Pub Date : 2024-10-01DOI: 10.1001/jamapsychiatry.2024.2040
Gil Grunfeld, Ann-Catherine Lemonde, Ian Gold, Vincent Paquin, Srividya N Iyer, Martin Lepage, Ridha Joober, Ashok Malla, Jai L Shah
<p><strong>Importance: </strong>Despite growing interest in the phenomenology of delusions in psychosis, at present little is known about their content and evolution over time, including whether delusion themes are consistent across episodes.</p><p><strong>Objective: </strong>To examine the course of delusions and thematic delusion content across relapse episodes in patients presenting to an early intervention service for psychosis.</p><p><strong>Design, setting, and participants: </strong>This longitudinal, observational study used clinical data systematically collected from January 2003 to March 2018 from a cohort of consenting patients with affective or nonaffective first-episode psychosis, followed up naturalistically for up to 2 years in an early intervention service for psychosis in Montréal, Quebec, Canada. Data included the thematic content and severity of delusions (scores ≥3 using the Scale for the Assessment of Positive Symptoms) and associated psychotic and nonpsychotic symptoms, both across an initial episode and, in the event of remission, a potential relapse. Data were analyzed from September 2021 to February 2023.</p><p><strong>Exposure: </strong>An early intervention service for psychosis, organized around intensive case management and a multidisciplinary team approach, which observed each patient for up to 2 years of care.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was positive symptom relapse and remission, including the presence and content of delusions, which was coded per the Scale for the Assessment of Positive Symptoms and accepted definitions. The main statistical measures included repeated paired-sample t tests and binary logistic regression analyses.</p><p><strong>Results: </strong>Of 636 consenting patients, mean (SD) age was 23.8 (4.75) years; 191 patients were female, 444 were male, and 1 patient was nonbinary. Remission rates were high, and relapse rates were relatively low: 591 individuals had baseline delusions, of which 558 (94.4%) achieved remission. Of these 558 patients, only 182 (32.6%) had a subsequent relapse to a second or later episode of psychosis. Of the 182 patients who did relapse, however, a large proportion (115 [63.2%]) reported threshold-level delusions. Of these 115, 104 patients (90.4%) had thematic delusion content consistent with that reported during the index (first) episode. Those who relapsed with delusions had fewer delusion themes present during subsequent episodes of psychosis compared with the index episode and lower levels of other psychotic and nonpsychotic symptoms.</p><p><strong>Conclusions and relevance: </strong>Specialized early intervention services for psychosis can achieve high rates of sustained remission. However, in this study, the minority of individuals with delusions who later relapsed experienced similar delusion themes during subsequent episodes. These findings raise important considerations for the conceptualization of delusions and have cl
{"title":"Consistency of Delusion Themes Across First and Subsequent Episodes of Psychosis.","authors":"Gil Grunfeld, Ann-Catherine Lemonde, Ian Gold, Vincent Paquin, Srividya N Iyer, Martin Lepage, Ridha Joober, Ashok Malla, Jai L Shah","doi":"10.1001/jamapsychiatry.2024.2040","DOIUrl":"10.1001/jamapsychiatry.2024.2040","url":null,"abstract":"<p><strong>Importance: </strong>Despite growing interest in the phenomenology of delusions in psychosis, at present little is known about their content and evolution over time, including whether delusion themes are consistent across episodes.</p><p><strong>Objective: </strong>To examine the course of delusions and thematic delusion content across relapse episodes in patients presenting to an early intervention service for psychosis.</p><p><strong>Design, setting, and participants: </strong>This longitudinal, observational study used clinical data systematically collected from January 2003 to March 2018 from a cohort of consenting patients with affective or nonaffective first-episode psychosis, followed up naturalistically for up to 2 years in an early intervention service for psychosis in Montréal, Quebec, Canada. Data included the thematic content and severity of delusions (scores ≥3 using the Scale for the Assessment of Positive Symptoms) and associated psychotic and nonpsychotic symptoms, both across an initial episode and, in the event of remission, a potential relapse. Data were analyzed from September 2021 to February 2023.</p><p><strong>Exposure: </strong>An early intervention service for psychosis, organized around intensive case management and a multidisciplinary team approach, which observed each patient for up to 2 years of care.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was positive symptom relapse and remission, including the presence and content of delusions, which was coded per the Scale for the Assessment of Positive Symptoms and accepted definitions. The main statistical measures included repeated paired-sample t tests and binary logistic regression analyses.