Stuart Watson

Background: Serious incidents, such as patient suicide, profoundly impact clinicians. In mental health settings, these events are uniquely distressing. Despite policy shifts towards learning from serious incidents, many doctors report inadequate support and significant emotional distress. Resident doctors, already vulnerable to burnout and emotional exhaustion, are particularly at risk. Aims: This study aimed to understand resident psychiatry doctors’ experiences of serious incidents. It sought to gather in-depth insights about how resident psychiatrists navigate the serious incident process, and the effect the process has on their professional and personal lives. Method: A qualitative study recruited 10 participants via email in 1 National Health Service (NHS) trust. Semi-structured online interviews were audio-recorded, transcribed and analysed using Braun and Clarke’s six-phase thematic analysis, employing an iterative, constant comparative approach. Results: Descriptive characteristics of the participants are reported. Three overarching themes were identified: (a) when the process becomes the experience, with subthemes focusing on how open and transparent the investigation process was, about communication during the process and how doctors felt the process impacted their clinical role; (b) from theory to practice: when training meets reality. Subthemes here reflected on whether resident doctors felt prepared and knowledgeable about the process. There was also focus on the experience itself being a learning opportunity; (c) the emotional undercurrents: trauma, grief and support. Here the subthemes focused on the emotional toll of an incident and investigation, the grief and wider impact of a patient death and lastly, the need for support to resident doctors including supervisor and peer-to-peer support. Themes are reported accompanied by verbatim quotes from participants. Conclusions: Findings confirm prior studies investigating the negative impact of serious incidents on resident doctors’ well-being and career confidence, highlighting the need for robust support. The study adds to the literature through emphasising the inadequacy of current support and highlights rectifiable issues such as the need for structured peer support and improved supervisor/resident training for emotional and professional complexities. Future research should compare these findings with experiences under the new Patient Safety Incident Framework (PSIRF) system to assess improvements.

Background: Catatonia, commonly seen in psychiatric and medical practice, is often associated with increased morbidity and mortality. The neurotransmitter systems involved in catatonia include GABA, dopamine and glutamate. Benzodiazepines such as lorazepam, which act on GABA-A receptors, are used to confirm the diagnosis of catatonia, and are the mainstay of treatment. However, several patients with catatonia either don’t respond to lorazepam or its use is not suitable or possible (e.g. due to supply issues). Zolpidem is a positive allosteric modulator of GABA-A receptors. There are an increasing number of case reports and one systematic review of its use in the diagnosis and treatment of catatonia. Objectives: The objective of this systematic review is to explore the published evidence of zolpidem’s efficacy as a diagnostic test and for treatment for catatonia. Design, data sources and methods: We systematically reviewed evidence for zolpidem use in diagnosis and/or treatment of catatonia, using the PRISMA guidelines. We identified 44 case reports and case series, with 79 patients who met the inclusion criteria through searches of PubMed, Medline, EMBASE, CINAHL, ProQuest and PsycInfo. Results: 67 out of 79 patients (84.8%) with catatonia showed a positive response to zolpidem, with remission of catatonic symptoms in 24.1% of patients. The high response rate was evident regardless of its use as a challenge test (85.7%) or treatment (86.1%), either used alone (85.7%), or with a benzodiazepine (81.3%). The mean dose of zolpidem was 14.7mg, with a median of 10mg, and a range of 5 to 45mg, with a rapid mean time to response of 30.2 minutes. A few patients responded better to zolpidem at a higher dose and/or when used over a longer duration though this was not always the case. The response rate was higher in women (88.6%) as compared to men (64.7%). Conclusions: Although the results from this systematic review generate optimism for the use of zolpidem in diagnosis and treatment of catatonia, these results should be used with caution as there are no randomised controlled trials of zolpidem compared to placebo and/or lorazepam.

Background: Depression is associated with increased mortality, with underlying causes unclear. We conducted a systematic review and meta-analysis of cardiovascular (CV) mortality in depression and how antidepressant treatments and comorbidities modify this. Methods: We searched Medline, Embase, Scopus, Web of Science and Cochrane registers (inception to 31 December 2024) for randomised controlled trials (RCTs) and observational studies comparing CV mortality in adults with depression vs without, and receiving antidepressants vs controls. We excluded studies with k = 26), depression was associated with a significantly higher CV mortality versus no-depression (hazard ratio (HR): 1.45, 95% CI: 1.25–1.69). Effects were similar in non-selected community-dwelling cohorts and those with CV disease or type 2 diabetes. Antidepressants overall were associated with increased CV mortality in cohorts but after adjustment only tricyclic antidepressants (TCAs) had significantly increased risk vs no antidepressant ( k = 4; HR: 1.27, 95% CI: 1.02–1.58). RCT findings were directionally consistent but underpowered. Conclusions: Depression is associated with increased risk of CV mortality irrespective of comorbid group studied. Antidepressants do not appear to modify this risk, apart from TCAs, which may increase it. The antidepressant models in particular had high heterogeneity, reflecting a knowledge gap on the long-term effects of antidepressants in patients with depression on CV mortality.

