Katie M. Douglas

To mark the 10th Anniversary of BJPsych Open, we explore the contributions of papers published in BJPsych Open to advance cultural psychiatry practice and policy. In our overview of papers published in BJPsych Open, we found examples of good practice where authors detailed the translation methods and interpretation models in the research. The task facing clinicians and public health practitioners is to evolve applied, locally relevant, culturally competent interventions in which specific adaptations are shaped by the potential beneficiaries, alongside theoretical and practical issues of cultural adaptation. Researchers and clinicians will need to provide evidence of acceptability and effectiveness of adapted interventions, alongside considering financial and implementation realities.

Purpose: Changes in facial emotion processing were examined over the course of anti-androgen treatment in women with PCOS. We also explored whether these changes in emotion processing correlated with changes in mood and anxiety symptoms over treatment. Methods: Thirty-three women with PCOS received 12 weeks of naturalistic treatment based on clinical presentation. Facial emotion processing was assessed at baseline and 12-weeks on the Reading the Mind in the Eyes Test, and a computerised Facial Expression Recognition (FER) Task, which measured accuracy and response time in recognising facial expressions (happiness, sadness, fear, disgust, anger, neutral), and neutral misinterpretation bias. The Hospital Anxiety and Depression Scale was completed at the same time-points. Outcomes were compared with a control group of 40 healthy women. Results: Women with PCOS (mean age = 29 years) were treated with a variety of medications, mainly spironolactone ( n = 22) and oral contraceptives ( n = 16). Within the PCOS group, significant improvement was found for 10 of 19 FER variables over treatment, and in depression and anxiety symptoms. When comparing the PCOS and control groups over time, the PCOS group became significantly faster in responding to disgusted and neutral expressions, and reduced in their tendency to misinterpret neutral faces as angry. Improved depression and anxiety symptoms correlated significantly with improved accuracy in recognising fearful expressions, but not with any other FER variables. Conclusions: In this preliminary study, anti-androgen treatment improved some aspects of facial emotion processing in women with PCOS, which has implications for understanding the mental health aspects of PCOS.

Background: Research demonstrates the effectiveness of evidence‐based psychological treatment adjunctive to pharmacotherapy for reducing mood symptoms in bipolar disorder. However, access to these treatments is limited, and innovative strategies are needed to ensure that more patients with bipolar disorder receive the gold‐standard treatments that may help them achieve wellness. “Stepped care” models of psychological service delivery represent one potential solution to this problem of treatment access. Under a stepped care model, patients are assigned the minimum necessary psychological treatment for symptom improvement. This typically means that patients who are experiencing more symptoms are assigned to a treatment of greater intensity (e.g., weekly individual therapy) whereas patients who are experiencing fewer symptoms are assigned to a treatment of relatively lesser intensity (e.g., biweekly group therapy). Stepped care models are dynamic, meaning that the level of treatment can be modified depending on the patient's response. Stepped care models have been explored in other clinical populations but require further exploration in bipolar disorder. Methods: Members of the Psychological Interventions Task Force for the International Society of Bipolar Disorders conducted a narrative review of stepped care models and their application to bipolar disorder. Results: We found evidence that stepped care models are useful approaches to delivering psychosocial treatments for bipolar disorder. We discuss several contextual factors in executing stepped care models in this population (i.e., cultural and pediatric applications), as well as share an example of a stepped care model—Focused Integrated Team‐based Treatment for Bipolar Disorder (FITT‐BD)—that is currently being evaluated in an academic medical center. Conclusion: Further research is warranted to develop and assess robust stepped care models to determine whether they can improve access to treatment of bipolar disorder while not sacrificing outcomes.

