Harvard Review of Psychiatry最新文献

Developmental psychopathology frameworks view development as a dynamic process that integrates multiple systems, clarifying how psychopathology develops and who develops it. High-risk study designs, such as those investigating progressive changes in youth with familial psychopathological histories, are one developmental research strategy. While much research focuses on clinical symptoms after they emerge, this approach hinders our understanding of when and how clinical symptoms and psychopathology develop and identification of risk factors, neural mechanisms, and clinical correlates. We review the critical value and advantages of using high-risk designs and developmental psychopathology frameworks to understand the emergence of affective psychopathology. We focus on anhedonia, a transdiagnostic affective symptom-defined as diminished experiences of pleasure-which emerges during adolescence, and occurs prior to onset of disorders like depression. We review the phenomenology, behavior, and neural mechanisms of anhedonia. Then we discuss the symptom from a developmental psychopathology perspective, outlining the advantages and disadvantages of using high-risk designs. From there, we synthesize the literature and conclude with clinical implications and considerations for future directions. These approaches are critical for understanding mental health, particularly affective psychopathology, and deserve more attention in the field.

Transgender and gender diverse (TGD) people with severe mental illness (SMI) face significant barriers to health care access, leading to unmet needs and inequitable health outcomes. Reverse integration models embed primary care services within mental health centers (MHCs) that serve as primary contact points to broader health care systems for people with SMI. Such models have been shown to improve health outcomes in this population by promoting access to screening, preventative care, and chronic metabolic condition management. This article highlights the benefits of gender-affirming medical care (GAMC)-including reductions in depression, at-risk substance use, and suicidality-and explores reverse integration models for promoting equitable access to GAMC for TGD people with SMI. We propose two strategies: (1) colocation of GAMC services within MHCs and (2) coordinated referrals to external GAMC practices. Additionally, we address clinical considerations for supporting GAMC access for people with SMI, emphasizing the importance of individualized, person-centered care, clinician education, care coordination, and ongoing collaboration between MHCs and gender-affirming medical practitioners to equitably serve this population. Recognizing the ethical principles of justice and autonomy, we advocate for integrating supportive GAMC pathways within MHCs to ensure access to comprehensive, affirming care in settings that foster trust and continuity.

Autism spectrum disorder (ASD) is often comorbid with other psychiatric disorders, such as anxiety and attention-deficit hyperactivity disorder (ADHD). While common, individuals with autism and their families often face challenges accessing appropriate community-based treatment for coexisting disorders. The case of a preadolescent boy with ASD and comorbid anxiety and ADHD illustrates challenges and frustrations associated with fragmented health care systems, prolonged wait times for specialized services, and limited availability of clinicians trained in neurodevelopmental and psychiatric comorbidity interventions. Evidence-based psychotherapeutic and pharmacologic treatments for neurodivergent patients with psychiatric comorbidities are also discussed. Ongoing advocacy to reduce disparities and improve outcomes for children with neurodevelopmental and mental health needs is critically needed.

Background: Increased firearm accessibility and related violence have generated global debate concerning public gun policies. Although the physical dangers associated with firearms are widely acknowledged, the psychological effects of firearm use and accessibility require greater exploration. We evaluate the influences of gun ownership, violence, and policies on mental health outcomes across different populations.

Methods: A comprehensive literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across multiple databases, including PubMed, Scopus, Web of Science, and PsycInfo, yielding 467 studies. A scoping review was then performed to thematically categorize and analyze the associations between gun access and aggressive behavior, substance abuse, societal violence, and mental health outcomes.

Results: Our findings identify three fundamental psychological mechanisms through which firearms affect mental health: (1) as enablers of impulsive action during distress; (2) as amplifiers of existing psychological states (e.g., aggression, fear, trauma); (3) and as symbols that transform power dynamics and vulnerability perceptions. Specifically, permissive gun policies and firearm ownership are linked to higher rates of firearm-related suicides and aggressive behavior. Exposure to gun violence significantly exacerbates psychological distress, especially among vulnerable populations, and its effects persist long after direct exposure.

Discussion: This review highlights the urgent need for comprehensive policies that address firearm accessibility, promote mental health interventions, and address the social determinants of firearm-related harm. Such an integrated public health approach addressing these individual and societal factors is essential for mitigating the complex psychological pathways through which firearms affect mental health across populations.

Learning objectives: After participating in this CME activity, the psychiatrist should be better able to:• Analyze neuroimaging findings to identify and explain structural and functional brain differences associated with SPD, including implications for impulse control, emotional regulation, and motor coordination.