</p><p><strong>Results: </strong>Of 636 consenting patients, mean (SD) age was 23.8 (4.75) years; 191 patients were female, 444 were male, and 1 patient was nonbinary. Remission rates were high, and relapse rates were relatively low: 591 individuals had baseline delusions, of which 558 (94.4%) achieved remission. Of these 558 patients, only 182 (32.6%) had a subsequent relapse to a second or later episode of psychosis. Of the 182 patients who did relapse, however, a large proportion (115 [63.2%]) reported threshold-level delusions. Of these 115, 104 patients (90.4%) had thematic delusion content consistent with that reported during the index (first) episode. Those who relapsed with delusions had fewer delusion themes present during subsequent episodes of psychosis compared with the index episode and lower levels of other psychotic and nonpsychotic symptoms.</p><p><strong>Conclusions and relevance: </strong>Specialized early intervention services for psychosis can achieve high rates of sustained remission. However, in this study, the minority of individuals with delusions who later relapsed experienced similar delusion themes during subsequent episodes. These findings raise important considerations for the conceptualization of delusions and have cl","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":" ","pages":"1039-1046"},"PeriodicalIF":22.5,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11307164/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141897489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-01DOI: 10.1001/jamapsychiatry.2024.1870
Robert D Gibbons, Mark Olfson, Loren Saulsberry, Mark J Edlund, Sahar Zangeneh, Natalie Bareis, Lydia Chwastiak, Jason B Gibbons, Ronald C Kessler
<p><strong>Importance: </strong>Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study.</p><p><strong>Objective: </strong>To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older.</p><p><strong>Design, setting, and participants: </strong>A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews.</p><p><strong>Main outcomes and measures: </strong>Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level.</p><p><strong>Results: </strong>The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80).</p><p><strong>Conclusions and relevance: </strong>In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, s
{"title":"Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders.","authors":"Robert D Gibbons, Mark Olfson, Loren Saulsberry, Mark J Edlund, Sahar Zangeneh, Natalie Bareis, Lydia Chwastiak, Jason B Gibbons, Ronald C Kessler","doi":"10.1001/jamapsychiatry.2024.1870","DOIUrl":"10.1001/jamapsychiatry.2024.1870","url":null,"abstract":"<p><strong>Importance: </strong>Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study.</p><p><strong>Objective: </strong>To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older.</p><p><strong>Design, setting, and participants: </strong>A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews.</p><p><strong>Main outcomes and measures: </strong>Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level.</p><p><strong>Results: </strong>The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80).</p><p><strong>Conclusions and relevance: </strong>In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, s","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":" ","pages":"976-984"},"PeriodicalIF":22.5,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11446668/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141751777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-25DOI: 10.1001/jamapsychiatry.2024.2854
Wouter van Ballegooijen,Josine Rawee,Christina Palantza,Clara Miguel,Mathias Harrer,Ioana Cristea,Remco de Winter,Renske Gilissen,Merijn Eikelenboom,Aartjan Beekman,Pim Cuijpers
ImportanceSuicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.ObjectiveTo investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts.Data SourcesPubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023.Study SelectionRandomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded.Data Extraction and SynthesisPRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses.Main Outcomes and MeasuresHedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts.ResultsOf 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results.Conclusions and RelevanceDirect and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.
重要性自杀意念和自杀未遂是使人衰弱的心理健康问题，通常采用间接心理疗法（即针对抑郁症或人格障碍等其他心理健康问题的心理疗法）进行治疗。直接和间接心理疗法对自杀意念的影响尚未在一项荟萃分析中进行过研究，而且自从之前的一项荟萃分析研究了直接和间接心理疗法对自杀未遂的影响后，又发表了几项试验。目的 研究直接和间接心理疗法对自杀意念和自杀未遂发生率的影响大小。数据来源检索了PubMed、Embase、PsycInfo、Web of Science、Scopus和Cochrane Central Register of Controlled Trials中截至2023年4月1日发表的文章。研究筛选纳入了针对任何心理健康问题、在任何环境下进行、与任何对照组进行比较、报告有自杀意念或自杀企图的心理治疗随机临床试验。数据提取与综合研究遵循PRISMA指南。由两名独立研究人员提取摘要数据，并采用3级元分析法进行汇总。主要结果和测量方法对自杀意念的Hedges g进行汇总，对自杀未遂的相对风险（RR）进行汇总。结果在确定的15 006项研究中，纳入了147项，包括193项比较和11 001名参与者。直接和间接心理治疗条件与自杀意念的减少有关（直接：g，-0.39；95% CI，-0.53 至 -0.24；I2，83.2；间接：g，-0.30；95% CI，-0.42 至 -0.18；I2，52.2）。直接和间接心理治疗条件也与自杀企图的减少有关（直接：RR，0.72；95% CI，-0.42 至-0.18；I2，52.2）：RR，0.72；95% CI，0.62 至 0.84；I2，40.5；间接：RR，0.68；95% CI，0.48 至 0.95；I2，0）。结论与相关性直接和间接干预对减少自杀意念和自杀企图的效果大小相似。自杀预防策略可以更多地利用间接治疗，为那些不可能因自杀意念或自残而寻求治疗的人提供有效的干预。
