Harvard Review of Psychiatry最新文献

Learning objective: After participating in this CME activity, the psychiatrist should be better able to:• Explain current understanding of the relationship between chronic benzodiazepine use and dementia.

Background: Chronic use of benzodiazepines (BZ) for managing conditions such as anxiety disorders, depression, sleep disorders, and other chronic diseases is widespread; yet, there is considerable controversy regarding its potential links to dementia risk. This systematic review and meta-analysis aims to clarify this relationship by synthesizing and analyzing the available evidence to provide a clearer understanding of whether prolonged BZ use contributes to developing dementia.

Methods: This study adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO to ensure methodological rigor and transparency. The research strategy incorporated terms such as "benzodiazepines" OR "benzodiazepine" AND "cognitive dysfunction" OR "dementia" AND "adult" OR "elderly" OR "aged." We included prospective and retrospective observational studies, as well as case-control studies. Data were meticulously extracted regarding chronic BZ use and dementia risk. Each study's risk of bias was assessed to ensure result validity. Statistical analysis was performed using hazard ratios (HR) as the primary meta-analysis summary measure to provide a precise evaluation of associated risk.

Results: Analysis of five studies showed that chronic BZ use was associated with a nonsignificant risk of dementia-without specification of cause-with an HR of 1.17 (95% CI: 0.96-1.43). Regarding Alzheimer's disease, three studies found no significant association with an HR of 1.00 (95% CI: 0.87-1.15).

Conclusions: Our findings did not reach statistical significance, suggesting no strong link between chronic BZ use and dementia. Further research is needed to clarify this potential association.

Background: Pain catastrophizing, or the interpretation of pain as unbearable or intolerable, can increase pain-related anxiety and severity. High levels of pain catastrophizing have also been linked to substance use, particularly for substances with analgesic properties. Importantly, behavioral treatments can reduce pain catastrophizing, making them promising interventions for mitigating pain-related substance use. The aim of this scoping review is to summarize literature investigating the relationship between pain catastrophizing and substance use in adults.

Methods: We performed a scoping review of peer-reviewed literature. Included articles had both a measurement of pain catastrophizing and substance use, and reported analyses characterizing the relationship between the two.

Results: Of the 341 abstracts identified, 47 articles met eligibility criteria. Most studies focused on people with chronic pain. Some studies also considered samples with substance use disorders (with and without chronic pain) or acute pain, and general population samples. There was generally a positive association between pain catastrophizing and substance misuse; this association was consistent across multiple samples and substances. Most studies were cross-sectional, although associations were also detected in longitudinal studies. The magnitude of associations tended to be stronger for higher severity substance use and more proximal tests of association. More longitudinal and experimental studies are needed, however, to better delineate these effects.

Discussion: Findings indicate a consistent positive association between pain catastrophizing and substance use, highlighting the potential for interventions targeting pain catastrophizing to reduce negative substance-related consequences.

Abstract: Borderline personality disorder (BPD) has been described as a condition of intolerance of aloneness. This characteristic drives distinguishing criteria, such as frantic efforts to avoid abandonment. Both BPD and loneliness are linked with elevated mortality risk and multiple negative health outcomes. Psychodynamic theories of BPD emphasize fundamental impairment in attachment and interpersonal functioning. Empirical research demonstrates an association between BPD diagnosis and increased loneliness. Individuals with BPD experience higher levels of loneliness than the general population, and their social networks are systematically smaller, less diverse, and less satisfying. Differences in the subjective experience of loneliness persist when controlling for these relevant social network features, indicating that people with BPD experience more loneliness than others in the same objective social circumstances. According to patients with BPD, increased social connection is often a primary treatment goal and marker of satisfying recovery. There are, however, few evidence-based approaches that primarily target loneliness and building life structures that support durable connections with others. Therefore, loneliness persists as an intractable problem, often failing to remit alongside other symptoms, and few resources are routinely implemented to address this problem. In this article, we argue that loneliness is central to the symptomatic oscillations and subjective experiences of many patients with BPD. We propose that treatment extend beyond the overemphasized therapeutic alliance relationship to also promote socialization and group and vocational settings to enhance patients' social networks. Building larger social networks that rely less on exclusive caregiving and/or romantic relationships and more on role-bound identity building and community relationships would more directly target long-term identity diffusion and relational instability. Such interventions can harness nonclinical community resources, such as group treatment, vocational supports, and peer supports.

