been more encouraging. The trial should therefore not be regarded as a definitive dismissal of the promise of these or related agents. 3 Theoretically, depression in bipolar disorder is a more heterogeneous construct than mania, which is more monothematically biological in its causation. Depression is driven by a far wider array and admixture of biological factors, consequences of behaviours while manic, losses in domains such as educational and vocational horizons, relationships, personality, finances, guilt, stigma, and self-stigma, among others. Therefore, it is arguably ambitious at the outset to expect a singular biological therapy targeting one biological marker of the disorder to address all phenotypes of this heterogeneous clinical presentation. The complexity of bipolar depression might be an explanation more broadly for the relatively common failure of singular treatment approaches. These failures suggest that polyvalent and personalised therapies predicated on individualised profiles are needed to select from the diverse pharmacological, neurostimulatory, nutraceutical, lifestyle, and psychological approaches that are available. 10 In sum, this might not be the last word on the potential role of anti-inflammatory drugs in the treatment of bipolar depression, but notwithstanding the methodological issues that accompany any clinical trial, the promise of targeting the inflammation pathway in the management of this challenging condition is today somewhat weaker.

Background The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. MethodsWe sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries' ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms "suicide" and "cause of death", before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis).Findings We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales

The difference may be partly accounted for by the factors that influence infectivity of the two viruses. Hepatitis B is much more likely to be transmitted from mother to infant if there is a high concentration of the virus in the mother's blood. This explains the ethnic differences that are observed-for example, the transmission rate is over 70% in Chinese women but less than 10% in white women. This ethnic difference does not seem to apply to hepatitis C infection.Alcohol intake and obesity are both thought to be associated with more severe hepatitis C, although the exact interaction is unknown. Advanced liver disease, for example, is far worse in people infected with hepatitis C who also have a high alcohol intake than in those with a low intake. AbstractObjective: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. Design: Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method. Setting: Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997. Subjects: Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data. Main outcome measure: Repetition of self harm. Results: 20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93). Conclusion: There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed.

Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.