{"title":"Suicidal Ideation and Suicide Attempts After Direct or Indirect Psychotherapy: A Systematic Review and Meta-Analysis.","authors":"Wouter van Ballegooijen,Josine Rawee,Christina Palantza,Clara Miguel,Mathias Harrer,Ioana Cristea,Remco de Winter,Renske Gilissen,Merijn Eikelenboom,Aartjan Beekman,Pim Cuijpers","doi":"10.1001/jamapsychiatry.2024.2854","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2854","url":null,"abstract":"ImportanceSuicidal ideation and suicide attempts are debilitating mental health problems that are often treated with indirect psychotherapy (ie, psychotherapy that focuses on other mental health problems, such as depression or personality disorders). The effects of direct and indirect psychotherapy on suicidal ideation have not yet been examined in a meta-analysis, and several trials have been published since a previous meta-analysis examined the effect size of direct and indirect psychotherapy on suicide attempts.ObjectiveTo investigate the effect sizes of direct and indirect psychotherapy on suicidal ideation and the incidence of suicide attempts.Data SourcesPubMed, Embase, PsycInfo, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up until April 1, 2023.Study SelectionRandomized clinical trials of psychotherapy for any mental health problem, delivered in any setting, compared with any control group, and reporting suicidal ideation or suicide attempts were included. Studies measuring suicidal ideation with 1 item were excluded.Data Extraction and SynthesisPRISMA guidelines were followed. Summary data were extracted by 2 independent researchers and pooled using 3-level meta-analyses.Main Outcomes and MeasuresHedges g was pooled for suicidal ideation and relative risk (RR) was pooled for suicide attempts.ResultsOf 15 006 studies identified, 147 comprising 193 comparisons and 11 001 participants were included. Direct and indirect psychotherapy conditions were associated with reduced suicidal ideation (direct: g, -0.39; 95% CI, -0.53 to -0.24; I2, 83.2; indirect: g, -0.30; 95% CI, -0.42 to -0.18; I2, 52.2). Direct and indirect psychotherapy conditions were also associated with reduced suicide attempts (direct: RR, 0.72; 95% CI, 0.62 to 0.84; I2, 40.5; indirect: RR, 0.68; 95% CI, 0.48 to 0.95; I2, 0). Sensitivity analyses largely confirmed these results.Conclusions and RelevanceDirect and indirect interventions had similar effect sizes for reducing suicidal ideation and suicide attempts. Suicide prevention strategies could make greater use of indirect treatments to provide effective interventions for people who would not likely seek treatment for suicidal ideation or self-harm.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"23 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142321184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-25DOI: 10.1001/jamapsychiatry.2024.2679
Ian H Stanley,Ellen P Embrey,Vikhyat S Bebarta
{"title":"Actualizing Military Suicide Prevention Through Digital Health Modernization.","authors":"Ian H Stanley,Ellen P Embrey,Vikhyat S Bebarta","doi":"10.1001/jamapsychiatry.2024.2679","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2679","url":null,"abstract":"","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"8 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142321177","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-25DOI: 10.1001/jamapsychiatry.2024.2744
Chris J Kennedy,Jaclyn C Kearns,Joseph C Geraci,Sarah M Gildea,Irving H Hwang,Andrew J King,Howard Liu,Alex Luedtke,Brian P Marx,Santiago Papini,Maria V Petukhova,Nancy A Sampson,Jordan W Smoller,Charles J Wolock,Nur Hani Zainal,Murray B Stein,Robert J Ursano,James R Wagner,Ronald C Kessler
ImportanceThe suicide rate of military servicemembers increases sharply after returning to civilian life. Identifying high-risk servicemembers before they leave service could help target preventive interventions.ObjectiveTo develop a model based on administrative data for regular US Army soldiers that can predict suicides 1 to 120 months after leaving active service.Design, Setting, and ParticipantsIn this prognostic study, a consolidated administrative database was created for all regular US Army soldiers who left service from 2010 through 2019. Machine learning models were trained to predict suicides over the next 1 to 120 months in a random 70% training sample. Validation was implemented in the remaining 30%. Data were analyzed from March 2023 through March 2024.Main outcome and measuresThe outcome was suicide in the National Death Index. Predictors came from administrative records available before leaving service on sociodemographics, Army career characteristics, psychopathologic risk factors, indicators of physical health, social networks and supports, and stressors.ResultsOf the 800 579 soldiers in the cohort (84.9% male; median [IQR] age at discharge, 26 [23-33] years), 2084 suicides had occurred as of December 31, 2019 (51.6 per 100 000 person-years). A lasso model assuming consistent slopes over time discriminated as well over all but the shortest risk horizons as more complex stacked generalization ensemble machine learning models. Test sample area under the receiver operating characteristic curve ranged from 0.87 (SE = 0.06) for suicides in the first month after leaving service to 0.72 (SE = 0.003) for suicides over 120 months. The 10% of soldiers with highest predicted risk accounted for between 30.7% (SE = 1.8) and 46.6% (SE = 6.6) of all suicides across horizons. Calibration was for the most part better for the lasso model than the super learner model (both estimated over 120-month horizons.) Net benefit of a model-informed prevention strategy was positive compared with intervene-with-all or intervene-with-none strategies over a range of plausible intervention thresholds. Sociodemographics, Army career characteristics, and psychopathologic risk factors were the most important classes of predictors.Conclusions and relevanceThese results demonstrated that a model based on administrative variables available at the time of leaving active Army service can predict suicides with meaningful accuracy over the subsequent decade. However, final determination of cost-effectiveness would require information beyond the scope of this report about intervention content, costs, and effects over relevant horizons in relation to the monetary value placed on preventing suicides.