There is a critical lack of exploration into the firsthand experiences of autistic children in the psychological literature. We sought to address this using baseline data from a wider mixed-methods study. A total of 136 autistic children (mean age = 10.35) completed an online questionnaire. Questions explored children’s understanding of autism, their feelings about being autistic in different contexts and challenges experienced. Quantitative data revealed limited autism knowledge and understanding for some. Challenges included talking about being autistic and self-advocating for needs, especially with non-family members. Children generally recognised both strengths and challenges of being autistic, although concerns about feeling/being different were widespread, and masking common. Strikingly, although most children felt positive about being autistic at home, significantly fewer felt this to be true when around peers or teachers. Using reflexive thematic analysis, four main themes were developed: (1) overwhelming experiences, (2) unsafe people, (3) sanctuary and (4) autistic identity. Overall, the children felt safest at home with family and/or with autistic/neurodivergent/understanding friends, but most unsafe at school with their teachers and neurotypical peers, where victimisation was rife. These findings offer valuable insights into the lives of autistic children, and demand we explore how places of education can be transformed into safe spaces for autistic children. Lay Autistic children are rarely asked directly about their own experiences. In this study, 136 autistic children (ages 8–14) shared their views through an online questionnaire. They were asked what being autistic means to them, how they feel about it and what challenges they face in different environments. Many said they knew little about autism, and most did not have the words to talk about being autistic or feel safe doing so. Talking was especially difficult outside the family; while over 60% felt comfortable with family, only 16.5% felt this way with other people. Children also told us how overwhelming everyday life can be. Noisy, crowded or unpredictable environments often caused distress or shutdown. Many described how strong emotions, especially anxiety, build up in these moments. Some lost the ability to speak, and tasks like decision-making or emotional regulation became especially hard and exhausting. School was often named as a major source of overwhelm. Children showed deep insight into the people around them. They were highly attuned to whether others, for example, friends, family, teachers or professionals, felt safe or unsafe. Feeling unsafe often meant being misunderstood, ignored or bullied. School peers were commonly described as sources of victimisation, and teachers as making children feel unsafe by not listening or misunderstanding their needs. When children did not trust those around them, they masked their autistic traits to avoid judgement. This came at a cost: many described exhaustion, loneliness or feeling like they had to hide who they really are. By contrast, home and trusted relationships, especially with neurodivergent family or friends, offered sanctuary. Children felt freer to be themselves, ask for what they need and talk about autism. Emergent positive autistic identities were evident in some children. These findings show autistic children are thoughtful, perceptive and deeply affected by their environments while simultaneously shining a bright light on the challenges growing up autistic in a neurotypical world. Their voices offer vital insights and a call to make schools and services safer, more respectful spaces.

Introduction: Bipolar disorder affects around 2% of the population and is linked with reduced life expectancy and socioeconomic burden. Depressive episodes are difficult to treat and typically more prevalent, enduring and burdensome than manic episodes. The use of antidepressants alone has limited effect and is associated with significant clinical risk through polarity switch. Current National Institute for Health and Care Excellence guidelines recommend quetiapine, olanzapine (with or without fluoxetine) and lamotrigine; however, these medications have limited efficacy, tolerability and acceptability. The ASCEnD study aims to assess the clinical and cost-effectiveness of aripiprazole plus sertraline compared with quetiapine, offering potential improvements for outcomes in bipolar depression. The study is funded by the National Institute for Health and Care Research Health Technology Assessment programme (NIHR132773). Methods and analysis: ASCEnD is a prospective, two-arm, superiority, individually 1:1 randomised, controlled, pragmatic, parallel group, type A open-label clinical trial of aripiprazole/sertraline medication combination compared with quetiapine for bipolar depression. The study is conducted in the UK National Health Service setting with the aim of recruiting and randomising 270 participants followed-up for 24 weeks. Adults with bipolar disorder self-refer or are recruited through primary and secondary care services. The primary outcome is change in depressive symptoms 12–16 weeks after randomisation. Secondary outcomes include measures of symptom change, treatment satisfaction, tolerability, medication adherence, concomitant medication use, psychosocial functioning, quality of life and cost-effectiveness and informal carer measures of quality of life and costs of caring. The exploratory outcome is change in participant reward and punishment responsiveness. Analysis will follow a prespecified statistical analysis plan. A nested qualitative study is included to examine feasibility and acceptability of the trial design. Ethics and dissemination: A Clinical Trial Authorisation from Medicines and Healthcare products Regulatory Agency, and approval from the Health Research Authority (IRAS 1007468) and North East – Newcastle and North Tyneside 1 Research Ethics Committee (23/NE/0132) were obtained. Results will be disseminated through peer-reviewed publications, conference presentations and lay summaries for participants and patient and public groups. Trial registration number: ISRCTN63917405 .

