Carmen Moreno

Summary: Epilepsy affects ~50 million people worldwide and is associated with increased psychiatric comorbidities, including depression, anxiety, psychosis and suicidality. Despite this, current epilepsy management primarily focusses on seizure control, potentially overlooking mental health concerns. This article explores the challenges of integrating psychiatric care into epilepsy treatment and proposes solutions for a more holistic approach. Using a consensus development panel method, a multidisciplinary team of neurologists, psychiatrists and a lived-experience expert identified key challenges to optimising the mental health of people living with epilepsy, such as healthcare system fragmentation, underdiagnosis of mental health conditions and inadequate resources. Among the proposed solutions, the need for routine mental health screening, interdisciplinary support and collaboration, and increased research into the neuropsychiatric aspects of epilepsy were highlighted. A shift from a seizure-centric model to a patient-centred approach is advocated, emphasising biopsychosocial care and improved access to psychiatric services. We also discuss prospective practical strategies to tackle the issues identified, including collaborative care models, structured decision trees and AI-driven screening tools, to enhance diagnosis and treatment. Addressing these challenges through systemic change, research investment and service innovation should significantly improve the care and quality of life for individuals with an epilepsy and co-occurring mental health disorders.

Numerous aspects of depressive symptomatology in first-episode schizophrenia spectrum disorders (FES) remain unclear. Based on data from the FES OPTiMiSE trial, we estimated the prevalence of depression (Calgary Depression Scale for Schizophrenia (CDSS) total score ≥7) at baseline ( n = 122, 27.5%) and at weeks 4 ( n = 57, 15.9%) and 10 ( n = 14, 21.5%). Baseline depression was cross-sectionally associated with more severe extrapyramidal symptoms ( p = 0.036) and poorer subjective wellbeing ( p < 0.001). At week 4, baseline depression was linked to poorer psychosocial functioning ( p < 0.001) and subjective wellbeing ( p < 0.001). At week 10, baseline depression was associated with psychosis non-remission ( p = 0.042) and worse subjective wellbeing ( p = 0.011). There was a significant correlation between decrease in CDSS and PANSS total scores ( p < 0.001) at weeks 4 and 10. Depressive symptomatology in the FES OPTiMiSE trial was prevalent and associated with poorer objectively- and subjectively-measured outcomes over a 10-week follow-up. Early intervention for depression may improve outcomes in FES.

This editorial focuses on the seven studies published in the BMJ Mental Health topic collection Advances in Clinical Psychopharmacology in Children and Young People. Collectively, these articles provide evidence that informs key steps in the psychopharmacological management of children and adolescents with mental health or neurodevelopmental conditions. Papers in this collection contribute to strengthen evidence-based psychopharmacological practice. We look forward to further developments in the field, supported by adequate research funding.

Objectives Should a young person receive psychotherapy or medication for their depression and on what evidence do we base this decision? In this paper, we test the factors across modalities that may influence comparability between medication and psychotherapy trials. Methods We included 92 randomised controlled trials (RCTs) of psychotherapy and medication for child and adolescent depression (mean age 4–18 years). Using meta-analyses, we compared (a) participant characteristics and (b) trial characteristics in medication and psychotherapy trials. Lastly, we examined whether psychotherapy controls are well-matched to active conditions. Results Participants in medication RCTs had higher depression severity and were more frequently male compared with psychotherapy RCTs. There was a dramatic difference in the within-subject improvement due to placebo (SMD=−1.9 (95% CI: −2.1 to −1.7)) vs. psychotherapy controls (SMD=−0.6 (95% CI: −0.9 to −0.3)). Within psychotherapy RCTs, control conditions were less intensive on average than active conditions. Conclusions Medication and psychotherapy RCTs differ on fundamental participant and methodological characteristics, thereby raising questions about their comparability. Psychotherapy controls often involve little therapist contact and are easy-to-beat comparators. These findings cast doubt on the confidence with which psychotherapy is recommended for youth depression and highlight the pressing need to improve the evidence base.