{"title":"Predicting Suicides Among US Army Soldiers After Leaving Active Service.","authors":"Chris J Kennedy,Jaclyn C Kearns,Joseph C Geraci,Sarah M Gildea,Irving H Hwang,Andrew J King,Howard Liu,Alex Luedtke,Brian P Marx,Santiago Papini,Maria V Petukhova,Nancy A Sampson,Jordan W Smoller,Charles J Wolock,Nur Hani Zainal,Murray B Stein,Robert J Ursano,James R Wagner,Ronald C Kessler","doi":"10.1001/jamapsychiatry.2024.2744","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2744","url":null,"abstract":"ImportanceThe suicide rate of military servicemembers increases sharply after returning to civilian life. Identifying high-risk servicemembers before they leave service could help target preventive interventions.ObjectiveTo develop a model based on administrative data for regular US Army soldiers that can predict suicides 1 to 120 months after leaving active service.Design, Setting, and ParticipantsIn this prognostic study, a consolidated administrative database was created for all regular US Army soldiers who left service from 2010 through 2019. Machine learning models were trained to predict suicides over the next 1 to 120 months in a random 70% training sample. Validation was implemented in the remaining 30%. Data were analyzed from March 2023 through March 2024.Main outcome and measuresThe outcome was suicide in the National Death Index. Predictors came from administrative records available before leaving service on sociodemographics, Army career characteristics, psychopathologic risk factors, indicators of physical health, social networks and supports, and stressors.ResultsOf the 800 579 soldiers in the cohort (84.9% male; median [IQR] age at discharge, 26 [23-33] years), 2084 suicides had occurred as of December 31, 2019 (51.6 per 100 000 person-years). A lasso model assuming consistent slopes over time discriminated as well over all but the shortest risk horizons as more complex stacked generalization ensemble machine learning models. Test sample area under the receiver operating characteristic curve ranged from 0.87 (SE = 0.06) for suicides in the first month after leaving service to 0.72 (SE = 0.003) for suicides over 120 months. The 10% of soldiers with highest predicted risk accounted for between 30.7% (SE = 1.8) and 46.6% (SE = 6.6) of all suicides across horizons. Calibration was for the most part better for the lasso model than the super learner model (both estimated over 120-month horizons.) Net benefit of a model-informed prevention strategy was positive compared with intervene-with-all or intervene-with-none strategies over a range of plausible intervention thresholds. Sociodemographics, Army career characteristics, and psychopathologic risk factors were the most important classes of predictors.Conclusions and relevanceThese results demonstrated that a model based on administrative variables available at the time of leaving active Army service can predict suicides with meaningful accuracy over the subsequent decade. However, final determination of cost-effectiveness would require information beyond the scope of this report about intervention content, costs, and effects over relevant horizons in relation to the monetary value placed on preventing suicides.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"33 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142320991","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-18DOI: 10.1001/jamapsychiatry.2024.2034
Joy Benatov,Liat Itzhaky,Shiri Daniels,Gil Zalsman
ImportanceChanges in suicide rates after a nationwide trauma may be different from changes in psychiatric symptoms or general distress after such events. However, very few studies have examined short-term suicide-related reactions after such an event.ObjectiveTo evaluate the short-term outcome of the events in Israel on October 7, 2023, a large-scale terror attack and unfolding war, on changes in suicidality as reflected in percentages of suicide-related calls in relation to all calls to a national mental health first aid helpline, the Israeli Association for Emotional First Aid (ERAN).Design, Setting and ParticipantsThe data included all interactions via the various ERAN helpline services between January 1, 2022, and December 31, 2023.ExposuresThe October 7, 2023, terror attack on Israel.Mean Outcomes and MeasuresChanges in the numbers of overall calls and suicide-related calls to the ERAN helpline using an interrupted time-series analysis.ResultsA total of 602 323 calls were received by the ERAN helpline. The number of calls reflecting psychological distress in the 3 months before October 7, 2023, was 67 555 compared with 89 445 calls in the 3 months after. Analysis indicated that overall calls increased significantly on October 7 (β = 2089.16; 95% CI, 1918.97-2259.35). In addition, the daily trajectory of all calls changed significantly after October 7 (β = -22.77; 95% CI, -33.37 to -12.16), such that there was a decrease in the number of calls per day (β = -11.34; SE = 1.213; t = -9.35; P < .001). The number of suicide-related calls in the 3 months before October 7 was 1887, whereas 1663 suicide-related calls were registered in the 3 months after. Analysis showed that there were no changes in the daily number of suicide-related calls from before October 7 (β = -0.001; 95% CI, -0.005 to 0.03) or on October 7 (β = -0.22; 95% CI, -3.69 to 3.25). Therefore, the percentage of suicide-related calls decreased significantly on October 7 (β = -1.42; 95% CI, -1.92 to -0.92) and gradually increased in the following period (β = 0.016; 95% CI, 0.006-0.026).Conclusions and RelevanceThe findings of this cohort study suggest that although short-term emotional distress increased after national trauma, the percentage of suicide-related calls decreased. These results support previous studies suggesting that suicidality is not one of the immediate reactions to such traumas.