Abstract: Recent global popularity of social media content about dissociative identity disorder (DID) has coincided with increased self-diagnosis among children and young people who have formed large online communities and presented in clinical settings seeking to affirm their self-diagnoses. We situate this phenomenon within a broader trend toward self-diagnosis due to the widespread visibility and accessibility of mental health content on social media. Social media propelled self-diagnosis raises particular questions for the study and treatment of DID due to long-standing debates over whether the condition is traumagenic, sociogenic, or iatrogenic. This paper draws from the current state of knowledge about psychiatric self-diagnosis, the influence of social media on youth mental health, and the authors' clinical experience to present preliminary conceptualizations of DID self-diagnosis and its significance for clinical practice. Established etiological models for DID acknowledge the role of sociocultural and contextual factors in shaping and reinforcing the elaboration of DID self-states. We hypothesize that multiple forms of online sociality and interaction encourage such elaborations. Social media content regarding DID, however, is routinely unreliable and low quality, often mischaracterizing the condition's symptoms and minimizing associated suffering and disability. This paper considers the likelihood that the self-diagnosing DID cohort includes genuine, genuine but exaggerated, imitative, and malingering cases, and underscores the importance of careful and personalized assessment and diagnosis.

Abstract: A majority of adults in the United States (US) report a range of stressful and potentially traumatic childhood experiences (e.g., physical or sexual abuse, witnessing violence, neglect). Such adversities are associated with a range of mental (e.g., anxiety, mood, and behavioral difficulties) and physical (e.g., cardiovascular illnesses, diabetes, asthma) health problems. Increasingly, precision medicine approaches seek to prevent and treat such multifinal downstream health problems by identifying common etiological pathways (e.g., inflammation and immune pathways) and candidate biomarkers to target interventions. In this context, we review the rationale for continued research to identify biomarkers of childhood adversity. Building on the bioecological theory, we emphasize that individual neurobiological profiles develop within multiple ecological levels (individual, family, neighborhood, macrosocial) that confer both risk and protective factors that can attenuate or amplify biological effects of childhood adversity. Given the limited data on adversity-associated biomarkers for children and adolescents, we discuss future recommendations for research, implications for clinical care, and ethical considerations. Preventing childhood adversity and supporting adversity- and trauma-informed systemic intervention approaches remains our primary recommendation. We highlight the continued need to consider both biomarkers of risk and protective factors across ecological levels in future research.

Background: Homelessness is a visible manifestation of large-scale societal challenges, such as lack of affordable housing, poverty, and health inequities. Governments may miss opportunities to address these structural problems by removing people experiencing homelessness from public spaces. On 29 November 2022, after a press conference by Mayor Eric Adams, the city of New York issued a directive entitled Mental Health Involuntary Removals. The program authorized mental health providers and NYPD officers to take any person into custody who appears mentally ill and displays inability to meet basic living needs, even when no dangerous act has been observed.

Methods: We reviewed the existing literature from 1973 to 2023 for studies, enacted legislation, state and federal policies, and interventions related to homelessness, mental health, and admission of people experiencing homelessness into psychiatric hospitals in the United States. We used academic databases, including PubMed, PsycInfo, and JSTOR for peer-reviewed articles, government reports, and policy analyses. Our search strategy included keyword combinations such as "homelessness and mental health," "policy interventions for homeless populations," and "health care services costs." We applied inclusion criteria focusing on reports and articles that directly address the intersectionality of homelessness, mental health policy, and psychiatric care.

Results: Homelessness and mental illness frequently intersect, creating complex challenges that require nuanced solutions. Forced hospitalization of people experiencing homelessness in New York City, while intended to address critical social and health care issues, carries a risk for significant long-term harm. This approach places strain on the mental health care system and may ultimately exacerbate the problems it purports to resolve.

