Gin S. Malhi

Objectives: To examine the relationship between irritability and mixed states in bipolar disorder to determine how subjective irritability and mixed symptoms of mania and depression manifest in patients with bipolar disorder over a period of 18 months. Methods: This exploratory analysis examined longitudinal data from a randomised controlled trial of a psychological intervention for patients with bipolar disorder. Scores of subjective irritability and mood morbidity were analysed from data sampled over ten timepoints over the trial from 82 patients. Results: Significant associations were found between the presence of irritability and mixed symptoms ( F (1, 684) = 20.468, p < 0.001). This relationship remained significant throughout the duration of the study and the administration of a psychological treatment which reduced both ratings of mood and irritability. Notably, when mixed symptoms are absent, irritability nevertheless remained for nearly half the time. Conclusions: Irritability and mixed symptoms are phenomenologically linked. The persistence of this link, regardless of the existence of mixed symptoms, suggests that irritability permeates bipolar disorder and is core to its phenomenology. Future studies should interrogate the tethering of mixed symptoms and irritability in the context of bipolar disorder as this may lead to a deeper understanding of the core characteristics of the illness—both clinically and in terms of its neurobiology.

Summary: Irritability is a ubiquitous clinical phenomenon, and yet its definition and specific role within psychiatric disorders have long eluded the field. By understanding what irritability is, in whom it should be studied and how it should be modelled, new insights into the disorders within which it manifests may be gained.

Summary: In recent years deprescribing mood disorder medications has attracted increasing attention, and guidance provides suggestions for clinical implementation of deprescribing strategies that have been derived through expert consensus. Summarising and highlighting key recommendations, we discuss their execution in various clinical contexts and discuss their integration into clinical practice.

Co-production is increasingly recognised as central to improving the quality, relevance and ethical integrity of mental health science, yet evidence is still needed on how lived experience involvement can be meaningfully embedded and sustained in complex research settings. Global Alliance for Living Evidence on Anxiety, Depression and Psychosis (GALENOS) is a Wellcome-funded collaboration conducting living systematic reviews and evidence triangulation, with people with lived experience contributing as Experiential Advisors and through a Global Lived Experience Advisory Board. This perspective uses GALENOS as a case example to reflect on what meaningful co-production practically requires especially in the context of large-scale, technical and international collaborations. It draws on a collective reflection designed and led by people with lived experience, developed through workshops and written contributions involving lived experience contributors, researchers and project-support staff. Discussions were organised around lived experience involvement, capacity development, diversity and representation and influence in strategic decision-making. Across these areas, contributors identified that experiential knowledge needs to become consequential, participation must be supported through care and flexibility, diversity must shape interpretation rather than representation alone and influence must be embedded in governance and decision-making. GALENOS shows that co-production is not a fixed method but an evolving relational practice requiring practical infrastructures for accessibility, accountability, continuity and ethical care.

Medicine is based on a long apprenticeship and mentorship that entails respect for skilled and experienced leaders – a process that lends the profession prestige. However, as is often the case with such professional values, this respect for leaders can be abused, and medicine continues to struggle with high levels of bullying, harassment and discrimination by medical leaders that adversely impact on medical staff and the communities they serve. We explore why inappropriate behaviour in the medical workplace has not seemingly receded in this context. Insights from anthropological and social psychology research on dysfunctional organisational leadership may inform collective action to enact change.