{"title":"Suicidality Calls to a National Helpline After a Terror Attack and War.","authors":"Joy Benatov,Liat Itzhaky,Shiri Daniels,Gil Zalsman","doi":"10.1001/jamapsychiatry.2024.2034","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2034","url":null,"abstract":"ImportanceChanges in suicide rates after a nationwide trauma may be different from changes in psychiatric symptoms or general distress after such events. However, very few studies have examined short-term suicide-related reactions after such an event.ObjectiveTo evaluate the short-term outcome of the events in Israel on October 7, 2023, a large-scale terror attack and unfolding war, on changes in suicidality as reflected in percentages of suicide-related calls in relation to all calls to a national mental health first aid helpline, the Israeli Association for Emotional First Aid (ERAN).Design, Setting and ParticipantsThe data included all interactions via the various ERAN helpline services between January 1, 2022, and December 31, 2023.ExposuresThe October 7, 2023, terror attack on Israel.Mean Outcomes and MeasuresChanges in the numbers of overall calls and suicide-related calls to the ERAN helpline using an interrupted time-series analysis.ResultsA total of 602 323 calls were received by the ERAN helpline. The number of calls reflecting psychological distress in the 3 months before October 7, 2023, was 67 555 compared with 89 445 calls in the 3 months after. Analysis indicated that overall calls increased significantly on October 7 (β = 2089.16; 95% CI, 1918.97-2259.35). In addition, the daily trajectory of all calls changed significantly after October 7 (β = -22.77; 95% CI, -33.37 to -12.16), such that there was a decrease in the number of calls per day (β = -11.34; SE = 1.213; t = -9.35; P < .001). The number of suicide-related calls in the 3 months before October 7 was 1887, whereas 1663 suicide-related calls were registered in the 3 months after. Analysis showed that there were no changes in the daily number of suicide-related calls from before October 7 (β = -0.001; 95% CI, -0.005 to 0.03) or on October 7 (β = -0.22; 95% CI, -3.69 to 3.25). Therefore, the percentage of suicide-related calls decreased significantly on October 7 (β = -1.42; 95% CI, -1.92 to -0.92) and gradually increased in the following period (β = 0.016; 95% CI, 0.006-0.026).Conclusions and RelevanceThe findings of this cohort study suggest that although short-term emotional distress increased after national trauma, the percentage of suicide-related calls decreased. These results support previous studies suggesting that suicidality is not one of the immediate reactions to such traumas.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"7 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-18DOI: 10.1001/jamapsychiatry.2024.2360
Anders Jørgensen, Frederikke Hoerdam Gronemann, Maarten P. Rozing, Martin B. Jørgensen, Merete Osler
ImportanceLarge-scale evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) is lacking.ObjectiveTo provide an exhaustive and naturalistic insight into the real-world outcomes and the cost-effectiveness of c/mECT in a large dataset.Design, Setting, and ParticipantsThis cohort study included all patients in the Danish National Patient Registry who initiated treatment with ECT from 2003 through 2022. The data were analyzed from October 2023 to February 2024.ExposuresECT. An algorithm to identify c/mECTs in the dataset was developed: (&gt;3 treatments with ≥7 and &lt;90 days between adjacent treatments, occurring within a time frame of 180 days [cECT] or more [mECT] after an acute [aECT] series).Main Outcomes and MeasuresThe association of c/mECT with subsequent 6- to 12-month risk of hospitalization or suicidal behavior using Cox proportional hazard regression with multiple adjustments and aECT only as a reference, propensity score matching, and self-controlled case series analysis using a Poisson regression model. A cost-effectiveness analysis based on hospitalization and ECT expenses was made.ResultsA total of 19 944 individuals were treated with ECT (12 157 women [61%], 7787 men [39%]; median [IQR] age, 55 [41-70] years). Of these, 1533 individuals (7.7%) received c/mECT at any time point (1017 [5.1%] cECT only and 516 [2.6%] mECT). Compared with patients receiving aECT only, c/mECT patients more frequently experienced schizophrenia (odds ratio [OR], 2.14; 95% CI, 1.86-2.46) and schizoaffective disorder (OR, 2.42; 95% CI, 1.90-3.09) and less frequently unipolar depression (OR, 0.56; 95% CI, 0.51-0.62). In all models, c/mECT was associated with a lower rate of hospitalization after finishing aECT (eg, 6-month adjusted hazard ratio, 0.68; 95% CI, 0.60-0.78 [Cox regression]; 6-month incidence rate ratio, 0.51; 95% CI, 0.41-0.62 [Poisson regression]). There was no significant difference in the risk of suicidal behavior. Compared with the periods before the end of aECT, c/mECT was associated with a substantial reduction in total treatment costs.Conclusions and RelevanceIn a nationwide and naturalistic setting, c/mECT after aECT was infrequently used but associated with a lower risk of readmission than aECT alone. The totality of the evidence indicates that c/mECT should be considered more often to prevent relapse after successful aECT in patients whose condition does not respond sufficiently to other interventions.
