Evidence Based Mental Health最新文献

Background: Available prediction models of cardiovascular diseases (CVDs) may not accurately predict outcomes among individuals initiating pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD).

Objective: To improve the predictive accuracy of traditional CVD risk factors for adults initiating pharmacological treatment of ADHD, by considering novel CVD risk factors associated with ADHD (comorbid psychiatric disorders, sociodemographic factors and psychotropic medication).

Methods: The cohort composed of 24 186 adults residing in Sweden without previous CVDs, born between 1932 and 1990, who started pharmacological treatment of ADHD between 2008 and 2011, and were followed for up to 2 years. CVDs were identified using diagnoses according to the International Classification of Diseases, and dispended medication prescriptions from Swedish national registers. Cox proportional hazards regression was employed to derive the prediction model.

Findings: The developed model included eight traditional and four novel CVD risk factors. The model showed acceptable overall discrimination (C index=0.72, 95% CI 0.70 to 0.74) and calibration (Brier score=0.008). The Integrated Discrimination Improvement index showed a significant improvement after adding novel risk factors (0.003 (95% CI 0.001 to 0.007), p<0.001).

Conclusions: The inclusion of the novel CVD risk factors may provide a better prediction of CVDs in this population compared with traditional CVD predictors only, when the model is used with a continuous risk score. External validation studies and studies assessing clinical impact of the model are warranted.

Clinical implications: Individuals initiating pharmacological treatment of ADHD at higher risk of developing CVDs should be more closely monitored.

Background: Predictors of antidepressant response in older patients with major depressive disorder (MDD) need to be confirmed before they can guide treatment.

Objective: To create decision trees for early identification of older patients with MDD who are unlikely to respond to 12 weeks of antidepressant treatment, we analysed data from 454 older participants treated with venlafaxine XR (150-300 mg/day) for up to 12 weeks in the Incomplete Response in Late-Life Depression: Getting to Remission study.

Methods: We selected the earliest decision point when we could detect participants who had not yet responded (defined as >50% symptom improvement) but would do so after 12 weeks of treatment. Using receiver operating characteristic models, we created two decision trees to minimise either false identification of future responders (false positives) or false identification of future non-responders (false negatives). These decision trees integrated baseline characteristics and treatment response at the early decision point as predictors.

Finding: We selected week 4 as the optimal early decision point. Both decision trees shared minimal symptom reduction at week 4, longer episode duration and not having responded to an antidepressant previously as predictors of non-response. Test negative predictive values of the leftmost terminal node of the two trees were 77.4% and 76.6%, respectively.

Conclusion: Our decision trees have the potential to guide treatment in older patients with MDD but they require to be validated in other larger samples.

Clinical implications: Once confirmed, our findings may be used to guide changes in antidepressant treatment in older patients with poor early response.

Question: Although mental pain is present in many mental disorders and is a predictor of suicide, it is rarely investigated in research or treated in care. A valid tool to measure it is a necessary first step towards better understanding, predicting and ultimately relieving this pain.

Study selection and analysis: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to identify all published standardised measures of mental pain. We used qualitative content analysis to evaluate the similarity of each measure, quantified via Jaccard Index scores ranging from no similarity (0) to full similarity (1). Finally, using the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we evaluated each measure's development (assessing 35 features), its content validity (31 features) and if the latter was rated at least adequate, its other psychometric properties.

Findings: We identified 10 self-reported scales of mental pain in 2658 screened studies relying on diverse definitions of this construct. The highest average similarity coefficient for any given measure was 0.24, indicative of weak similarity (individual pairwise coefficients from 0 to 0.5). Little to no information was provided regarding the development and the content validity of all 10 scales. Therefore, their development and content validity were rated 'inadequate' or 'doubtful'.

Conclusions and clinical implications: There is not enough evidence of validity to recommend using one measure over others in research or clinical practice. Heterogeneous use of disparate measures across studies limits comparison and combination of their results in meta-analyses. Development by all stakeholders (especially patients) of a consensual patient-reported measure for mental pain is needed.

Prospero registration number: CRD42021242679.

Question: Effective prevention of suicide requires a comprehensive understanding of risk factors.

Study selection and analysis: Five databases were systematically searched to identify psychological autopsy studies (published up to February 2022) that reported on risk factors for suicide mortality among adults in the general population. Effect sizes were pooled as odds ratios (ORs) using random-effects models for each risk factor examined in at least three independent samples.

Findings: A total of 37 case-control studies from 23 countries were included, providing data on 40 risk factors in 5633 cases and 7101 controls. The magnitude of effect sizes varied substantially both between and within risk factor domains. Clinical factors had the strongest associations with suicide, including any mental disorder (OR=13.1, 95% CI 9.9 to 17.4) and a history of self-harm (OR=10.1, 95% CI 6.6 to 15.6). By comparison, effect sizes were smaller for other domains relating to sociodemographic status, family history, and adverse life events (OR range 2-5).

