Harvard Review of Psychiatry最新文献

Background: Internet-based psychological interventions are becoming a feasible substitute for conventional in-person therapy. This article provides a perspective on health economic evaluations of internet-based interventions employed for preventing and managing eating disorders (EDs).

Methods: A comprehensive search was undertaken from January 2000 to December 2023 across five general medical and three health economic databases. The goal was to identify complete economic evaluations of internet-based strategies for managing and preventing EDs.

Results: A total of seven economic evaluations were found, carried out across four countries. The studies utilized internet-based cognitive behavioral therapy, Featback, and virtual Body Project groups as experimental interventions. The controls were either wait-list comparison groups or recipients of face-to-face cognitive behavioral therapy. Among the seven studies evaluated, five indicated that internet-based interventions were more advantageous in terms of cost and clinical benefits based on both societal and health care perspectives. One study supported implementation of the internet-based intervention primarily based on cost, and one study's findings were inconclusive.

Conclusion: From both societal and health care perspectives, internet-based interventions offer significant benefits in terms of cost and clinical effectiveness. The current body of evidence, however, is limited by the small number of studies and methodological variations. It is also essential to understand that these intervention outcomes may be influenced by comparator choice and thresholds for willingness to pay.

Learning objectives: After participating in this CME activity, the psychiatrist should be better able to:• Summarize findings from systematic reviews and meta-analyses on the efficacy of psychotherapeutic bereavement interventions.• Identify and apply key moderating factors (e.g., symptom severity, timing, age, gender) that influence intervention outcomes.• Analyze methodological limitations in the bereavement literature, including study design and review quality issues.

Abstract: In recent decades, there have been diverse reviews published on intervention program value for bereaved people. The variation and multiplicity of such reviews makes it difficult to obtain an overview of what is known about treatment effectiveness. In this systematic umbrella review, we explore the current knowledge base on psychotherapeutic bereavement intervention program efficacy. Thirty-three quantitative systematic reviews and/or meta-analyses published between January 2001 and October 2021 were included. Quality was assessed using the Assessment of Multiple Systematic Reviews criteria. Intervention efficacy was determined by rating overall conclusions into three categories according to strength of evidence: positive-unconditional, positive-conditional, and negative-no evidence. Our results indicate that bereavement interventions are generally helpful. Seven reviews indicated positive-unconditional support for bereavement interventions. Twenty-four reviews found positive-conditional support (i.e., some evidence of value, but efficacy did not apply in all circumstances or was constrained by database weaknesses or weak effects), and only two reviews indicated negative-no evidence for support. Notably, conclusions were generally limited by poor review quality and methodological concerns (e.g., lack of randomized controlled trials and follow-up studies). As such, we call for future empirical studies and review articles to abide by methodological quality standards. Furthermore, we recommend further study of the subgroup variables and intervention features that contribute to treatment efficacy.

Abstract: The bidirectional relationship between sleep and obsessive-compulsive spectrum disorders (OCSDs), chronic tic disorders (CTDs), and attention-deficit/hyperactivity disorder (ADHD) is not well understood. To better treat individuals with these co-occurring sleep and developmental neuropsychiatric conditions, it is necessary to determine the common neural underpinnings to then target with treatment. Research has implicated dysregulated cortico-striatal-thalamo-cortical (CSTC) neurocircuitry in the development of CTDs, OCSDs, and ADHD. We review current literature to assess the state of knowledge about the neurocircuitry of OCSDs, CTDs, and ADHD, and their related sleep disturbances. Our review consistently implicates CSTC-pathway disruptions in OCSDs, CTDs, and ADHD, as well as dopamine and GABA dysregulation, primary neurotransmitters in CSTC circuitry, in sleep disorders. In addition, we highlight reports of subjective poor sleep and insomnia in adults with OCSDs, CTDs, and ADHD, and sleep movement disorders in adults with CTDs. The limited sleep research on youth with these conditions has demonstrated some similar findings. Unfortunately, much of the current research to date has not employed polysomnographic methods for objective sleep-related assessments. Future research should further clarify the neural association between these neuropsychiatric conditions and sleep disturbances to better guide potential therapeutic targets. Determining the most effective treatments for subjective sleep-related complaints in patients with these conditions will be crucial, particularly for determining treatment course-whether to prioritize treatment of the underlying condition, the specific sleep symptoms, or both simultaneously.

Abstract: In an evolving health care landscape, community health workers (CHWs) have emerged as invaluable assets, bridging gaps to mental health service access and fostering community resilience. In this article, we explore the multifaceted responsibilities shouldered by CHWs, encompassing outreach, education, and support, and underscore their unique abilities to establish trust within diverse communities. We also highlight evolving recognition of CHWs as integral health care team members and examine the growing body of evidence on CHW effectiveness in enhancing mental health outcomes, reducing disparities, and promoting preventative measures. Additionally, we review how, in the wake of the COVID-19 pandemic, the CHW role has shifted with increased demand for their services within the mental health care landscape. The pandemic laid bare the vulnerabilities in existing health care structures, disproportionately affecting communities with limited resource access, including mental health support. Furthermore, we review six primary research domains that could potentially help expand the CHW workforce: standardization and training, sustainability and retention, integration into health systems, impact measurement, cost-effectiveness and financing, and scaling up and adaptation. Last, we examine the pandemic's transformative effects on CHWs; we shed light on their resilience and adaptability in the face of unprecedented challenges and underscore their heightened relevance within the evolving health care response paradigm post-COVID.

