Background: There are few population-based cohort studies of the emergence, development, and persistence of mental health problems in sexual minorities compared to heterosexuals.We compared trajectories of depressive symptoms from 10 to 21 years of age in sexual minority and heterosexual adolescents, and examined self-harm at ages 16 and 21. Methods:The study included 4828 adolescents from the ALSPAC birth cohort (Bristol, UK) who reported their sexual orientation at age 16. Depressive symptoms were assessed with the short Mood and Feelings Questionnaire (sMFQ) at seven time-points between ages 10 and 21. A self-harm questionnaire was completed at ages 16 and 21. Analyses were linear multilevel models with growth curves (depressive symptoms), logistic multilevel models (self-harm in the past year at ages 16 and 21) and multinomial regression (lifetime self-harm with and without suicidal intent at age 21). Findings:In sexual minorities, depressive symptoms were higher at age 10 and increased to a larger extent compared to heterosexuals. In heterosexuals, depressive symptoms increased by 0.31 sMFQ points at each time-point (95% CI 0.27 to 0.34) and in sexual minorities by 0.49 sMFQ points (95% CI 0.40 to 0.59). Sexual minority adolescents were more likely to report self-harm in the past year at ages 16 and 21 (adjusted odds ratio 4.23, 95% CI 2.90 to 6.16), with no evidence that this estimate reduced with age (p=0.798). At 21, sexual minorities were 4.53 (95% CI 3.02 to 6.78) times more likely to report previous self-harm with suicidal intent.

Background Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians’ perspectives and experience of supporting adults with severe AN in intensive settings. Methods We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software. Results Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients’ Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients’ home environments, the necessity of patient motivation, and the management of risk. Conclusions Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Key Points Question Do associations exist between disordered eating behaviors and other mental health disorders in adolescence, and if so, to what extent are those associations genetically predisposed? Findings Longitudinal assessments in this cohort study of a population-based sample of 1623 adolescents indicated that body mass index (BMI), neuroticism, impulse control, and addiction-related behaviors at 14 years of age were differentially associated with future disordered eating behaviors and symptoms of depression and generalized anxiety. Genetic analyses suggested etiologic overlaps between BMI, neuroticism, and attention-deficit/hyperactivity disorder with dieting, binge eating, and purging, respectively. Meaning Genetic and phenotypic assessments of BMI, impulse control problems, and personality may inform early and differential diagnoses of eating disorders.

Background There are few population-based cohort studies of the emergence, development, and persistence of mental health problems in sexual minorities compared with heterosexuals. We compared trajectories of depressive symptoms in sexual-minority adolescents and heterosexual adolescents from when they were aged 10 to 21 years, and examined self-harm at ages 16 and 21 years. Methods The study included 4828 adolescents born between April 1, 1991, and Dec 31, 1992, from the Avon Longitudinal Study of Parents and Children birth cohort (Bristol, UK) who reported their sexual orientation when aged 16 years. Depressive symptoms were assessed with the short Mood and Feelings Questionnaire at seven timepoints between ages 10 and 21 years. A self-harm questionnaire was completed at ages 16 and 21 years. Analyses were linear multilevel models with growth curves (depressive symptoms), logistic multilevel models (self-harm in the previous year at ages 16 and 21 years), and multinomial regression (lifetime self-harm with and without suicidal intent at age 21 years). Findings At age 10, depressive symptoms were higher in sexual minorities than in heterosexuals and increased with age to a larger extent. Depressive symptoms increased at each timepoint by 0·31 points in hetereosexuals, and by 0·49 points in sexual minorities. Sexual-minority adolescents were more likely than heterosexual adolescents to report self-harm in the previous year at ages 16 and 21 years, with no evidence that this estimate decreased with age. At aged 21, sexual minorities were more likely to report lifetime self-harm (ie, on at least one previous occasion) with suicidal intent than heterosexuals. Interpretation Mental health disparities between heterosexuals and sexual minorities are present early in adolescence and increase throughout the school years, persisting to young adulthood. Prevention of these mental health problems and early intervention must be a priority.

Background Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a ‘step-down’ treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation. Methods 386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m2 and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden. Discussion The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision. Trial registration ISRCTN ISRCTN10166784. Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.