David Osborn

Sexual minorities (e.g., lesbian, gay, and bisexual individuals) experience significant health inequalities and report negative identity-related experiences within UK health and social care services. Despite staff training being recommended to improve care for this population, training provision remains inconsistent. This systematic review synthesised UK-focussed guidance documents, training materials, and training evaluations aimed at improving health and social care staff’s work with sexual minority people. We systematically searched nine databases (MEDLINE^®, EMBASE, PsycINFO, Social Policy and Practice, CINAHL Plus, ERIC, Applied Social Sciences Index & Abstracts, International Bibliography of the Social Sciences, and Web of Science) and searched the supplementary grey literature. Studies of any design, training materials, and guidance documents, published from 2010 onwards, were eligible. Screening, data extraction, and quality assessment were conducted independently by two researchers. A narrative synthesis, and content analysis of the guidance documents, was conducted. Study quality was assessed using the QualSyst tool, and guidance documents were appraised using the AGREE II. Thirty-one guidance documents, five training evaluations, one good practice paper, and one set of training materials were included. Guidance documents targeted health and social care staff, services, and commissioners. Consistent recommendations included using neutral language, avoiding assumptions about sexual orientation, recognising the diversity of sexual minority identities, explicitly including sexual minorities in policies, addressing prejudice and discrimination, providing staff training, having visible signs of inclusivity, and routinely collecting and monitoring sexual orientation data. Training evaluations suggested that training can improve staff competence in working with sexual minorities. This review provides the most comprehensive synthesis to date of UK guidance and training relating to health and social care provision for sexual minority service users. It identifies a consistent set of practical, largely low-cost actions that organisations and staff can prioritise to create safe and inclusive services.

Background: People diagnosed with severe mental illnesses (SMI) including bipolar disorder, schizophrenia and psychosis are disproportionately exposed to adverse social determinants of health, contributing to premature morbidity and mortality. Social prescribing aims to address social risk factors for poor health by linking patients in primary care to community activities. However, whether people with SMI access social prescribing through primary care remains unexplored. Aims: To describe prevalence of, and sociodemographic characteristics associated with, social prescribing consultations in patients with SMI in primary care. Methods: Using the UK Clinical Practice Research Datalink, we identified patients aged 18+ with a diagnosis of SMI between 2004-2019. We calculated the percentage of patients with SMI who received a social prescribing consultation between 2019-2023 and used logistic regression to examine associations between sociodemographic, health-related factors and social prescribing consultations and refusals. We used fixed effects analysis to determine whether a new diagnosis of SMI made between 2019-2023 was associated with an increased odds of receiving a social prescribing consultation. Results: Among 112,334 patients with SMI, 0.8% received a social prescribing consultation in 2019 increasing to 9.5% in 2023. Between 2020-2023, older age (OR=1.18-2.34), being female (OR=1.16-1.31) and living in more deprived areas (OR=1.14-1.49) were associated with higher odds of receiving a social prescribing consultation amongst patients with SMI. Across all years, patients with SMI and depression (OR=1.32-1.92), diabetes (OR=1.19-1.35) or obesity (OR=1.17-1.54) also had increased odds. In 140,514 patients with time-varying SMI status, a new diagnosis of SMI was associated with higher odds of receiving a social prescribing consultation (OR=1.39, 95% CI 1.26-1.53). Conclusion: Since 2019, social prescribing consultations among patients with SMI in primary care have increased and are reaching those in areas of higher deprivation and with greater health needs. Strategies to remove barriers to consultations among younger adults and males are still needed.

Background: Improving access to community-based crisis care and reducing in-patient admissions are key policy objectives in England, yet evidence on who uses crisis-related services remains limited. Aims: To examine sociodemographic patterns in the use of six crisis-related services in England: crisis phonelines; crisis cafés; Crisis Resolution and Home Treatment teams (CRHTs); voluntary in-patient admissions; compulsory in-patient admissions under the Mental Health Act 1983 (MHA); and conveyance to a Place of Safety (PoS) by police under section 136 of the MHA. Method: This retrospective observational study used the Mental Health Services Data Set (2021/2022−2023/2024). Adults (18+ years) using any of the six services were included. A multinomial logit regression model estimated average marginal effects for age, gender, ethnicity and area-level deprivation, with robust patient-level standard errors and year fixed effects. Results: Among crisis-related patients, adjusted analysis showed that several ethnic minority groups were more likely than White individuals to be compulsorily detained or brought to a PoS, and less likely to use CRHTs, with the largest disparities in compulsory admissions for Black (+15.0 percentage points) and Asian (+7.3 percentage points) groups. Compulsory admissions were more common among older adults and men (+1.5 percentage points). Crisis phonelines were used less by older adults, men (−4.8 percentage points), Black (−15.6 percentage points) and Asian (−4.7 percentage points) groups. Although adjusted differences by deprivation were small (<1.0 percentage points), over half of users lived in the 2 most deprived quintiles. Conclusions: Groups at greater risk of coercive care were less likely to access community crisis services. Addressing these disparities could reduce inequalities.

