight at their age. Self-classified overweight children were more likely to have spoken with someone about their weight over the last year than self-classified under/normal weight children.

Children demonstrated good understanding of issues regarding weight, overweight, nutrition, physical activity and related socio-behavioural factors. Their perceptions are important and can be helpful in crafting solutions that will resonate with children.