Background: The Consensus on subdomains and measures of Affective and Social cognition for research on Bipolar Disorder (CAS‐BD) project aimed to formulate preliminary consensus‐based recommendations for assessing affective and social cognition in BD. Methods: Three sequential surveys administered to experts on affective and social cognition in BD were conducted using the Delphi process. Experts responded to questions regarding affective and social cognition subdomains and rated their importance to research on BD. Experts also nominated measures, rated them for suitability, and ranked them by preference for use. Consensus was defined as ≥ 80% agreement. Results: 31 experts completed the initial survey, with 20–23 completing subsequent surveys. Consensus was obtained for the subdomain structure of both affective cognition and social cognition , and the definition of each subdomain within. Explicit emotion regulation was ranked as being of highest priority for further research on affective cognition, and theory of mind as highest priority for further research on social cognition. The top‐preferenced measures of all affective cognition subdomains were considered by consensus to be suitable for use in BD research. Agreement that the top‐preferenced measures of social cognition were suitable ranged from 71.5% to 95.3%. Discussion: Expert consensus on subdomains and measures of affective and social cognition for research on BD was obtained via a staged approach. Prior familiarity may have influenced some experts' rankings, but generally there was a notable lack of consistency in the use of available measures by BD experts. This reaffirms the need for more specific guidance and validated batteries of social and affective cognition to direct the field and allow for more consistency and replication of research in the future.

Introduction: The association between subjective and objective cognitive function in mood disorders is hotly debated, particularly in the choice of outcomes to measure pro‐cognitive effects of interventions. We systematically reviewed the evidence regarding this association, including analysis of predicting or moderating factors. Methods: We searched Ovid MEDLINE, EMBASE, PsycINFO, and Cochrane Library for studies examining subjective and objective cognitive function in mood disorders (from inception to July 2024). Studies using correlational analyses to examine the association between subjective and objective cognitive function were included in the meta‐analysis. Results: Fifty‐five studies (59 publications) were identified ( n = 5798), with 35 studies included in the meta‐analysis. There were weak but statistically significant positive correlations between subjective and objective cognition in all domains except sustained attention, which was at a trend level ( p = 0.05). Mood state or mood disorder diagnosis did not impact these correlations. No subjective measure was more highly associated with objective cognitive function than others. Our narrative review of the remaining 20 studies (that did not examine subjective‐objective correlations) demonstrated a shift towards calculation of a discrepancy or sensitivity score, rather than simply correlating measures. Conclusion: This is the first systematic review and meta‐analysis examining the association between subjective and objective cognition in mood disorders. Our results support the general consensus that there is not a strong relationship. This may relate to the limited ecological validity of objective cognitive tests and highlights the need for assessment of both subjective and objective cognitive function to adequately capture patients' cognitive status.

Background: Attention-deficit hyperactivity disorder (ADHD) in childhood is associated with various adverse long-term outcomes. Aims: We aimed to examine the independent associations between ADHD symptoms at age 14–16 years and long-term mental health and psychosocial functioning outcomes in a 40-year birth cohort study. Method: Study members from the Christchurch Health and Development Study, a population-based New Zealand birth cohort study ( N = 1265 at birth) were followed to age 40 years. Generalised estimating equations were used to model associations between ADHD symptoms at age 14–16 years and outcomes at age 18–40. Adjusted models were fitted to account for confounding by antecedent individual and familial risk factors, and coexisting symptoms of conduct disorder or oppositional defiant disorder. Results: Adolescents in the highest quartile for ADHD symptoms at age 14–16 years were at elevated risk of substance use disorder, depression, suicidal ideation, criminal offending and unemployment across early adulthood. They also had lower income, home ownership, relationship stability and living standards. The size of these associations attenuated after adjusting for confounding factors and the effect of coexisting conduct disorder and oppositional defiant disorder. However, in adjusted models, ADHD symptoms remained associated with elevated odds of substance use and criminal offending outcomes, with odds ratios ranging from 1.4 to 1.6. Conclusions: Higher levels of adolescent ADHD symptoms are associated with substance use problems and criminal offending in adulthood. Long-term secondary prevention activities are needed to detect and manage coexisting problems among adults with a history of ADHD.