Sexual minorities (e.g., lesbian, gay, and bisexual individuals) experience significant health inequalities and report negative identity-related experiences within UK health and social care services. Despite staff training being recommended to improve care for this population, training provision remains inconsistent. This systematic review synthesised UK-focussed guidance documents, training materials, and training evaluations aimed at improving health and social care staff’s work with sexual minority people. We systematically searched nine databases (MEDLINE®, EMBASE, PsycINFO, Social Policy and Practice, CINAHL Plus, ERIC, Applied Social Sciences Index & Abstracts, International Bibliography of the Social Sciences, and Web of Science) and searched supplementary grey literature. Studies of any design, training materials, and guidance documents, published from 2010 onwards were eligible. Screening, data extraction, and quality assessment were conducted independently by two researchers. A narrative synthesis, and content analysis of the guidance documents, was conducted. Study quality was assessed using the QualSyst tool, and guidance documents were appraised using the AGREE II. Thirty-one guidance documents, six training evaluations, and one set of training materials were included. Guidance targeted health and social care staff, services, and commissioners. Consistent recommendations included using neutral language, avoiding assumptions about sexual orientation, recognising the diversity of sexual minority identities, explicitly including sexual minorities in policies, addressing prejudice and discrimination, providing staff training, having visible signs of inclusivity, and routinely collecting and monitoring sexual orientation data. Training evaluations suggested that training can improve staff competence in working with sexual minorities. This review provides the most comprehensive synthesis to date of UK guidance and training relating to health and social care provision for sexual minority service users. It identifies a consistent set of practical, largely low-cost actions that organisations and staff can prioritise to create safe and inclusive services.

Background: Dihydropyridine calcium channel blockers have been implicated in both symptom improvement and exacerbation in pre-existing severe mental illness (SMI). We aimed to test the hypothesis that blood-brain barrier penetrant dihydropyridines (DHPs) reduce rates of mental health hospitalisation and self-harm compared to non-penetrant DHPs. Methods: We used English electronic health records (Clinical Practice Research Datalink) to conduct a target trial emulation study in people with schizophrenia, bipolar disorder or other psychosis. We compared admissions for mental health and self-harm in those prescribed blood-brain barrier penetrant (intervention) and non-penetrant DHPs (control). Our primary endpoint was a 12-month intention-to-treat analysis using covariate adjustment. We additionally completed overlap weighting, per-protocol analyses and negative outcome controls. Results: We included 918 people prescribed blood-brain barrier penetrant DHPs and 3384 prescribed amlodipine (control). In the primary covariate-adjusted intention-to-treat analysis, there was no clear evidence of a difference in rates of combined mental health admissions and self-harm events (adjusted hazard ratio (HR): 1.22; 95% confidence interval (CI): 0.78–1.91 at 12 months). In a pre-specified sensitivity analysis using overlap weighting, self-harm event rates were elevated in the intervention group at 12 months (HR: 2.10; 95% CI: 1.13–3.94); however, the equivalent covariate-adjusted estimate showed no clear difference (HR: 1.81; 95% CI: 0.52–6.26). Conclusion: In people with SMI, blood-brain barrier penetrant DHPs were not associated with reduced mental health hospitalisations or self-harm events compared to those treated with amlodipine, though estimates were imprecise. This active comparator design cannot distinguish between absence of effect or equivalent benefit of both drug classes. There are peripheral pathways through which DHPs may impact psychiatric symptoms and these require further exploration.