Abstract: Skin-picking (excoriation) disorder (SPD), characterized by recurrent and excessive skin picking without underlying skin disease, leads to significant tissue damage. This review highlights the disorder's influences on brain function and structure. Neuroimaging and neurocognitive studies indicate that impairments in frontostriatal circuits are critical to SPD development. Abnormalities in motor control circuits also contribute to motor control issues and impulsivity, suggesting that these circuits play a role in SPD's pathophysiology. Functional imaging studies show hypoactivity in the anterior cingulate cortex, dorsal striatum, and right medial frontal areas, regions essential for motor movement formation and suppression. Structurally, patients with SPD exhibit brain volume and cortical thickness changes in frontal regions involved in impulse control, such as the inferior frontal gyrus, orbitofrontal cortex, and nucleus accumbens, compared to those with trichotillomania and healthy controls. These findings suggest that SPD has distinct neurobiological and neuroanatomical features, emphasizing the importance of further research to understand its underlying mechanisms.

Background: Maternal depression is an established risk factor for parenting disruptions with potential consequences for child development. Although previous studies have examined the effects of maternal depression on parenting behaviors, the most recent systematic reviews and meta-analyses only include data up to 2013. Given evolving perspectives and methodologies, updated insights are necessary. This systematic review synthesizes evidence on the association between maternal depression and parenting over the past decade.

Method: Systematic searches were conducted in MEDLINE/PubMed, SciELO, BVS, LILACS, Embase, Web of Science, and PsycInfo with no language restrictions. The search focused on studies published between 2013 and 2023. Inclusion criteria were comprised of observational studies assessing parenting among mothers diagnosed with depression during their child's youth or adolescence. Of the 11,305 studies screened, 166 were fully reviewed by two independent reviewers, resulting in 29 eligible studies. No gray literature was included.

Results: Among the 29 studies, 28 reported an association between maternal depression and parenting. Most were conducted in high-income countries, focused on children under 36 months, and used cross-sectional designs. Two-thirds were published after 2017. This review's limitations include studies predominantly from high-income settings, exclusive assessment of parenting practices without broader parenting constructs, and the absence of meta-analysis.

Conclusion: Findings consistently highlight the association between maternal depression and negative parenting practices, influencing sensitivity, affection, attachment, involvement, commitment, responsiveness, and stimulation. Mothers experiencing depression face challenges across these domains, which may affect child development. Future research should explore these associations in diverse sociocultural contexts and include longitudinal studies to better understand long-term effects.

Introduction: Vicarious racism, or second-hand/indirect exposure to racism, is a highly prevalent phenomenon linked to negative emotions and poor mental health. We performed a scoping review to summarize and analyze the literature on how vicarious racism is defined and measured, where it occurs, samples and study designs used, racial makeup of witnesses compared to targets, evidence connecting vicarious racism to negative emotions and poor mental health, and recommendations for future research.

Methods: We followed the Population, Concept, and Context framework for scoping reviews and searched PubMed and PsycInfo for relevant studies. Five reviewers performed study selection, screening, and extraction using Covidence. We reviewed 51 empirical studies published between 2014 and 2024 using adult samples from the United States.

Results: There is a lack of consensus about how vicarious racism is defined and measured. The majority of papers focused on Black and/or Asian samples; a limited number included Latine samples. Most studies used a cross-sectional design. Positive associations between vicarious racism and poor mental health were observed, with few studies reporting null findings. The two most common recommendations for future research were: (1) identifying pathways from vicarious racism to mental health outcomes and (2) increasing sample diversity.

Conclusions: Comprehensive definitions of vicarious racism and gold-standard measures are necessary for the unified progression of knowledge. Increasing sample diversity in future research will lead to more generalizable findings. Identifying pathways from vicarious racism to mental health outcomes is critical for intervention and prevention among those most vulnerable.

Abstract: Clinician well-being and patient safety culture play critical roles in how clinicians respond to adverse events. These elements, in turn, affect clinician experience and future patient access to care, both key drivers of health care quality. While there is literature on the relationship between well-being and safety culture, in this column we critically examine their importance after patient suicide, a most devastating medical outcome. We discuss the definition of well-being and safety culture; clarify their relationship; and offer recommendations to achieve both following patient suicide to mitigate future risk.

Abstract: Feigning and fabrication by a patient can evoke anger and distress in staff and generate diagnosis and management challenges. When faced with difficulties that can lead to moral injury among health care providers, and even risk compromised patient care, clinical teams must balance empathy with appropriate boundaries. This case report examines an individual with a history of polysubstance use and acute-on-chronic pain whose persistent patterns of fabrication-spanning exaggerated military service, terminal illness, family trauma, and academic accomplishments-posed substantial risk-assessment and treatment-planning challenges across multiple clinical presentations. Insights from three expert discussants with distinct specializations in psychodynamic formulation, distress management, and forensic psychiatry are provided. Through their analyses, the complex interplay among chronic pain, inadequate distress tolerance, personality pathology, and health care utilization are evaluated in conjunction with evidence-based approaches to differential diagnosis and management. This article presents practical recommendations for preserving therapeutic engagement while protecting appropriate boundaries and, ultimately, working toward optimized care delivery for such challenging, vulnerable patients.