Introduction: Major depressive disorder (MDD) and bipolar disorder (BD) are often associated with persistent cognitive deficits that impair psychosocial functioning. While pro‐cognitive interventions show promise, trial findings are inconsistent, potentially due to baseline factors influencing treatment response. This systematic review summarizes evidence on pre‐treatment characteristics associated with cognitive improvement and offers methodological recommendations. Methods: A systematic search was conducted in PubMed/MEDLINE, EMBASE, PsycINFO, and Cochrane Library from inception to February 28, 2025. Eligible studies included primary or secondary analyses of randomized controlled trials (RCTs) investigating predictors of cognitive response to pro‐cognitive interventions in MDD and/or BD. Two researchers independently conducted study selection and risk of bias assessments. Findings were synthesized qualitatively. Results: Forty studies ( N = 3864) were identified, covering pharmacological treatments (k = 20; N = 2299), psychological therapies (k = 16; N = 1165), brain stimulation (k = 2; N = 168), and physical activity (k = 2; N = 232). Poorer baseline cognitive performance was the most consistent predictor of greater cognitive improvement, though the direction of the effect was not entirely uniform across all studies. Baseline depression severity showed no significant association with cognitive outcomes. Age, education, sex, IQ, diagnosis, and medication status were similarly non‐predictive. Risk of bias was high in 77% of studies, mainly due to deviations from specified outcomes, poor randomization processes, and inconsistent handling of missing data. Considerable heterogeneity in interventions, outcome measures, and sample characteristics limited replicability and precluded meta‐analysis. Conclusion: Poorer baseline cognition emerged as the most reliable predictor of greater cognitive improvement across interventions. More rigorous, well‐powered studies are needed to replicate these findings and identify robust predictors to guide personalized pro‐cognitive treatment approaches in mood disorders.

Introduction: Individuals hospitalized with depression are particularly impacted by cognitive impairment. Identifying variables that predict improvements in cognition across treatment may inform more targeted and effective treatment approaches. We conducted secondary analyses to investigate baseline predictors of objective cognitive change in a severely depressed inpatient sample. Methods: A randomized controlled trial (RCT) comparing 2 weeks of Activation Therapy (AT; Cognitive Activation combined with Behavioural Activation) with treatment‐as‐usual (TAU) was conducted in inpatients with major depression. Research assessments were conducted at baseline (on admission) and at 14 weeks (12 weeks after treatment‐end). A series of analyses of covariance models were conducted to examine associations between change in executive functioning/attention, verbal learning and memory, visuospatial learning and memory, and psychomotor speed, in global cognition, and a range of putative baseline predictor variables (e.g., demographic, mood, cognition, general functioning, childhood trauma) across the whole RCT sample. Treatment arm was included as a fixed factor in all models. Sensitivity analyses were run in the AT group only to examine predictors of cognitive change in those receiving this targeted cognitive treatment. Results: Sixty‐eight individuals completed baseline and follow‐up cognitive testing assessments in the RCT (AT, n = 32, TAU, n = 36). Significantly poorer domain‐specific baseline cognitive functioning was associated with greater cognitive improvement in all four domains. Older age was associated with less cognitive change in verbal learning and memory, visuospatial learning and memory, psychomotor speed, and global cognition. Sensitivity analyses (AT group only) identified these same factors as significant predictors. Conclusion: Age and domain‐specific baseline cognitive performance were consistently associated with cognitive change in this RCT. Findings suggest that cognition seems to recover better in younger inpatients with poorer baseline cognitive functioning. Clinical Registration: Australian New Zealand Clinical Trials Registry [ANZCTR], ACTRN12617000024347p.

Neuropsychological memory testing is vital in the assessment of neurological conditions but evidence suggests that cultural factors can significantly impact upon the validity of the scores obtained. The lack of normative data for different populations may lead to misleading scores/inappropriate diagnoses. The present study aimed to assess clinicians’ perspectives around the validity of memory tests for use in NZ. Clinicians (n = 76) across NZ answered an online survey assessing the perceived validity of memory tests within the domains of working memory, visual learning and retrieval, auditory learning and retrieval, and prospective and autobiographical memory. Several of the most commonly used tests with a large language component were judged as lacking validity amongst clinicians. Current findings provide further evidence that common neuropsychological tests may lack validity and that the development of NZ-normative data and/or NZ specific tests are now long overdue.