Background: Bipolar disorder is an episodic mental illness, often requiring complex pharmacological management. Lithium is a first-line treatment, while antidepressant monotherapy can precipitate mania symptoms in some patients. Aims: To (a) describe patterns of antidepressant, antipsychotic and mood stabiliser prescribing in the 12-month periods before and after first-recorded bipolar diagnosis; (b) describe treatment trajectories in the year post-diagnosis; and (c) investigate associations between sociodemographic and treatment-related characteristics of (i) antidepressant monotherapy and (ii) lithium prescription post-diagnosis. Method: A longitudinal cohort study of patients with a first-recorded diagnosis of bipolar disorder between 2000 and 2022 derived from Clinical Practice Research Datalink. Prescriptions for antidepressants, antipsychotics and mood stabilisers were examined in the 12 months before and after diagnosis. Logistic regression models tested associations between sociodemographic and treatment-related characteristics and prescribing outcomes. A web application ( https://dop-mhds.shinyapps.io/bpd-prescribing-uk-shiny/ ) was developed to visualise treatment trajectories over the year following diagnosis. Results: We included 40 965 patients with a first-recorded diagnosis of bipolar disorder between 2000 and 2022 (median age at diagnosis 43 years, 60.9% female, 11.1% ethnic minority). Of these, 32 460 (79.2%) were prescribed a relevant medication in the year prior to diagnosis compared with 37 208 (90.8%) in the year after. Antidepressant monotherapy was the most common pre-diagnosis treatment (48.4%), but was also prescribed to 28.9% during at least 1 month in the year after diagnosis. Antipsychotic monotherapy was the most common post-diagnosis treatment (36.0%). Lithium was prescribed to 18.5% within 1 year of diagnosis, with 4.0% receiving it as first-line monotherapy. Almost half (46.0%) switched medication at least once within 1 year. Males, ethnic minorities and patients residing in the most deprived areas had lower odds of receiving either lithium or antidepressant monotherapy. Conclusions: Prescribing patterns for bipolar disorder in the UK are highly variable and often outside of guideline recommendations, with persistent use of antidepressant monotherapy and potential under-utilisation of lithium.

Anxiety and depression are increasingly prevalent among young people and significantly impact their lives. However, research on the referral pathways into Child and Adolescent Mental Health Services (CAMHS) for young people with these disorders, and how these pathways vary according to socio-demographic characteristics, remains limited. Moreover, few studies have examined whether educational factors are associated with these referral pathways. Therefore, this study aimed to examine the relationships of sociodemographic and educational characteristics with CAMHS referral pathways for anxiety disorders and depression. We used routinely collected educational data linked with CAMHS records from South London and Maudsley NHS Foundation Trust, focusing on young people aged 12–17 years with clinical diagnoses of anxiety disorders and depression ( N = 4,169). Using multinominal logistic regression, we identified that referral pathways to CAMHS are associated with various sociodemographic and educational factors. Specifically, youth with lower educational attainment, school exclusion, or SEN status, were more likely to be referred to CAMHS through education. This suggests that educational services may be a key referral pathway for young people in need of mental health support for anxiety and/or depression and referring to CAMHS. However, Black young people, those who speak English as an additional language (EAL), individuals eligible for free school meals (FSM), and young people under the care of local authorities were more likely to be referred via social care or youth justice services. Also, older young people, females and those under the care of local authority showed a higher likelihood of being referred via emergency services rather than primary care. These findings highlight that efforts to identify problems earlier through primary care or education services could benefit for those young people who are more frequently referred via emergency or social care/youth justice routes. Further research is needed to examine the potential under-utilisation of certain referral pathways by specific groups, in order to improve accessibility and ensure that more young people can access effective mental health care.

Background: People with severe mental illness (SMI) are more likely to develop long-term physical health conditions compared with those without SMI, contributing to an inequality in life expectancy. Chronic kidney disease (CKD) is a growing global health concern set to be the fifth leading cause of life-years lost by 2040. Although people with SMI may have a higher risk of CKD, there is limited research exploring the relationship between CKD and SMI. Aims: This review aimed to examine the prevalence, incidence and risk of CKD among people with SMI. Method: We searched Medline, Embase, PsycINFO, CINAHL, Scopus and Web of Science for epidemiological research reporting the prevalence of CKD (of any stage according to Kidney Disease Improving Global Outcomes guidelines) among people with SMI. Records were imported into Covidence and screened by two reviewers. Meta-analyses were conducted using random-effects models to examine the prevalence, incidence and risk of CKD among people with SMI. Results: Forty-eight studies were included in the review. The pooled prevalence of CKD was 8% in studies of people with SMI (95% CI 5%, 18%) and was highest in studies focused only on participants with bipolar disorder (95% CI 0.15 (0.06, 0.26)). The pooled incidence rate of CKD was 26.83 cases (95% CI 18.66, 38.58) per 1000 person-years. People with SMI had significantly higher odds of CKD compared with those without SMI (odds ratio 2.33 [95% CI 1.70, 3.21]). Conclusion: People with SMI are at a significantly higher risk of having CKD compared with those without SMI. Although psychiatric medication and high rates of diabetes may play a role, the drivers of this inequality are under-researched.