Introduction: Patients living with bipolar disorder in the UK face, on average, a delay of 9.5 years from initial presentation of symptoms to confirmation of diagnosis. The aim of this qualitative study was to understand the challenges and facilitators involved in diagnosing individuals with BD from the perspectives of GPs and psychiatrists and how the delay in diagnosis of BD from the first presentation might be reduced. Methods: Semi‐structured interviews with clinicians (GPs and psychiatrists) were used to explore attitudes and perspectives towards diagnosing, managing, and accessing or delivering specialist opinion for BD within the current NHS systems and pathways. Thematic analysis was conducted. Results: GPs report a lack of confidence in identifying BD due to limited understanding of the condition, resources, and lack of continuity of care. Both primary and secondary care clinicians expressed frustrations with the referral pathway in relation to high thresholds for secondary care acceptance and long waiting times for assessments. Clinicians suggest that further education and training in primary care supported by psychometric tools and mood diaries to improve identification of BD. Clinicians also advocated for enhanced communication and collaboration between primary and secondary care to streamline and reduce delays in the diagnostic process. Conclusion: We suggest a number of strategies which could reduce the harmful delay in diagnosis of bipolar. Patient or Public Contribution: A Lived Experience Advisory Panel (LEAP) was convened with the support of the McPin Foundation. LEAP members have contributed towards the development of public‐facing documents, including the topic guides, qualitative data analysis and dissemination of findings.

Summary: Recent changes to US research funding are having far-reaching consequences that imperil the integrity of science and the provision of care to vulnerable populations. Resisting these changes, the BJPsych Portfolio reaffirms its commitment to publishing mental science and advancing psychiatric knowledge that improves the mental health of one and all.

Background: There are limited options currently recommended in National Institute for Health and Care Excellence guidelines for the treatment of bipolar depression. Pramipexole has been shown to improve mood symptoms in two small pilot studies in such patients. Objectives: Primary: to evaluate the clinical effectiveness of pramipexole versus placebo alongside routine mood-stabilising medications over 12 weeks in patients with treatment-resistant bipolar depression. Secondary: evaluate the impact of pramipexole on mood and anxiety, psychosocial function, cost-effectiveness, and safety and tolerability over 48 weeks. Design: Multicentre, randomised, placebo-controlled trial of pramipexole versus placebo in addition to standard-of-care mood stabilisers. Clinicians, researchers and participants were blinded throughout the duration of the study. Pre-randomisation stage (to adjust antipsychotics or commence mood stabilisers where required) before randomisation. Weekly online assessments of mood and anxiety from randomisation to week 52, with psychosocial function, quality of life and healthcare resource utilisation assessments conducted at regular intervals. Setting: Twenty-one National Health Service trusts and Health Boards across England and Scotland. Participants: Patients aged 18 years and over with a diagnosis of treatment-resistant bipolar depression currently under secondary care mental health services. Aim to randomise 290 participants. Interventions: Pramipexole or matched placebo orally once daily, titrated from 0.25 mg to maximum of 2.5 mg (salt weight) depending on efficacy and tolerability. Main outcome measures: Depression – Quick Inventory for Depressive Symptomology; anxiety – Generalised Anxiety Disorder-7-item scale; psychosocial functioning – Work and Social Adjustment Scale; hypomania/mania – Altman Self-rating Scale of Mania; tolerability – Treatment Satisfaction Questionnaire for Medication; well-being and quality of life – EuroQol-5 Dimensions, five-level version, ICEpop CAPability measure for Adults and Oxford CAPabilities questionnaire-Mental Health tools. Results: Thirty-nine participants randomised (18 to pramipexole and 21 to placebo) with 36 providing data for the primary analysis. Pramipexole led to greater reductions in depressive symptoms at 12 weeks compared to placebo [4.4 (4.8) vs. 2.1 (5.1)]: a medium-sized (d = −0.72) but not statistically significant difference (95% confidence interval −0.4 to 6.3; p = 0.087). There were some statistically significant positive effects of pramipexole on secondary outcomes (reduction in depressive symptoms at 36 weeks, response and remission rates at trial exit, psychosocial function). Pramipexole was associated with an increased rate of hypomania/manic symptoms, but this appeared to be reduced by coadministration with an antipsychotic. General tolerability of pramipexole was good. There were significant annual gains in health-related quality of life and capability-well-being and tendency towards reduced health and social care costs. Limitations: Small sample size and variable follow-up period due to recruitment during COVID-19 pandemic and the trial closing early. Participants limited to those in secondary care mental health services. All assessments only available in English. Conclusions: No change in clinical practice can be recommended as there was not a significant difference between pramipexole and placebo on the primary efficacy outcome measure. However, there was evidence of positive effects of pramipexole on mood, psychosocial function and quality of life. Future work: Replication in a larger population and research to investigate the impact of coadministration of antipsychotics alongside pramipexole. Trial registration: This trial is registered as ISRCTN72151939 and EudraCT 2018-2869-18. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/154/01) and is published in full in Health Technology Assessment; Vol. 29, No. 21. See the NIHR Funding and Awards website for further award information.