{"title":"Clinical Outcomes of Continuation and Maintenance Electroconvulsive Therapy","authors":"Anders Jørgensen, Frederikke Hoerdam Gronemann, Maarten P. Rozing, Martin B. Jørgensen, Merete Osler","doi":"10.1001/jamapsychiatry.2024.2360","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2360","url":null,"abstract":"ImportanceLarge-scale evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) is lacking.ObjectiveTo provide an exhaustive and naturalistic insight into the real-world outcomes and the cost-effectiveness of c/mECT in a large dataset.Design, Setting, and ParticipantsThis cohort study included all patients in the Danish National Patient Registry who initiated treatment with ECT from 2003 through 2022. The data were analyzed from October 2023 to February 2024.ExposuresECT. An algorithm to identify c/mECTs in the dataset was developed: (&amp;gt;3 treatments with ≥7 and &amp;lt;90 days between adjacent treatments, occurring within a time frame of 180 days [cECT] or more [mECT] after an acute [aECT] series).Main Outcomes and MeasuresThe association of c/mECT with subsequent 6- to 12-month risk of hospitalization or suicidal behavior using Cox proportional hazard regression with multiple adjustments and aECT only as a reference, propensity score matching, and self-controlled case series analysis using a Poisson regression model. A cost-effectiveness analysis based on hospitalization and ECT expenses was made.ResultsA total of 19 944 individuals were treated with ECT (12 157 women [61%], 7787 men [39%]; median [IQR] age, 55 [41-70] years). Of these, 1533 individuals (7.7%) received c/mECT at any time point (1017 [5.1%] cECT only and 516 [2.6%] mECT). Compared with patients receiving aECT only, c/mECT patients more frequently experienced schizophrenia (odds ratio [OR], 2.14; 95% CI, 1.86-2.46) and schizoaffective disorder (OR, 2.42; 95% CI, 1.90-3.09) and less frequently unipolar depression (OR, 0.56; 95% CI, 0.51-0.62). In all models, c/mECT was associated with a lower rate of hospitalization after finishing aECT (eg, 6-month adjusted hazard ratio, 0.68; 95% CI, 0.60-0.78 [Cox regression]; 6-month incidence rate ratio, 0.51; 95% CI, 0.41-0.62 [Poisson regression]). There was no significant difference in the risk of suicidal behavior. Compared with the periods before the end of aECT, c/mECT was associated with a substantial reduction in total treatment costs.Conclusions and RelevanceIn a nationwide and naturalistic setting, c/mECT after aECT was infrequently used but associated with a lower risk of readmission than aECT alone. The totality of the evidence indicates that c/mECT should be considered more often to prevent relapse after successful aECT in patients whose condition does not respond sufficiently to other interventions.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"6 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236316","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-18DOI: 10.1001/jamapsychiatry.2024.2731
David M Gardner,Justin P Turner,Sandra Magalhaes,Malgorzata Rajda,Andrea L Murphy
ImportanceDirect-to-patient interventions enabling transitions from long-term benzodiazepine receptor agonist (BZRA) use to cognitive behavioral therapy for insomnia (CBTI) by older adults has the potential to reduce BZRA use and related harms while improving sleep outcomes without requiring prearranged clinician involvement.ObjectiveTo compare 2 direct-to-patient behavior change interventions with treatment as usual (TAU) on BZRA use, sleep, and other health outcomes, and uptake of CBTI techniques.Design, Setting, and ParticipantsThe Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study was a 3-arm, pragmatic, open-label, minimum-contact, randomized clinical trial. The study began November 2020 and ended June 2022. Participants were randomly allocated to 1 of 3 groups, including 2 different mailed behavior change interventions or no intervention (TAU). Participants were from communities across the province of New Brunswick, Canada, and included adults 65 years and older living independently with long-term use of BZRAs and current or past insomnia.InterventionsThe Sleepwell package (YAWNS-1) consisted of a cover letter and 2 booklets ("How to Stop Sleeping Pills" and "How to Get Your Sleep Back"). The other package (YAWNS-2) included updated versions of the 2 booklets ("You May Be at Risk" and "How to Get a Good Night's Sleep Without Medication") used in the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) study.Main Outcomes and MeasuresBZRA use at 6 months was the primary measure. Secondary measures included CBTI use, sleep, insomnia, daytime sleepiness, safety, anxiety, frailty, and quality of life.ResultsA total of 1295 individuals expressed interest in the study, and 565 (43.6%) completed a baseline assessment. Participants had a mean (SD) age of 72.1 (5.7) years, a mean (SD) BZRA use duration of 11.4 (9.1) years, and 362 (64.1%) were female. Discontinuations