Conclusions: A wide range of predisposing and precipitating factors are associated with suicide among adults in the general population, but with clear differences in their relative strength.

Prospero registration number: CRD42021232878.

Question: Amphetamine use is a risk factor for psychosis, which imposes a substantial burden on society. We aimed to investigate the incidence of psychosis associated with illicit amphetamine use and whether rehabilitation treatments could influence the psychosis risk.

Study selection and analysis: A retrospective cohort study was conducted using the population based Taiwan Illicit Drug Issue Database (TIDID) and the National Health Insurance Research Database (NHIRD), from 2007 to 2016. We identified 74 601 illicit amphetamine users as the amphetamine cohort and 2 98 404 subjects as the non-amphetamine cohort. The incidence rate of newly diagnosed psychosis was the main outcome. Cox proportional hazards models were applied to assess the effects of amphetamine, and the Kaplan-Meier method was used to estimate the cumulative psychosis incidence curves.

Findings: Illicit amphetamine users were 5.28 times more likely to experience psychosis than those without illicit drug use records. The risk was higher for subjects with multiple arrests for amphetamine use. A greater hazard ratio (HR) magnitude was observed in female patients. We also observed a significant decrease in the risk of psychosis in patients receiving rehabilitation treatments during deferred prosecution (adjusted HR 0.74, 95% CI 0.61 to 0.89).

Conclusions: Illicit amphetamine use was associated with an increased incidence of psychosis. The risk was identified across all age groups, particularly in women and in those arrested multiple times, and was inversely correlated with rehabilitation treatments for amphetamine misuse.

Background: Previous research suggests that mindfulness training (MT) appears effective at improving mental health in young people. MT is proposed to work through improving executive control in affectively laden contexts. However, it is unclear whether MT improves such control in young people. MT appears to mitigate mental health difficulties during periods of stress, but any mitigating effects against COVID-related difficulties remain unexamined.

Objective: To evaluate whether MT (intervention) versus psychoeducation (Psy-Ed; control), implemented in after-school classes: (1) Improves affective executive control; and/or (2) Mitigates negative mental health impacts from the COVID-19 pandemic.

Methods: A parallel randomised controlled trial (RCT) was conducted (Registration: https://osf.io/d6y9q/; Funding: Wellcome (WT104908/Z/14/Z, WT107496/Z/15/Z)). 460 students aged 11-16 years were recruited and randomised 1:1 to either MT (N=235) or Psy-Ed (N=225) and assessed preintervention and postintervention on experimental tasks and self-report inventories of affective executive control. The RCT was then extended to evaluate protective functions of MT on mental health assessed after the first UK COVID-19 lockdown.

Findings: Results provided no evidence that the version of MT used here improved affective executive control after training or mitigated negative consequences on mental health of the COVID-19 pandemic relative to Psy-Ed. No adverse events were reported.

Conclusions: There is no evidence that MT improves affective control or downstream mental health of young people during stressful periods.

Clinical implications: We need to identify interventions that can enhance affective control and thereby young people's mental health.

Question: Mindfulness-based programmes (MBPs) are an increasingly popular approach to improving mental health in young people. Our previous meta-analysis suggested that MBPs show promising effectiveness, but highlighted a lack of high-quality, adequately powered randomised controlled trials (RCTs). This updated meta-analysis assesses the-state-of the-art of MBPs for young people in light of new studies. It explores MBP's effectiveness in active vs passive controls; selective versus universal interventions; and studies that included follow-up.

Study selection and analysis: We searched for published and unpublished RCTs of MBPs with young people (<19 years) in PubMed Central, PsycINFO, Web of Science, EMBASE, ICTRP, ClinicalTrials.gov, EThOS, EBSCO and Google Scholar. Random-effects meta-analyses were conducted, and standardised mean differences (Cohen's d) were calculated.

Findings: Sixty-six RCTs, involving 20 138 participants (9552 receiving an MBP and 10 586 controls), were identified. Compared with passive controls, MBPs were effective in improving anxiety/stress, attention, executive functioning, and negative and social behaviour (d from 0.12 to 0.35). Compared against active controls, MBPs were more effective in reducing anxiety/stress and improving mindfulness (d=0.11 and 0.24, respectively). In studies with a follow-up, there were no significant positive effects of MBPs. No consistent pattern favoured MBPs as a universal versus selective intervention.

Conclusions: The enthusiasm for MBPs in youth has arguably run ahead of the evidence. While MBPs show promising results for some outcomes, in general, the evidence is of low quality and inconclusive. We discuss a conceptual model and the theory-driven innovation required to realise the potential of MBPs in supporting youth mental health.

Background: Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health.

Objective: The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU).

Methods: MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11-14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.

Findings: Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI -0.05 to 0.06) for risk for depression; 0.02 (-0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (-0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed.

Conclusions: Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence.

Clinical implications: There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors.

Trial registration: Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).