Learning objective: After participating in this CME activity, the psychiatrist should be better able to:• Explain current understanding of how religiosity, spirituality, and meaning-making (R/S/M) affect patients with psychiatric diagnoses.

Introduction: R/S/M generally protect against suicidality and suicide. Thus far, reviews on the topic have largely been descriptive, and there are no meta-analyses focused on psychiatric patients. This study systematically evaluates all empirical evidence on R/S/M's potential influences on suicidality for psychiatric patients and recent suicide attempters.

Methods: A systematic PROSPERO preregistered search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was performed in MEDLINE and PsycInfo. Quantitative studies until 31 December 2022 on R/S/M and suicidality in psychiatric populations and recent suicide attempters were selected; psychological autopsy studies were excluded.

Results: The search identified 4,374 studies for screening. This resulted in 108 eligible studies for the systematic review and 75 studies for the meta-analysis, including 231 effect sizes (ES) and 17,561 subjects. Research focused mainly on the emotional, moral, and ritual aspects of R/S/M. Most research was cross-sectional; repeated R/S/M assessments were rarely reported. A combined significant and negative ES (Fisher Z = -0.13, p = .006, equivalent to Cohen's d = -0.26) was found for all good- and fair-quality studies.

Conclusion: Overall, R/S/M was associated with lowering suicidality. Maladaptive-distressing dimensions of R/S/M correlated with higher rates of suicidality (e.g., religious struggles). The explanatory value was limited by the predominantly cross-sectional nature of ESs.

Registration and funding: PROSPERO registration 2023 CRD42023398692; there was no funding involved.

Background: Cariprazine (CAR), an antipsychotic with partial agonism at the D3 receptor and higher affinity than dopamine, has shown significant procognitive effects in preclinical animal studies. This study systematically reviews CAR's effects on cognitive measures in patients with schizophrenia and bipolar disorder.

Methods: Two independent reviewers systematically searched PubMed, Web of Science, Scopus, and the Cochrane Library up to May 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Additional studies were found by hand searching the references of included studies. Eligible studies were randomized controlled trials (RCTs) in English that assessed CAR's effects on cognition in patients with schizophrenia or bipolar disorder. Quality was assessed using the Jadad scale.

Results: Out of 139 reports, 5 studies (involving 6,104 patients with schizophrenia or bipolar disorder) were included. In schizophrenia, CAR showed better cognitive outcomes (mainly indirect measures) than placebo (PBO) in both early and late stages. It also outperformed risperidone and aripiprazole in attention-related cognitive tests. In bipolar disorder, CAR improved cognition compared to PBO (also using indirect measures). Most studies found the greatest cognitive benefits with low doses of CAR (1.5-3 mg/d).

Conclusions: CAR improved cognitive measures compared to PBO and other D2 antagonists or partial agonists in RCTs, especially in patients with greater baseline impairment. Thus, CAR may be a promising option for enhancing cognition in schizophrenic and bipolar patients; though, more trials using specific cognitive assessment tools are needed.

Systematic review registration: PROSPERO CRD42023485028.

Abstract: Over the past decade, researchers translating anthropological theories for clinical use have debated how practitioners should assess cultural factors, social structures, and social determinants of health with patients. Advocates of structural competency have suggested that clinical cultural competency programs demonstrate limited effects on health outcomes because of the static understanding of culture employed. They recommend that cultural factors be reformulated with an emphasis on social structures. In response, researchers in cultural psychiatry specializing in cultural assessments have developed three models-sociocultural formulation (SCF), the cultural-ecosocial view, and the contextual developmental assessment-to integrate cultural and structural factors. Their methods for integration, however, differ, resulting in various understandings of psychopathology mechanisms. This paper analyzes arguments from all four positions in this debate. It reveals a lack of consensus about interrelationships among these constructs, their definitions, and methods for assessment. The article concludes with recommendations, such as developing consensus definitions with broad stakeholder involvement; adopting a data-driven approach to clarify how specific cultural, social, or structural factors interact; and identifying how extant assessments capture clinically relevant factors across constructs to develop additional assessment tools.