and dose reductions of 25% or greater were highest with YAWNS-1 (50 of 191 [26.2%]; 39 of 191 [20.4%]; total, 46.6%) compared with YAWNS-2 (38 of 187 [20.3%]; 27 of 187 [14.4%]; total, 34.8%, P = .02) and TAU (14 of 187 [7.5%]; 24 of 187 [12.8%]; total, 20.3%, P < .001). YAWNS-1 also demonstrated better uptake of CBTI techniques and sleep outcomes compared with YAWNS-2 (new CBTI techniques: 3.1 vs 2.4; P =.03; sleep efficiency change: 4.1% vs -1.7%; P =.001) and reduced insomnia severity and daytime sleepiness compared with TAU (insomnia severity index change: -2.0 vs 0.3; P <.001; Epworth Sleepiness Scale change: -0.8 vs 0.3; P =.001).Conclusions and RelevanceResults of the YAWNS NB randomized clinical trial show that, as a simple, scalable, direct-to-patient intervention, YAWNS-1 substantially reduced BZRA use and improved sleep outcomes. It could be implemented to transform insomnia care for older adults at the population level.Trial RegistrationClinicalTrials.gov Identifier: NCT04406103.
{"title":"Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep: The YAWNS NB Randomized Clinical Trial.","authors":"David M Gardner,Justin P Turner,Sandra Magalhaes,Malgorzata Rajda,Andrea L Murphy","doi":"10.1001/jamapsychiatry.2024.2731","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2731","url":null,"abstract":"ImportanceDirect-to-patient interventions enabling transitions from long-term benzodiazepine receptor agonist (BZRA) use to cognitive behavioral therapy for insomnia (CBTI) by older adults has the potential to reduce BZRA use and related harms while improving sleep outcomes without requiring prearranged clinician involvement.ObjectiveTo compare 2 direct-to-patient behavior change interventions with treatment as usual (TAU) on BZRA use, sleep, and other health outcomes, and uptake of CBTI techniques.Design, Setting, and ParticipantsThe Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study was a 3-arm, pragmatic, open-label, minimum-contact, randomized clinical trial. The study began November 2020 and ended June 2022. Participants were randomly allocated to 1 of 3 groups, including 2 different mailed behavior change interventions or no intervention (TAU). Participants were from communities across the province of New Brunswick, Canada, and included adults 65 years and older living independently with long-term use of BZRAs and current or past insomnia.InterventionsThe Sleepwell package (YAWNS-1) consisted of a cover letter and 2 booklets (\"How to Stop Sleeping Pills\" and \"How to Get Your Sleep Back\"). The other package (YAWNS-2) included updated versions of the 2 booklets (\"You May Be at Risk\" and \"How to Get a Good Night's Sleep Without Medication\") used in the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) study.Main Outcomes and MeasuresBZRA use at 6 months was the primary measure. Secondary measures included CBTI use, sleep, insomnia, daytime sleepiness, safety, anxiety, frailty, and quality of life.ResultsA total of 1295 individuals expressed interest in the study, and 565 (43.6%) completed a baseline assessment. Participants had a mean (SD) age of 72.1 (5.7) years, a mean (SD) BZRA use duration of 11.4 (9.1) years, and 362 (64.1%) were female. Discontinuations and dose reductions of 25% or greater were highest with YAWNS-1 (50 of 191 [26.2%]; 39 of 191 [20.4%]; total, 46.6%) compared with YAWNS-2 (38 of 187 [20.3%]; 27 of 187 [14.4%]; total, 34.8%, P = .02) and TAU (14 of 187 [7.5%]; 24 of 187 [12.8%]; total, 20.3%, P < .001). YAWNS-1 also demonstrated better uptake of CBTI techniques and sleep outcomes compared with YAWNS-2 (new CBTI techniques: 3.1 vs 2.4; P =.03; sleep efficiency change: 4.1% vs -1.7%; P =.001) and reduced insomnia severity and daytime sleepiness compared with TAU (insomnia severity index change: -2.0 vs 0.3; P <.001; Epworth Sleepiness Scale change: -0.8 vs 0.3; P =.001).Conclusions and RelevanceResults of the YAWNS NB randomized clinical trial show that, as a simple, scalable, direct-to-patient intervention, YAWNS-1 substantially reduced BZRA use and improved sleep outcomes. It could be implemented to transform insomnia care for older adults at the population level.Trial RegistrationClinicalTrials.gov Identifier: NCT04406103.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"197 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-11DOI: 10.1001/jamapsychiatry.2024.2652
Stefan Leucht, Jim van Os, Markus Jäger, John M. Davis