Background: Evidence regarding the efficacy of adjunct statins to treat severe mental illness (SMI) is mixed. The varying pharmacokinetic properties of statins mean that specific statin-antipsychotic combinations might improve psychiatric symptoms. Objective: To test whether some statin-antipsychotic/mood stabiliser combinations result in psychiatric symptom improvement in patients with SMI, while others do not, using target trial emulation in observational data. Methods: We identified patients with SMI (schizophrenia, bipolar disorder, ‘other’ psychoses) prescribed antipsychotics/mood stabilisers and statins from 2000 to 2019 in English linked primary care records (Clinical Practice Research Datalink). We defined hypothetical randomised trials and observational emulations: (1) blood-brain barrier (BBB)-penetrant (simvastatin) versus non-penetrant (atorvastatin/pravastatin/rosuvastatin) statins; (2A) P-glycoprotein inhibitors (simvastatin/atorvastatin) versus non-inhibitors (pravastatin) in patients prescribed aripiprazole/risperidone/olanzapine (P-glycoprotein affinity); (2B) high (aripiprazole/risperidone/olanzapine) versus low (quetiapine) P-glycoprotein affinity antipsychotics in patients prescribed P-glycoprotein-inhibiting statins. Findings: We found no reduction in our primary outcomes (12-month psychiatric admissions) in trial 1 (HR 1.07, 95% CI 0.88 to 1.31); trial 2A (HR 0.77, 95% CI 0.28 to 2.15); or trial 2B (HR 0.93, 95% CI 0.79 to 1.09). In trial 2B, we observed lower self-harm events (HR 0.60, 95% CI 0.38 to 0.97) in per-protocol analysis and lower psychiatric admissions in the ‘other’ psychoses subgroup (HR 0.53, 95% CI 0.34 to 0.85). Conclusions: BBB penetrance appears unlikely to be the mechanism by which statins improve SMI symptoms. Interaction with P-glycoprotein may have some effect. Further mechanistic and clinical research is needed to understand statin-antipsychotic interactions and the role of interaction with P-glycoprotein. Clinical implications: There is currently not enough evidence to guide the prescription of statins for psychiatric symptom improvement in patients with SMI. If there is an effect of statins, it may be through specific statin-antipsychotic combinations.

Background: A higher prevalence of neurological conditions has been found in schizophrenia, bipolar disorder and other psychotic illnesses compared to the general population. We aimed to understand the cumulative prevalence of 15 neurological conditions in people with severe mental illness (SMI) from 5 years before to 5 years after their SMI diagnosis. Methods: We identified patients with SMI, aged 18–100 years from 1 Jan 2000 to 31 Dec 2018, from the UK Clinical Practice Research Datalink. Each SMI patient was matched 1:4 to individuals without SMI. The cumulative prevalence of 15 neurological conditions was recorded at 5, 3 and 1 years prior to SMI diagnosis; at SMI diagnosis; and 1, 3 and 5 years after SMI diagnosis. Prevalences were compared with logistic regression. Results: We identified 68 789 patients with SMI and 274 827 comparators. Of 15 neurological conditions, 13 (multiple sclerosis, cerebrovascular disease, dementia, ataxic disorders, epilepsy, Parkinson’s disease, other parkinsonism, paralysis, other movement disorders, cerebrospinal fluid disorders, cerebral palsy, disorders of nerve root, plexus or peripheral nerves and autonomic disorders) were more prevalent in SMI compared with comparators at the time of SMI diagnosis. Dementia (OR: 4.22; 95% CI 3.88 to 4.58), epilepsy (OR: 3.01; 95% CI 2.83 to 3.19) and Parkinson’s disease (OR: 3.97; 95% CI 3.45 to 4.57) were particularly elevated at 5 years post-SMI diagnosis. Conclusions: Many neurological conditions have higher prevalence in the SMI cohort compared with those without SMI. The different prevalence patterns observed in our study highlight the need to establish the causal pathways between specific SMI and neurological disease diagnoses.