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-depressive distress 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.

The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries.

Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents.

3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness.

ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

To reach 80% adherence to DVANI (Driving and Vehicle Agency Northern Ireland) guidance in acute inpatients ward, T&F Hospital

This is a scale-up of a previous successful QI project on driving and Attention Deficit Hyperactivity Disorder in Belfast Trust. According DVLA's guidance for medical practitioners on the current medical standards of fitness to drive, patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. Different factors are considered in order to determine patients’ fitness to drive. According to DVLA and GMC, it is medical professionals’ responsibility to advise patients to inform DVLA/DVANI of their mental health diagnosis. It is the patient's legal duty to notify DVLA/DVANI of their diagnosis. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition.

Outcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in %

Process: Document clearly in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for

Balancing: increased the time of reviews, increased numbers of consultant reports requested from DVA

4 cycles have been completed. Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Clear changes were seen after cycle 3 showing an increase of mean of 25% completeness of driving advice to over 90%.

It is the legal duty of patients to notify DVANI of mental health diagnosis, however it is the responsibility of medical professionals to advise patients to do so. This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback.

The restrictions experienced due to the COVID-19 pandemic had impacts on how clinical teaching and assessment is conducted. The Royal College of Psychiatrists decided to run the final part of the membership exam, the Clinical Assessment of Skills and Competencies (CASC) online for the first time in September 2020. We aimed to prepare candidates in the Northern Ireland deanery for this by developing a virtual mock examination using the Zoom platform.

In previous years, higher psychiatry trainees in the Northern Ireland deanery have run successful face to face mock examinations to help pre-membership trainees prepare for the CASC. We adapted some of this material to our virtual examination. 16 stations were run in total, in two circuits of eight. These stations were mapped to the Royal College CASC blueprint. Higher trainees were recruited to act as examiners, with core trainees acting as simulated patients. The mock examination was advertised through the local deanery and all candidates sitting in September availed of the opportunity (a total of 8 trainees).

Zoom was used as the platform due to ease of use, familiarity and breakout room function. Each station formed one breakout room, and a facilitator moved candidates between rooms and provided timing prompts. Instructions were emailed to candidates in advance.

A comfort break was provided between circuits. At the end of the mock examination, everyone was returned to the main room and examiners gave general feedback and tips. Individual feedback was provided by collating mark schemes for each candidate, which included free text feedback, and sending these via email.

Despite the evident challenges involved, the mock CASC ran smoothly. There was one minor delay of approximately 3 minutes due to technical difficulties, which was easily recouped. We obtained qualitative feedback from candidates which was positive, with trainees commenting that they felt “more at ease … less worried” about a digital exam, and that it was “efficient and effective”.

All candidates who sat the mock examination were successful in the face to face CASC sitting which followed in September.

We were able to successfully adapt what was previously an in-person mock CASC exam to the new digital format in a way that reflected how the actual CASC exam will run, and it was considered beneficial preparation by the candidates who sat this mock. This has improved trainee experience at a time when many teaching opportunities have been suspended.

Depressive and anxiety disorders are highly comorbid, which has been theorized to be due to an underlying internalizing vulnerability. We aimed to identify groups of participants with differing vulnerabilities by examining the course of internalizing psychopathology up to age 45.

We used data from 24158 participants (aged 45+) in 23 population-based cross-sectional World Mental Health Surveys. Internalizing disorders were assessed with the Composite International Diagnostic Interview (CIDI). We applied latent class growth analysis (LCGA) and investigated the characteristics of identified classes using logistic or linear regression.

The best-fitting LCGA solution identified eight classes: a healthy class (81.9%), three childhood-onset classes with mild (3.7%), moderate (2.0%), or severe (1.1%) internalizing comorbidity, two puberty-onset classes with mild (4.0%) or moderate (1.4%) comorbidity, and two adult-onset classes with mild comorbidity (2.7% and 3.2%). The childhood-onset severe class had particularly unfavorable sociodemographic outcomes compared to the healthy class, with increased risks of being never or previously married (OR = 2.2 and 2.0, p < 0.001), not being employed (OR = 3.5, p < 0.001), and having a low/low-average income (OR = 2.2, p < 0.001). Moderate or severe (v. mild) comorbidity was associated with 12-month internalizing disorders (OR = 1.9 and 4.8, p < 0.001), disability (B = 1.1–2.3, p < 0.001), and suicidal ideation (OR = 4.2, p < 0.001 for severe comorbidity only). Adult (v. childhood) onset was associated with lower rates of 12-month internalizing disorders (OR = 0.2, p < 0.001).

We identified eight transdiagnostic trajectories of internalizing psychopathology. Unfavorable outcomes were concentrated in the 1% of participants with childhood onset and severe comorbidity. Early identification of this group may offer opportunities for preventive interventions.

Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.

Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.

MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.

Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.

Previous work has identified associations between psychotic experiences (PEs) and general medical conditions (GMCs), but their temporal direction remains unclear as does the extent to which they are independent of comorbid mental disorders.

In total, 28 002 adults in 16 countries from the WHO World Mental Health (WMH) Surveys were assessed for PEs, GMCs and 21 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders. Discrete-time survival analyses were used to estimate the associations between PEs and GMCs with various adjustments.

After adjustment for comorbid mental disorders, temporally prior PEs were significantly associated with subsequent onset of 8/12 GMCs (arthritis, back or neck pain, frequent or severe headache, other chronic pain, heart disease, high blood pressure, diabetes and peptic ulcer) with odds ratios (ORs) ranging from 1.3 [95% confidence interval (CI) 1.1–1.5] to 1.9 (95% CI 1.4–2.4). In contrast, only three GMCs (frequent or severe headache, other chronic pain and asthma) were significantly associated with subsequent onset of PEs after adjustment for comorbid GMCs and mental disorders, with ORs ranging from 1.5 (95% CI 1.2–1.9) to 1.7 (95% CI 1.2–2.4).

PEs were associated with the subsequent onset of a wide range of GMCs, independent of comorbid mental disorders. There were also associations between some medical conditions (particularly those involving chronic pain) and subsequent PEs. Although these findings will need to be confirmed in prospective studies, clinicians should be aware that psychotic symptoms may be risk markers for a wide range of adverse health outcomes. Whether PEs are causal risk factors will require further research.

Traumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.

To investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.

We assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.

Respondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR=3.1, 95% CI 2.7–3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.

Exposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.

Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity.

To examine the associations of parent with respondent disorders.

Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews.

Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle- than low-/lower-middle-income countries, and consistently higher for behaviour (11.0–19.9%) than other (7.1–14.0%) disorders.

Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.