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The pervasive effect of personality disorder is often overlooked in clinical practice, both as an important moderator of mental state and physical disorders, and as a disorder that should be recognised and managed in its own right. Contemporary research has shown that maladaptive personality (when personality traits are extreme and associated with clinical distress or psychosocial impairment) is common, can be recognised early in life, evolves continuously across the lifespan, and is more plastic than previously believed. These new insights offer opportunities to intervene to support more adaptive development than before, and research shows that such intervention can be effective. Further research is needed to improve classification, assessment, and diagnosis of personality disorder across the lifespan; to understand the complex interplay between changes in personality traits and clinical presentation over time; and to promote more effective intervention at the earliest possible stage of the disorder than is done at present. Recognition of how personality disorder relates to age and developmental stage can improve care of all patients.

Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.AimsOur aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters. This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics. Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27-0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43-2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies. Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.Declaration of interestNone.

There continues to be debate about the influence of personality disorder on the outcome of depressive disorders and is relative interactions with treatment. To determine whether personality disorder, both generically and in terms of individual clusters, leads to a worse outcome in patients with depressive disorders and whether this is influenced by type of treatment, a systematic electronic search of MEDLINE, CINAHL, and PsycINFO from 1966, 1982, and 1882, respectively, until February 2007 was undertaken. The keyword terms depression, mental illness, and personality disorder were used. All references were reviewed and personal correspondence was undertaken. Only English language papers were considered. Any English language paper studying a depressed adult population was considered for inclusion. Studies needed to clearly define depression and personality disorder using peer-reviewed instruments or International Classification of Disease/Diagnostic Statistical Manual criteria. Outcome assessment at greater than 3 weeks was necessary. Final inclusion papers were agreed on by consensus by at least two reviewers. All data were extracted using predetermined criteria for depression by at least two reviewers in parallel. Disagreement was settled by consensus. Complex data extraction was confirmed within the study group. Data were synthesized using log odds ratios in the Cochrane RevMan 5 program. The finding of comorbid personality disorder and depression was associated with a more than double the odds of a poor outcome for depression compared with those with no personality disorder (OR 2.16, CI 1.83-2.56). This effect was not ameliorated by the treatment modality used for the depressive disorder. This finding led to the conclusion that personality disorder has a negative impact on the outcome of depression. This finding is important in considering prognosis in depressive disorders.

There is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined. Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies. Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small. Combined depression and personality disorder is associated with a poorer outcome than depression alone.

Personality disorders commonly coexist with alcohol use disorders (AUDs), but there is conflicting evidence on their association with treatment outcomes. To determine the size and direction of the association between personality disorder and the outcome of treatment for AUD. We conducted a systematic review and meta-analysis of randomised trials and longitudinal studies. Personality disorders were associated with more alcohol-related impairment at baseline and less retention in treatment. However, during follow-up people with a personality disorder showed a similar amount of improvement in alcohol outcomes to that of people without such disorder. Synthesis of evidence was hampered by variable outcome reporting and a low quality of evidence overall. Current evidence suggests the pessimism about treatment outcomes for this group of patients may be unfounded. However, there is an urgent need for more consistent and better quality reporting of outcomes in future studies in this area.

Traditionally, teaching in psychiatry has had a passing focus on human rights. Against this backdrop, the aim of this study was to construct a theory of the learning value of a service user-led human rights focused teaching program for final-year medical students. We used descriptive qualitative analysis based on constructivist grounded theory to examine final-year medical students’ understandings of human rights following a formal teaching program. The overarching theory that emerged focuses on an awareness of the need for change within student learning. This involves both a need for understanding the mental health care system and a need for self-reflection. These two processes appear to interact, promoting learning about the value of a human rights focus. While acknowledging the difficulties in securing such a change, students felt that doing so would be valuable to the practice of mental health. This service user-led human rights teaching program produced new awareness in medical students, both in terms of their understanding of their own biases and in terms of understanding the influence of systemic and structural elements of the psychiatric system on the protection of service users’ human rights. Teaching human rights in psychiatry is likely to enrich their future self-reflective practice.

BackgroundThe long-term cumulative impact of exposure to childhood adversity is well documented. There is an increasing body of literature examining protective factors following childhood adversity. However, no known reviews have summarised studies examining protective factors for broad psychosocial outcomes following childhood adversity.AimsTo summarise the current evidence from longitudinal studies of protective factors for adult psychosocial outcomes following cumulative exposure to childhood adversity.MethodWe conducted a formal systematic review of studies that were longitudinal; were published in a peer-reviewed journal; examined social, environmental or psychological factors that were measured following a cumulative measure of childhood adversity; and resulted in more positive adult psychosocial outcomes.ResultsA total of 28 studies from 23 cohorts were included. Because of significant heterogeneity and conceptual differences in the final sample of articles, a meta-analysis was not conducted. The narrative review identified that social support is a protective factor specifically for mental health outcomes following childhood adversity. Findings also suggest that aspects of education are protective factors to adult socioeconomic, mental health and social outcomes following childhood adversity. Personality factors were protective for a variety of outcomes, particularly mental health. The personality factors were too various to summarise into meaningful combined effects. Overall GRADE quality assessments were low and very low, although these scores mostly reflect that all observational studies are low quality by default.ConclusionsThese findings support strategies that improve connection and access to education following childhood adversity exposure. Further research is needed for the roles of personality and dispositional factors, romantic relationship factors and the combined influences of multiple protective factors.

Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices. We determined rates of coercive practices and compared them across countries. We identified nine country- or region-wide data-sets of rates and durations of restrictive practices in Australia, England, Germany, Ireland, Japan, New Zealand, The Netherlands, the USA and Wales. We compared the data-sets with each other and with mental healthcare indicators in World Health Organization and Organisation for Economic Cooperation and Development reports. The types and definitions of reported coercive practices varied considerably. Reported rates were highly variable, poorly reported and tracked using a diverse array of measures. However, we were able to combine duration measures to examine numbers of restrictive practices per year per 100 000 population for each country. The rates and durations of seclusion and restraint differed by factors of more than 100 between countries, with Japan showing a particularly high number of restraints. We recommend a common set of international measures, so that finer comparisons within and between countries can be made, and monitoring of trends to see whether alternatives to restraint are successful. These measurements should include information about the total numbers, durations and rates of coercive measures. We urge the World Health Organization to include these measures in their Mental Health Atlas.

Compulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical. To report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis. Data for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis. A total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14-1.45; < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23-2.42; < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07-1.40; < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81-2.12; = 0.22). Increased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.

BackgroundCompulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use.AimsTo examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis.MethodNew Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status.ResultsIn total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups.ConclusionsCTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.