ImportancePsychiatry mainly deals with conditions that are mediated by brain function but are not directly attributable to specific brain abnormalities. Given the lack of concrete biological markers, such as laboratory tests or imaging results, the development of diagnostic systems is difficult.ObservationsThis narrative review evaluated 9 diagnostic approaches. The validity of the DSM and the International Classification of Disorders (ICD) is limited. The Research Domain Criteria is a research framework, not a diagnostic system. The clinical utility of the quantitatively derived, dimensional Hierarchical Taxonomy of Psychopathology is questionable. The Psychodynamic Diagnostic Manual Version 2 follows psychoanalytic theory and focuses on personality. Unlike the personality assessments in ICD-11 or DSM-5’s alternative model, based on pathological extremes of the big 5 traits (extraversion, agreeableness, openness, conscientiousness, and neuroticism), it lacks foundation in empirical evidence. Network analytic approaches are intriguing, but their complexity makes them difficult to implement. Staging would be easier if individually predictive biological markers were available. The problem with all these new approaches is that they abstract patient experiences into higher-order constructs, potentially obscuring individual symptoms so much that they no longer reflect patients’ actual problems.Conclusions and RelevanceICD and DSM diagnoses can be questioned, but the reality of psychopathological symptoms, such as hallucinations, depression, anxiety, compulsions, and the suffering stemming from them, cannot. Therefore, it may be advisable to primarily describe patients according to the psychopathological symptoms they present, and any resulting personal syndromes, embedded in a framework of contextual clinical characterization including personality assessment and staging. The DSM and ICD are necessary for reimbursement, but they should be simplified and merged. A primarily psychopathological symptoms–based, clinical characterization approach would be multidimensional and clinically useful, because it would lead to problem-oriented treatment and support transdiagnostic research. It should be based on a universally used instrument to assess psychopathology and structured clinical characterization.
{"title":"Prioritization of Psychopathological Symptoms and Clinical Characterization in Psychiatric Diagnoses","authors":"Stefan Leucht, Jim van Os, Markus Jäger, John M. Davis","doi":"10.1001/jamapsychiatry.2024.2652","DOIUrl":"https://doi.org/10.1001/jamapsychiatry.2024.2652","url":null,"abstract":"ImportancePsychiatry mainly deals with conditions that are mediated by brain function but are not directly attributable to specific brain abnormalities. Given the lack of concrete biological markers, such as laboratory tests or imaging results, the development of diagnostic systems is difficult.ObservationsThis narrative review evaluated 9 diagnostic approaches. The validity of the <jats:italic>DSM</jats:italic> and the <jats:italic>International Classification of Disorders</jats:italic> (<jats:italic>ICD</jats:italic>) is limited. The Research Domain Criteria is a research framework, not a diagnostic system. The clinical utility of the quantitatively derived, dimensional Hierarchical Taxonomy of Psychopathology is questionable. The Psychodynamic Diagnostic Manual Version 2 follows psychoanalytic theory and focuses on personality. Unlike the personality assessments in <jats:italic>ICD-11</jats:italic> or <jats:italic>DSM-5</jats:italic>’s alternative model, based on pathological extremes of the big 5 traits (extraversion, agreeableness, openness, conscientiousness, and neuroticism), it lacks foundation in empirical evidence. Network analytic approaches are intriguing, but their complexity makes them difficult to implement. Staging would be easier if individually predictive biological markers were available. The problem with all these new approaches is that they abstract patient experiences into higher-order constructs, potentially obscuring individual symptoms so much that they no longer reflect patients’ actual problems.Conclusions and Relevance<jats:italic>ICD</jats:italic> and <jats:italic>DSM</jats:italic> diagnoses can be questioned, but the reality of psychopathological symptoms, such as hallucinations, depression, anxiety, compulsions, and the suffering stemming from them, cannot. Therefore, it may be advisable to primarily describe patients according to the psychopathological symptoms they present, and any resulting personal syndromes, embedded in a framework of contextual clinical characterization including personality assessment and staging. The <jats:italic>DSM</jats:italic> and <jats:italic>ICD</jats:italic> are necessary for reimbursement, but they should be simplified and merged. A primarily psychopathological symptoms–based, clinical characterization approach would be multidimensional and clinically useful, because it would lead to problem-oriented treatment and support transdiagnostic research. It should be based on a universally used instrument to assess psychopathology and structured clinical characterization.","PeriodicalId":14800,"journal":{"name":"JAMA Psychiatry","volume":"25 1","pages":""},"PeriodicalIF":25.8,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142170779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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