Abstract: Many individuals diagnosed with psychosis make multiple attempts to discontinue antipsychotic medications. In this clinical challenge, we examine three snapshots in which shared decision-making (SDM) breaks down due to ongoing disagreement between the service user and the health care provider. We offer three perspectives on how to think about such disagreement: philosophical, psychological, and psychiatric perspectives. Finally, we propose shared deliberation as a potential model for when SDM fails, emphasizing an iterative process of mutual value sharing that avoids binary yes/no responses.

Abstract: As practitioners seek more personalized approaches, exploring how patients' environments, relationship templates, and mindsets factor into symptom burden can help broaden understanding of how psychotropic medications facilitate recovery. Despite increasing focus on medications to provide relief, there is an important and undeniable influence the therapeutic environment has on shaping outcomes, particularly for the patient-clinician alliance. While environmental dimensions are relevant for informing possible placebo or nocebo responses, they also build upon the pharmacodynamic and neurobiological effects of medications. By heightening neuroplasticity, some antidepressants may amplify the effects of nonmedication factors in patients' lives, including the patient-prescriber therapeutic relationship. There are important parallels between antidepressants and psychedelics in emerging literature. For instance, the preparatory and integrative work with a provider can be crucial in determining outcomes. This paper will draw from the extant literature to discuss the therapeutic relationship in psychiatric practice, including in acute care settings and instances in which psychotropic prescribing is a key aspect of treatment.

Abstract: The growing body of clinical neuroscience knowledge is transforming the psychiatry field. Today's psychiatrists must have strong command of clinical neuroscience and its applications to clinical practice. Over the past few decades, increased emphasis has been placed on clinical neuroscience education for psychiatrists and psychiatric trainees; residency training serves as a primary avenue for such educational intervention. These efforts, however, have been met with varying beliefs, attitudes, and responses. In this perspective, we examine the existing literature on clinical neuroscience education in North American psychiatry residency training programs as reported by department chairs, program directors, practicing psychiatrists, and trainees. We note key challenges, including perceived lack of clinical relevance in teaching, insufficient integration of clinical neuroscience education into residency training, and a shortage of specialized faculty educators. We summarize existing efforts to address these challenges, then propose future directions that may further advance clinical neuroscience education in psychiatric residency training. Such propositions include further developing longitudinal and integrated curricula, tailoring teaching for diverse learner and institutional needs, incorporating effective teaching methods, and continually collaborating across parties of interest.

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, 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.

Abstract: Discrimination is an established social determinant of mental health that contributes to psychiatric illness disparities among marginalized populations. There is emerging research elucidating the biological mechanisms connecting discrimination to mental health outcomes, revealing inflammation as a key pathway. This column synthesizes evidence from existing literature on the links between discrimination and inflammation, and outlines both the opportunities and challenges in this field. The discussion highlights the necessity of a multifaceted approach to address discrimination, and thus, reduce inflammation at both individual and population levels.

Learning objective: After participating in this CME activity, the psychiatrist should be better able to:• Discuss the effects of structural racism on pregnancy and obstetric care and their contributions to maternal mental health challenges and inequitable outcomes.• Outline the current understanding of interventions initiated during pregnancy or childbirth that use reproductive justice principles to improve Black maternal perinatal and intergenerational mental health outcomes.

Background: There are significant racial disparities in maternal outcomes for Black compared to White birthing people in the United States (US). Maternal mental health problems negatively affect mothers and their infants. Effects of structural racism during pregnancy and obstetric care may contribute to inequitable maternal mental health challenges and negative offspring outcomes. A reproductive justice framework provides a path for addressing these inequities. This systematic review examines whether pregnancy care interventions driven by reproductive justice principles have successfully improved Black maternal perinatal and intergenerational mental health outcomes.

Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies identified in November 2024 in PubMed, PsycInfo, and CINAHL. The studies included randomized clinical trials of Black birthing parents in the US and their offspring. Interventions incorporating reproductive justice principles were defined as those explicitly designed to increase autonomy, community input, racial equity, and/or cultural relevance.

Results: The search revealed 619 unique records. After screening and full-text review, 12 studies were included. Of these, 7 studies reported statistically significant effects on mental health outcomes. The interventions included interpersonal therapy, culturally tailored cognitive behavioral therapy, group prenatal care, community health worker home visits, and an educational online platform. Six studies reported positive effects on maternal mental health outcomes (e.g., depressive symptoms or anxiety). One study reported positive infant mental health or developmental effects.

Conclusions: The effects of reproductive justice-driven interventions on Black maternal and offspring mental health outcomes are promising, but studies are limited. Future studies should further identify active intervention components and assess mental health-related outcomes in both generations to improve the mental health of Black mothers and prevent negative intergenerational effects.